fluid management post cardiac surgery

marbrit · Oct 1, 2007

Hi Eamon: I worked cardiothoracic surgery for 14 yrs and still do it when I can--I travel. I loved the adrenaline of getting an immediate post op pt with all kinds of lines and access. These people (cabg, valve and VAD) pts were fun and we had to watch all these parameters and protocols to make sure the pt became stable in 2 to 4 hrs.

I see you've been "nursing" for 16 years but it sounds like you're going to be new to cardiothoracic sugery? We had swan-ganz lines in everyone also art lines and sometimes other specialized access/diagnostic lines. Our pts routinely gained at least

3 kg of fluid and it wasn't uncommon to see 10 kg gains--pts got fluid according to protocols and were diuresed also by protocols. Our surgeons trusted us and knew our education on this stuff. We used lots of vasoactive drips too.

This is a pretty general overview of my experiience.

Have Fun, Marianne at 0715 in SLC, UT:welcome:

smilesammyjane · Oct 3, 2007

i think one of the most important thing to look at is your cardiac index (haemo calcs) this provides you with a direct measurement of systemic vascular resistance and cardiac output.

Of course all other measurement should be watch such as art BP and CVP.

nurseabc123 · Oct 3, 2007

Hi, of all care aspects following open heart surgery, I think that the area of fluid management/haemodynamics is arguably the most challenging for nurses. Possibly because it needs particular attention to alot of fine detail. I just wanted to draw on the experiences of other cardiac surgical nurses. I've worked in a variety of different cardiac surgical areas and it's amazing how management can vary. What are your gold standards for care? What parameters do you particularly pay attention to when deciding whether to fill, offload, increase/decrease/commence inotropes? I know this is a huge area but I'm really interested in hearing of other people's experiences. Thanks

We can give 3 plasmanates per our standing orders immediately post-op. Usually, if a patient's BP is pretty labile, CVP is low, and PA pressures are low, they will usually get 1-2 right off the bat. That allows me to wean off the pressors, etc.

If we feel a patient needs more fluid than that, we need a order for another plasmanate or Hespan.

Once in a while, in specific cases will have Keep Hgb >10, and will transfuse PRBCs for less than that.

eamon66 · Oct 3, 2007

Thanks for your responses. Marianne, I've been doing cardiothoracics for 7 yrs now but mainly in high-dependency settings where swan ganz/doppler studies are rarely undertaken so didn't have the luxury of measuring CO/CI/SVRs etc. However, have been working in recovery/HDU setting for the past 4 months so this is now all new to me. Do any of you guys use SVO2/lactate measurements as a guide to overall tissue perfusion? As a rule of thumb, I personally think assessing effects on CVP during rapid administration of plasma substitutes (voluven, volplex, gelofusion etc) is very useful as a guide to whether low ouptuts/BPs is secondary to hypovolaemia. Thanks again, Eamon.

marbrit · Oct 4, 2007

Dear Eamon: Enjoyed hearing from you and the others on this thread. I agree that the hemodynamic numbers are really important in order to manage fluid replacement.

We had S/G numbers and followed the PAW the most (keeping it in the 15 range).

CVP was also very important of R heart function but if you could get a S/G with a PAW you were set!! We used SVO2 alot before we got out continunous cardiac out with continuous cardiac index machine. Mostly out pts were afterload impaired (high) so

they got dobutamine and amiodarone for awhile. We diuresed according to wt gain and uop less than 30cc/hr. Lasix, of course.

Like I said, our docs knew our limitations and allowed us great latitude.

Hope you're having nice weather--I guess we'll be seeing snow soon.

Sincerely, Marianne in SLC:balloons:

hrvojefranjic · Dec 2, 2007

Does anyone use Vigileo haemodynamic monitor in CSICU instead S/G?

Dinith88 · Dec 3, 2007

. Do any of you guys use SVO2/lactate measurements as a guide to overall tissue perfusion? .

Our CCI/CCO machines are capable of continuos SVo2 monitoring. Oddly, we rarely use this function on our post-hearts...at least it's not 'ordered' routinely. I personally like to use it, others i work with dont ( i think some of the other nurses just dont like to hassle with calibrating the machine). I think the main reason it's not ordered all the time is because there're so many other 'indicators' (Index/output, PAP's, ABG's, Hem. calc's, etc.) that by the time your SVO2 is bad you're already aware that perfusion is poor.

jbp0529 · Dec 8, 2007

Our CCI/CCO machines are capable of continuos SVo2 monitoring. Oddly, we rarely use this function on our post-hearts...at least it's not 'ordered' routinely. I personally like to use it, others i work with dont ( i think some of the other nurses just dont like to hassle with calibrating the machine). I think the main reason it's not ordered all the time is because there're so many other 'indicators' (Index/output, PAP's, ABG's, Hem. calc's, etc.) that by the time your SVO2 is bad you're already aware that perfusion is poor.

That's true. Our CV docs usually dont place Svo2 lines since they feel that we have many other tools available to determine tissue perfusion and oxygen consumption. I think the only time they like to use Svo2 Swans is with our post lung and heart transplant patients. Different tastes for different people, I guess.

Grifter · Dec 17, 2007

hi from my experience here in the Philippines post CABG fluid management are some what on the dry side doctors here are afraid of the ill effects of pulmonary congestion post bypass the moment patient is out of or nitrates will be running and and then if bp drops just up your inotropes but most doctors here would want the nitrate to run at least 1mg/hr...due to the massive amount of blood components given during and post by pass diuretics are given once the patient is a little over loaded with fluids they then to want the cvp at around 5 since we dont use swanz that much due to the cost you have to make do with a CVP and SAT from the pulse oxy and then depend on good ol ABG when you think that your pts saturation is down thats probably why the management here is deferent from where you guys practice....i have noticed that by day 2 post bypass my balance will be around 1-1.5L on the dry side and the MD seem to be happy with this