Discuss About The Synopsis Postoperative Cardiac Management.
Cardiovascular surgery or cardiac surgery refers to surgery that is performed in the heart or the blood vessels by cardiac surgeon, with the aim of treating cardio vascular complications. It is often used for curing ischemic heart disease, correcting congenital heart diseases or valvular heart diseases that might arise due to a range of factors. Furthermore, cardiac operation also involves treatment of atherosclerosis, rheumatic heart disease, and heart transplantation. Showing similarity with other surgical procedures, cardiac surgery also requires postoperative precautions, with the aim of avoiding complications. There is a need to maintain appropriate insertion care, for avoiding infections and minimising complications (Hausenloy et al., 2015). Further complications are also associated with loss of appetite and swelling. Postoperative cardiovascular complications have always been associated with an increase in morbidity and mortality during the postoperative period. They also result in an increase in the length of hospitalization and lead to higher healthcare-associated treatment cost (Sutton, Bailey, Bellomo, Eastwood & Pilcher, 2014).
Hypertension and tachycardia often arise from pain, surgical stress or interruption of beta blockers therapy that lead to an increase in myocardial oxygen demand. Research evidences state that the immune system of some patients is present in a prime susceptible stage, before conduction of the surgery that increases the likelihood to subsequently suffer from postoperative cardiac complications. The gastrointestinal tract also acts as a source of inflammation that leads to release of endotoxin, systemically from bacteria and lowers the cardiovascular performance of the patients, thereby leaving the cardiac tissue at a risk of hypoxia and under perfusion (Imazio & Hoit, 2013). Hence, there is a need to prevent postoperative complications, with the aim of reducing rates of mortality and associated morbidity among such patients.
Methods- A literature review was conducted in order to gain exhaustive information from academic oriented literature that focused on postoperative cardiac management and formed the basis of research. The methodology focused on recognition retrieval and recollection of articles, relevant to postoperative cardiac management, followed by comprehension of the materials that has been collected and read (Aveyard, 2014). This was followed by gaining a sound understanding of the conceptual framework methodology and new terminologies that were present in the retrieved articles. Research question was formulated that acted as the fundamental code of this review of literature or research project. The question was kept comprehensive and specific and focused on the study and determined the methodology. This question guided all the stages of literature review that includes enquiry, analysis, followed by reporting of the key findings. The Research question for this literature review was as follows:
This Research question helped in specifying the major objectives of the research, and helped in guiding the research and assisted in construction of logical arguments. The research started by identifying the search terms and key concepts within the research question. Each component was treated as a separate concept and the keywords were derived from the research question, along with their synonyms that were found in preliminary research. With the aim of identifying potential relevant articles that pertains to the topic, two databases namely PubMed and MEDLINE were searched. The search terms were ‘cardiac’, ‘heart’, ‘operation’, ‘surgery’, ‘postoperative’, ‘therapy’, ‘management’, and ‘intervention’. The search terms were used in combination with several Boolean operators AND, NOT and OR that helped in broadening on narrowing down the search results. The operator ‘AND’ retrieved results that contained all the keywords. On the other hand, ‘OR’ helped in broadening the search results, by retrieving articles that contained either of the keywords (McGowan, Sampson, Salzwedel, Cogo, Foerster & Lefebvre, 2016).
Results/findings- According to research findings the common postoperative problems that are seen among cardiac patients, hemodynamics was identified as an aspect of cardiovascular physiology, concerned with the forces that the heart generates, thereby resulting in movement of blood through the cardiovascular system (Salzwedel et al., 2013). The basic management techniques identified from the literature focused on measuring the hemodynamics state of the patient, followed by classifying it as hypertension, hypotension or a hyperdynamic and hyperdynamic state, on finding abnormalities (Ji et al., 2013). The management procedure generally involves identification of the causes that lead to abnormal hemodynamics. This is generally followed by administration of a therapy such as, a vasoactive or cardioactive agent that is able to mend the deviation that has been identified (Nielsen et al., 2013). According to research evidences, continuous monitoring of the hemodynamic states of the patient includes conduction of electrocardiogram, monitoring the pulse oximetry, invasive arterial pressure, and endtidal carbon dioxide concentration (Peretto, Durante, Limite & Cianflone, 2014). A pulmonary artery catheter or central venous pressure monitor is generally used for the preload assessment. The myocardial performance determines the insertion of pulmonary artery catheter, which in turn helps to better assist the performance of the patient, during heart manipulation (McLaughlin et al., 2013).
Similar findings were also reported by other research articles that focused on monitoring the hemodynamics of the patient followed by administration of pharmaceutical drugs or endogenous agents, commonly called vasoactive substances that have been conferred the ability of bringing about an increase or decrease in blood pressure depending on the hemodynamic abnormality (Nishimura et al., 2014). These have been found to adjust vascular resistance and vascular compliance, typically by bringing about vasoconstriction or dilation, which in turn helps to maintain the homeostatic mechanism of the body under control. Evidences have been provided by researchers for the use of bradykinin, angiotensin, histamine and vasoactive internal peptide, when the patient shows abnormalities in heart rate and blood pressure, following a cardiac surgery (Beylin et al., 2013). Researchers also said that the dosage of such vasoactive substances are typically titrated by adjusting them upwards or downwards, with the aim of achieving a desired effect or specific range of values as a determined by competent cardiac surgeons.
Similar findings were also reported by other articles that illustrated the mechanism of administering vasoactive drugs, with the use of any intravenous pump, or volumetric in fusion device (Prys-Picard, Shah, Williams, Cardenas Jr & Sharma, 2013). These research articles also elaborated on the use of ionotropic agents that increase the myocardial contractility. Moreover, ionodilators are also used in the form of vasoactive agents owing to their ionotropic effects that lead to vasodilation, and result in decreasing pulmonary and systemic vascular resistance (Gaies et al., 2014). Cardiovascular complications are often related to the development of septic shock that occurs in response to certain infection, and results in hypertension and other abnormalities in cellular metabolism. Universal agreement was obtained from all the articles, related to use of aggressive fluid resuscitation, as the initial intervention for supporting patients having experienced septic shock. Similarities were obtained related to implementation of vasoactive drug therapy either through use of ionotropic agents and vasopressors or by administering drugs that directly increase the blood pressure (Vincent & De Backer, 2013). Most commonly used ionotropic agents have been found to increase MAP, by bringing about an elevation in the cardiac index, along with limited impacts on systemic vascular resistance. Moreover, research evidences also established dobutamine as the drug of choice for increasing cardiac output among such patients. The drug acts as another ionotropic agent and stimulates the β-1 and β-2 receptors, during septic shock, thereby increasing cardiac index, in combination with heart rate and stroke volume (Mallat et al., 2014).
Discussion- Most patients having undergone cardiac surgery include hypertension risks of bleeding pacing, atrial fibrillation and flutter. Moreover, in such patients the lungs are found to be not optimally ventilated, and they often report renal impairment. Severe pain is another postoperative complication that patients experience, which in turn affects postoperative recovery. Hemodynamic management was identified as the basic therapeutic intervention related to addressing such postoperative complications. Hence, the research evidences identified hemodynamic management as the primary therapeutic management procedure among patients who have undergone high risks of cardiac surgery. Monitoring the hemodynamic even provides extensive information about the adequacy of circulation oxygenation and perfusion. Administration of vasoactive agents therefore helps in stabilizing the abnormal hemodynamics, and facilitates elimination or reduction of the chances of mortality and morbidity.
The major strength of the research lies in the fact that it focused on one aspect of management of postoperative cardiac complications, thereby providing distinct information that pertain to the topic. However, attention to rewarming, fluid resuscitation and appropriate ventilator management are the key components that are generally administered, while being involved in critical care of cardiac patients, following cardiac surgery (Thiele, Ohman, Desch, Eitel & de Waha, 2015). Hence, consideration of the aforementioned three aspects in the literature review would have helped in gaining a deeper understanding of postoperative cardiac management.
Conclusion- Postoperative complications can be general or specific, to the kind of cardiac surgery undertaken and is generally treated by hemodynamic management. General postoperative complications include atelectasis, postoperative fever, wound infection, deep vein thrombosis, and embolism. Vasoactive agents should be used for treating postoperative cardiac complications, with the aim of reducing or eliminating abnormalities in blood pressure and circulation of blood in the blood vessels, and septic shock. Thus, it can be stated that vascular activity of these drugs pertains to their effect on the blood vessel.
References
Aveyard, H. (2014). Doing a literature review in health and social care: A practical guide. McGraw-Hill Education (UK). Retrieved from- https://books.google.co.in/books?hl=en&lr=&id=qYdFBgAAQBAJ&oi=fnd&pg=PP1&dq=practical+guide+literature+review&ots=aQ4Z1Cz7k4&sig=W8L4S3C3gHxY5J_y0yPozIqUWlY#v=onepage&q=practical%20guide%20literature%20review&f=false
Beylin, M. E., Perman, S. M., Abella, B. S., Leary, M., Shofer, F. S., Grossestreuer, A. V., & Gaieski, D. F. (2013). Higher mean arterial pressure with or without vasoactive agents is associated with increased survival and better neurological outcomes in comatose survivors of cardiac arrest. Intensive care medicine, 39(11), 1981-1988. https://doi.org/10.1007/s00134-013-3075-9
Gaies, M. G., Jeffries, H. E., Niebler, R. A., Pasquali, S. K., Donohue, J. E., Yu, S., … & Thiagarajan, R. R. (2014). Vasoactive-Inotropic Score (VIS) is Associated with Outcome After Infant Cardiac Surgery: An Analysis from the Pediatric Cardiac Critical Care Consortium (PC4) and Virtual PICU System Registries. Pediatric critical care medicine: a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 15(6), 529. doi: 10.1097/PCC.0000000000000153
Hausenloy, D. J., Candilio, L., Evans, R., Ariti, C., Jenkins, D. P., Kolvekar, S., … & Pepper, J. (2015). Remote ischemic preconditioning and outcomes of cardiac surgery. New England Journal of Medicine, 373(15), 1408-1417. Marketing: 10.1056/NEJMoa1413534
Imazio, M., & Hoit, B. D. (2013). Post-cardiac injury syndromes. An emerging cause of pericardial diseases. International journal of cardiology, 168(2), 648-652. https://doi.org/10.1016/j.ijcard.2012.09.052
Ji, F., Li, Z., Nguyen, H., Young, N., Shi, P., Fleming, N., & Liu, H. (2013). Perioperative dexmedetomidine improves outcomes of cardiac surgery. Circulation, CIRCULATIONAHA-112. https://doi.org/10.1161/CIRCULATIONAHA.112.000936
Mallat, J., Benzidi, Y., Salleron, J., Lemyze, M., Gasan, G., Vangrunderbeeck, N., … & Thevenin, D. (2014). Time course of central venous-to-arterial carbon dioxide tension difference in septic shock patients receiving incremental doses of dobutamine. Intensive care medicine, 40(3), 404-411. https://doi.org/10.1016/j.tvjl.2015.04.002
McGowan, J., Sampson, M., Salzwedel, D. M., Cogo, E., Foerster, V., & Lefebvre, C. (2016). PRESS peer review of electronic search strategies: 2015 guideline statement. Journal of clinical epidemiology, 75, 40-46. https://doi.org/10.1016/j.jclinepi.2016.01.021
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Nielsen, N., Wetterslev, J., Cronberg, T., Erlinge, D., Gasche, Y., Hassager, C., … & Pellis, T. (2013). Targeted temperature management at 33 C versus 36 C after cardiac arrest. New England Journal of Medicine, 369(23), 2197-2206. DOI: 10.1056/NEJMoa1310519
Nishimura, R. A., Otto, C. M., Bonow, R. O., Carabello, B. A., Erwin, J. P., Guyton, R. A., … & Sundt, T. M. (2014). 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 63(22), 2438-2488. DOI: 10.1016/j.jacc.2014.02.537
Peretto, G., Durante, A., Limite, L. R., & Cianflone, D. (2014). Postoperative arrhythmias after cardiac surgery: incidence, risk factors, and therapeutic management. Cardiology research and practice, 2014. https://dx.doi.org/10.1155/2014/615987
Prys-Picard, C. O., Shah, S. K., Williams, B. D., Cardenas Jr, V., & Sharma, G. (2013). Outcomes of patients on multiple vasoactive drugs for shock. Journal of intensive care medicine, 28(4), 237-240. https://doi.org/10.1177/0885066612448738
Salzwedel, C., Puig, J., Carstens, A., Bein, B., Molnar, Z., Kiss, K., … & Reuter, D. A. (2013). Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. Critical care, 17(5), R191. https://doi.org/10.1186/cc12885
Sutton, A. D. J., Bailey, M., Bellomo, R., Eastwood, G. M., & Pilcher, D. V. (2014). The association between early arterial oxygenation and mortality post cardiac surgery. Anaesthesia and intensive care, 42(6), 730. Retrieved from- https://search.proquest.com/openview/50d9e4d45d8da9e939f8e956e3322e13/1?pq-origsite=gscholar&cbl=37547
Thiele, H., Ohman, E. M., Desch, S., Eitel, I., & de Waha, S. (2015). Management of cardiogenic shock. European heart journal, 36(20), 1223-1230. https://doi.org/10.1093/eurheartj/ehv051
Vincent, J. L., & De Backer, D. (2013). Circulatory shock. New England Journal of Medicine, 369(18), 1726-1734. DOI: 10.1056/NEJMra1208943
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