Information to obtain

  1. Details of repair… Ex: size of shunt, where incision was made, valve-sparing procedure, etc
  2. Complications during repair (arrhythmias, bleeding, etc)
  3. Post-operative TEE findings… Ex: gradients, residual VSD leak, valve regurg
  4. Cardiopulmonary bypass time and aorta cross clamp times…longer times tend to have more complicated post-op courses
  5. Specific post-operative parameters or goals… Ex: SBP <70 to prevent any tension on sutures or leak at anastomosis
  6. Specific lines and tubes… Ex: IJ, art lines, MTs or CTs
  7. Trends during case… Ex: what CVP did pt tolerate, BP trends, heart rate ranges
  8. Blood product administration… Ex: FFP, plts, etc
  9. Any worrisome labs… Ex: coags, lactate
  10. Airway management… Ex: easy intubation, reasons why they did not extubate
  11. Rhythm problems intra/postoperatively. Pacing yes/no

Helpful hints w/ post-op orders

  • Tina Davenport usually takes care of all orders… go assess pt!
  • For big cases on bypass, IVF are written for 1/2 maintenance b/c we try to account for
    1. Cardiac gtts
    2. Fluid boluses or blood product administration
    3. SIRS & capillary leak
    that can cause some edema
  • IVF often are D5W so pay attention to pt's Na. Will need to adjust once Na is in the normal range.
  • Hourly labs need to be drawn initially, adjust lab frequency as needed as pt stabilizes
  • Please check over orders. Make sure the morphine dose, tylenol dose, etc are appropriate.
  • Goal K > 4, iCa > 4, Mg > 2, replace as needed.

Important trends to follow

  • SVO2 — good indicator of oxygen extraction,changes in trends may indicate change in pt status>
    1. High SVO2 — inadequate extraction
    2. Low SVO2 — inadequate oxygen delivery
     
  • Cerebral & renal somenetics — also indicator of oxygen extraction
  • Lactate — <2 is normal, watch trends!
  • Hct — Many repairs require higher HCT to maintain good oxygen delivery
  • CVP — marker of volume status, important b/c some repairs require higher CVP but may also indicate concern for issues like tamponade
  • Vital Signs — Changes in HR may be a subtle sign of an arrhythmia
  • UOP and I/O balance
  • Chest, mediastinal, and peritoneal drainage

Important exam findings

  • Murmurs — any changes in quality, new murmurs
  • Edema/ wts — are they volume overloaded or dry
  • Hepatomegaly — worsening CHF?
  • Perfusion — warm, cool, clamped down
  • Drainage from tubes — chylous, increased output, bloody

The fellow and staff are there to help

Please don't hesitate to ask questions