Spezielle Aspekte der intensivmedizinischen Therapie nach herzchirurgischen Eingriffen

Kernaussagen

• Patienten nach einem kardiochirurgischen Eingriff benötigen besondere Aufmerksamkeit und eine spezielle intensivmedizinische Betreuung.

• Zum Basisüberwachung gehören im Wesentlichen EKG, SO₂, ZVD, invasive Blutdruckmessung, Diurese, Blutgasanalyse und Temperaturmessung. Eine erweiterte Überwachung umfasst die Echokardiografie, transpulmonale Thermodilution, kalibrierte Pulskonturanalyse und/oder den pulmonalarteriellen Katheter.

• Postoperative Rhythmusstörungen sind typisch. Insbesondere das Vorhofflimmern tritt häufig auf und kann durch eine einfache Prophylaxe vermindert werden.

• Die kardiale Dysfunktion wird anhand von Zielparametern diagnostiziert und therapiert. Therapeutische Optionen sind die Volumen- und Katecholamingabe und ggf. der Einsatz kardialer Unterstützungssysteme.

• Postoperativ besteht eine erhöhte Gefahr von Thrombembolien und Blutungen. Daher ist eine individuelle und risikoadaptierte Antikoagulation und Antiaggregation notwendig.

• Literatur

• 1 Lunz D, Zausig YA. Komplikationen bei intensivmedizinischen Standardinterventionen. Intensivmed up2date 2010; 6: E1-E14
• 2 Lange M, Lanckohr C. Analgosedierung und Delir in der Intensivmedizin. Intensivmed up2date 2012; 8: 213-229
• 3 Kirchberg J, Reißfelder C, Mieth M et al. Darmpassagestörungen in der Intensivtherapie. Intensivmed up2date 2012; 8: 181-194
• 4 Holmes DR Jr, Mack MJ, Kaul S et al. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement. Journal of thoracic and cardiovascular surgery 2012; 144: e29-84
• 5 Hemmerling TM, Romano G, Terrasini N et al. Anesthesia for off-pump coronary artery bypass surgery. Annals of cardiac anesthesia 2013; 16: 28-39
• 6 Hawkes CA, Dhileepan S, Foxcroft D. Early extubation for adult cardiac surgical patients. The Cochrane database of systematic reviews 2003; CD003587
• 7 Zhu F, Lee A, Chee YE. Fast-track cardiac care for adult cardiac surgical patients. The Cochrane database of systematic reviews 2012; 10 CD003587
• 8 Constantinides VA, Tekkis PP, Fazil A et al. Fast-track failure after cardiac surgery: development of a prediction model. Crit Care Med 2006; 34: 2875-2882
• 9 Bainbridge D, Cheng DC. Minimally invasive direct coronary artery bypass and off-pump coronary artery bypass surgery: anesthetic considerations. Anesthesiology clinics 2008; 26: 437-452
• 10 Carl M, Alms A, Braun J et al. S3 Leitlinie Intensivmedizinische Versorgung herzchirurgischer Patienten – Hämodynamisches Monitoring und Herz-Kreislauf-Therapie. AWMF Leitlinie. 2010
• 11 Kastrup M, Carl M, Spies C et al. Clinical impact of the publication of S3 guidelines for intensive care in cardiac surgery patients in Germany: results from a postal survey. Acta anaesthesiologica Scandinavica 2013; 57: 206-213
• 12 Seward JB, Khandheria BK, Oh JK et al. Critical appraisal of transesophageal echocardiography: limitations, pitfalls, and complications. Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 1992; 5: 288-305
• 13 Guarracino F, Baldassarri R. Transesophageal echocardiography in the OR and ICU. Minerva anestesiologica 2009; 75: 518-529
• 14 Gouveia V, Marcelino P, Reuter DA. The role of transesophageal echocardiography in the intraoperative period. Current cardiology reviews 2011; 7: 184-196
• 15 Schmidt C, Harding U, Van Aken H et al. Echokardiografie in der Intensivmedizin. Intensiv up2date 2011; 7: 197-222
• 16 De Backer D, Fagnoul D, Herpain A. The role of invasive techniques in cardiopulmonary evaluation. Current opinion in critical care 2013; 19: 228-233
• 17 Provenchere S, Plantefeve G, Hufnagel G et al. Renal dysfunction after cardiac surgery with normothermic cardiopulmonary bypass: incidence, risk factors, and effect on clinical outcome. Anesthesia and analgesia 2003; 96: 1258-1264 , table of contents
• 18 Rosner MH, Portilla D, Okusa MD. Cardiac surgery as a cause of acute kidney injury: pathogenesis and potential therapies. Journal of intensive Care Med 2008; 23: 3-18
• 19 Haase M, Haase-Fielitz A, Bellomo R et al. Sodium bicarbonate to prevent increases in serum creatinine after cardiac surgery: a pilot double-blind, randomized controlled trial. Crit Care Med 2009; 37: 39-47
• 20 Haase M, Haase-Fielitz A, Plass M et al. Prophylactic perioperative sodium bicarbonate to prevent acute kidney injury following open heart surgery: a multicenter double-blinded randomized controlled trial. PLoS medicine 2013; 10: e1001426
• 21 Martensson J, Martling CR, Bell M. Novel biomarkers of acute kidney injury and failure: clinical applicability. Br J of anesthesia 2012; 109: 843-850
• 22 Brener SJ, Lytle BW, Schneider JP et al. Association between CK-MB elevation after percutaneous or surgical revascularization and three-year mortality. J Am Coll Cardiol 2002; 40: 1961-1967
• 23 Anderson JL, Adams CD, Antman EM et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127: e663-e828
• 24 Fellahi JL, Gue X, Richomme X et al. Short- and long-term prognostic value of postoperative cardiac troponin I concentration in patients undergoing coronary artery bypass grafting. Anesthesiology 2003; 99: 270-274
• 25 Gorlinger K, Bergmann L, Dirkmann D. Coagulation management in patients undergoing mechanical circulatory support. Best practice & research Clinical anesthesiology 2012; 26: 179-198
• 26 Weber CF, Klages M, Zacharowski K. Perioperative coagulation management during cardiac surgery. Current opinion in anesthesiology 2013; 26: 60-64
• 27 Silbernagel SL. Taschenatlas Pathophysiologie. Stuttgart: Thieme; 2011
• 28 Kaplan JA, Reich DL, Konstadt SN. Kaplan’s Cardiac Anesthesia. Philadelphia: Saunders; 2011
• 29 el-Banayosy A, Doring B, Korner MM et al. New avenues in therapy of postoperative low output syndrome. Zeitschrift fur Kardiologie 1994; 83 (Suppl. 02) 69-74
• 30 Swan HJ, Ganz W, Forrester J et al. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Engl J Med 1970; 283: 447-451
• 31 Boulain T, Achard JM, Teboul JL et al. Changes in BP induced by passive leg raising predict response to fluid loading in critically ill patients. Chest 2002; 121: 1245-1252
• 32 Cavallaro F, Sandroni C, Marano C et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systematic review and meta-analysis of clinical studies. Intensive Care Med 2010; 36: 1475-1483
• 33 Rivers E, Nguyen B, Havstad S et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377
• 34 Bunn F, Trivedi D. Colloid solutions for fluid resuscitation. The Cochrane database of systematic reviews 2012; 7 CD001319
• 35 Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. The Cochrane database of systematic reviews 2013; 2 CD000567
• 36 Werner S, Geldner G, Koch T. Stellungnahme der Präsidenten der DGAI und des BDA sowie der Präsidentin der DAAF. Anästh Intensivmed 2013; 54: 332-333
• 37 Dickstein K, Cohen-Solal A, Filippatos G et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Med (ESICM). Eur Heart J 2008; 29: 2388-2442
• 38 Gillies M, Bellomo R, Doolan L et al. Bench-to-bedside review: Inotropic drug therapy after adult cardiac surgery – a systematic literature review. Critical care 2005; 9: 266-279
• 39 Harrison RW, Hasselblad V, Mehta RH et al. Effect of Levosimendan on Survival and Adverse Events After Cardiac Surgery: A Meta-analysis. Journal of cardiothoracic and vascular anesthesia 2013;
• 40 Landoni G, Biondi-Zoccai G, Greco M et al. Effects of levosimendan on mortality and hospitalization. A meta-analysis of randomized controlled studies. Crit Care Med 2012; 40: 634-646
• 41 Toller W, Algotsson L, Guarracino F et al. Perioperative use of levosimendan: best practice in operative settings. Journal of cardiothoracic and vascular anesthesia 2013; 27: 361-366
• 42 Haddad F, Hunt SA, Rosenthal DN et al. Right ventricular function in cardiovascular disease, part I: Anatomy, physiology, aging, and functional assessment of the right ventricle. Circulation 2008; 117: 1436-1448
• 43 Lahm T, McCaslin CA, Wozniak TC et al. Medical and surgical treatment of acute right ventricular failure. J Am Coll Cardiol 2010; 56: 1435-1446
• 44 Ewert R, Hummel A, Opitz CF. Diagnostik der rechtsventrikulären Funktionsstörung. Intensivmed up2date 2006; 1: 41-55
• 45 Westerkamp V, Welte T, Hoeper MM. Therapie des Rechtsherzversagens. Intensivmed up2date 2006; 2: 57-67
• 46 Lahm T. Pulmonary hypertension update from CHEST 2012. International journal of clinical practice Supplement 2013; 179: 2-4
• 47 Havel C, Arrich J, Losert H et al. Vasopressors for hypotensive shock. The Cochrane database of systematic reviews 2011; CD003709
• 48 Ferguson-Myrthil N. Vasopressor use in adult patients. Cardiology in review 2012; 20: 153-158
• 49 Graf BM, Sinner B, Zink W. Anästhesie bei alten Menschen. Stuttgart: Thieme; 2009
• 50 Ferrari AU. Modifications of the cardiovascular system with aging. The Am J of geriatric cardiology 2002; 11: 30-33
• 51 Ebert TJ, Morgan BJ, Barney JA et al. Effects of aging on baroreflex regulation of sympathetic activity in humans. Am J of physiology 1992; 263: H798-803
• 52 Shingu Y, Kubota S, Wakasa S et al. Postoperative atrial fibrillation: mechanism, prevention, and future perspective. Surgery today 2012; 42: 819-824
• 53 Chung MK. Cardiac surgery: postoperative arrhythmias. Crit Care Med 2000; 28 (Suppl. 10) N136-144
• 54 Palin CA, Kailasam R, Hogue CW Jr. Atrial fibrillation after cardiac surgery: pathophysiology and treatment. Seminars in cardiothoracic and vascular anesthesia 2004; 8: 175-183
• 55 Crystal E, Connolly SJ, Sleik K et al. Interventions on prevention of postoperative atrial fibrillation in patients undergoing heart surgery: a meta-analysis. Circulation 2002; 106: 75-80
• 56 Dunning J, Fabbri A, Kolh PH et al. Guideline for resuscitation in cardiac arrest after cardiac surgery. Eur J of cardio-thoracic surgery 2009; 36: 3-28
• 57 Arsenault KA, Yusuf AM, Crystal E et al. Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery. The Cochrane database of systematic reviews 2013; 1 CD003611
• 58 De Oliveira GS Jr, Knautz JS, Sherwani S. Systemic magnesium to reduce postoperative arrhythmias after coronary artery bypass graft surgery: a meta-analysis of randomized controlled trials. Journal of cardiothoracic and vascular anesthesia 2012; 26: 643-650
• 59 Baker WL, Cios DA, Sander SD et al. Meta-analysis to assess the quality of warfarin control in atrial fibrillation patients in the United States. Journal of managed care pharmacy JMCP 2009; 15: 244-252
• 60 Ramlawi B, Otu H, Mieno S et al. Oxidative stress and atrial fibrillation after cardiac surgery: a case-control study. The Annals of thoracic surgery 2007; 84: 1166-1172 ; discussion 1172–1163
• 61 Anderson JL, Halperin JL, Albert NM et al. Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 61: 1935-1944
• 62 Baraka AS, Taha SK, Yazbeck VK et al. Transient atrioventricular block after release of aortic cross-clamp. Anesthesia and analgesia 1995; 80: 54-57
• 63 Khorsandi M, Muhammad I, Shaikhrezai K et al. Is it worth placing ventricular pacing wires in all patients post-coronary artery bypass grafting?. Interactive cardiovascular and thoracic surgery 2012; 15: 489-493
• 64 Reade MC. Temporary epicardial pacing after cardiac surgery: a practical review: part 1: general considerations in the management of epicardial pacing. Anesthesia 2007; 62: 264-271
• 65 Matthews IG, Fazal IA, Bates MG et al. In patients undergoing aortic valve replacement, what factors predict the requirement for permanent pacemaker implantation?. Interactive cardiovascular and thoracic surgery 2011; 12: 475-479
• 66 Epstein AE, Dimarco JP, Ellenbogen KA et al. ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities. Heart rhythm: the official journal of the Heart Rhythm Society 2008; 5: e1-e62
• 67 Berg RA, Hemphill R, Abella BS et al. Part 5: adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122 (Suppl. 03) 685-705
• 68 Dhaliwal AS, Chu D, Huh J et al. Prognostic impact of intra-aortic balloon pump insertion before versus after cardiac surgical intervention in a veteran population. Am J Surg 2009; 198: 628-632
• 69 Ferguson JJ 3rd, Cohen M, Freedman RJ Jr et al. The current practice of intra-aortic balloon counterpulsation: results from the Benchmark Registry. J Am Coll Cardiol 2001; 38: 1456-1462
• 70 Litmathe J, Feindt P, Boeken U et al. Mechanical heart support using intraaortic balloon counterpulsation. A retrospective view and current perspectives. Acta cardiologica 2004; 59: 159-164
• 71 Mehlhorn U, Fattah M, Kuhn-Regnier F et al. Impact of myocardial protection during coronary bypass surgery on patient outcome. Cardiovascular surgery 2001; 9: 482-486
• 72 Borowski A, Ruhparwar A, Korb H. Mechanical circulatory support. 1: Intra-aortic balloon counterpulsation (IABP). Zentralblatt fur Chirurgie 1995; 120: 159-165
• 73 Nanas JN, Moulopoulos SD. Counterpulsation: historical background, technical improvements, hemodynamic and metabolic effects. Cardiology 1994; 84: 156-167
• 74 Thiele H, Zeymer U, Neumann FJ et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012; 367: 1287-1296
• 75 Sjauw KD, Engstrom AE, Vis MM et al. A systematic review and meta-analysis of intra-aortic balloon pump therapy in ST-elevation myocardial infarction: should we change the guidelines?. Eur Heart J 2009; 30: 459-468
• 76 Unverzagt S, Machemer MT, Solms A et al. Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock. The Cochrane database of systematic reviews 2011; CD007398
• 77 Steg PG, James SK, Atar D et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012; 33: 2569-2619
• 78 Baskett RJ, O’Connor GT, Hirsch GM et al. A multicenter comparison of intraaortic balloon pump utilization in isolated coronary artery bypass graft surgery. The Annals of thoracic surgery 2003; 76: 1988-1992 ; d1992
• 79 Miceli A, Duggan SM, Capoun R et al. A clinical score to predict the need for intraaortic balloon pump in patients undergoing coronary artery bypass grafting. The Annals of thoracic surgery 2010; 90: 522-526
• 80 Boning A, Buschbeck S, Roth P et al. IABP before cardiac surgery: clinical benefit compared to intraoperative implantation. Perfusion 2013; 28: 103-108
• 81 Dyub AM, Whitlock RP, Abouzahr LL et al. Preoperative intra-aortic balloon pump in patients undergoing coronary bypass surgery: a systematic review and meta-analysis. Journal of cardiac surgery 2008; 23: 79-86
• 82 Lauten A, Engström AE, Jung C et al. Percutaneous Left-Ventricular Support With the Impella-2.5-Assist Device in Acute Cardiogenic Shock: Results of the Impella-EUROSHOCK-Registry. Circulation: Heart Failure 2013; 6: 23-30
• 83 Thiele H, Sick P, Boudriot E et al. Randomized comparison of intra-aortic balloon support with a percutaneous left ventricular assist device in patients with revascularized acute myocardial infarction complicated by cardiogenic shock. Eur Heart J 2005; 26: 1276-1283
• 84 Sauren LDC, Accord RE, Hamzeh K et al. Combined Impella and Intra-aortic Balloon Pump Support to Improve Both Ventricular Unloading and Coronary Blood Flow for Myocardial Recovery: An Experimental Study. Artificial Organs 2007; 31: 839-842
• 85 Klotz SS. Mechanische Assist-Systeme zur Herzunterstützung. Intensivmed up2date 2008; 2: 145-164
• 86 Ganslmeier P, Philipp A, Rupprecht L et al. Percutaneous cannulation for extracorporeal life support. The Thoracic and cardiovascular surgeon 2011; 59: 103-107
• 87 Haneya A, Philipp A, Diez C et al. Successful use of temporary right ventricular support to avoid implantation of biventricular long-term assist device: a transcutaneous approach. ASAIO journal 2011; 57: 274-277
• 88 Kohler K, Valchanov K, Nias G et al. ECMO cannula review. Perfusion 2013; 28: 114-124
• 89 Sayer GT, Baker JN, Parks KA. Heart rescue: the role of mechanical circulatory support in the management of severe refractory cardiogenic shock. Current opinion in critical care 2012; 18: 409-416
• 90 Schmid C, Philipp A, Mueller T et al. Extracorporeal life support - systems, indications, and limitations. The Thoracic and cardiovascular surgeon 2009; 57: 449-454
• 91 Bisdas T, Beutel G, Warnecke G et al. Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support. The Annals of thoracic surgery 2011; 92: 626-631
• 92 Haneya A, Philipp A, Diez C et al. A 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrest. Resuscitation 2012; 83: 1331-1337
• 93 Encke A, Sauerland S, Beckmann MW et al. AWMF-S3-Leitlinie Prophylaxe der venösen Thromboembolie (VTE). 2009
• 94 Bonow RO, Carabello BA, Chatterjee K et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. Circulation 2008; 118: e523-e661
• 95 Hermans H, Vanassche T, Herijgers P et al. Antithrombotic therapy in patients with heart valve prostheses. Cardiology in review 2013; 21: 27-36
• 96 Edmunds LH Jr. Thrombotic and bleeding complications of prosthetic heart valves. The Annals of thoracic surgery 1987; 44: 430-445
• 97 Heras M, Chesebro JH, Fuster V et al. High risk of thromboemboli early after bioprosthetic cardiac valve replacement. J Am Coll Cardiol 1995; 25: 1111-1119
• 98 Cannegieter SC, Rosendaal FR, Briet E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation 1994; 89: 635-641
• 99 Selleng KG. Heparininduzierte Thrombozytopenie in der Intensivmedizin. Intensiv up2date 2005; 1: 329-340
• 100 Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia and cardiac surgery. The Annals of thoracic surgery 2003; 76: 2121-2131
• 101 Ickx BE, Faraoni D. Management of the clotting system: a European perspective. Current opinion in anesthesiology 2012; 25: 80-85
• 102 Ferraris VA, Ferraris SP, Saha SP et al. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. The Annals of thoracic surgery 2007; 83 : 27-86
• 103 Vivacqua A, Koch CG, Yousuf AM et al. Morbidity of bleeding after cardiac surgery: is it blood transfusion, reoperation for bleeding, or both?. The Annals of thoracic surgery 2011; 91: 1780-1790
• 104 Meybohm P, Zacharowski K, Weber CF. Point-of-care coagulation management in intensive care med. Critical care 2013; 17: 218
• 105 Calatzis A, Heesen M, Spannagl M. Point-of-care testing of hemostatic alterations in anesthesia and intensive care. Der Anaesthesist 2003; 52: 229-237
• 106 Ganter MT, Hofer CK. Coagulation monitoring: current techniques and clinical use of viscoelastic point-of-care coagulation devices. Anesthesia and analgesia 2008; 106: 1366-1375
• 107 Avidan MS, Alcock EL, Da Fonseca J et al. Comparison of structured use of routine laboratory tests or near-patient assessment with clinical judgement in the management of bleeding after cardiac surgery. Br J of anesthesia 2004; 92: 178-186
• 108 Weber CF, Gorlinger K, Meininger D et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 2012; 117: 531-547