An Exploration of Issues Associated with Pericardial Dysfunction in Postoperative Cardiac Surgery Patients Glenda Pack, RN, NP, MN, CCCN(C), CCN(C) Dynamics 2013 Nurse Practitioner, CV Surgery September 23/13 Eastern Health, St. John’s, Newfoundland Review the anatomy and pathophysiology associated with conditions involving the pericardium Explore the trajectory of pericardial dysfunction Assist the nurse to hone assessment skills to detect pericardial dysfunction Review historical and current treatment methodologies Approach to Excising Approach to Closing Open Improved hemodynamics in the early phase Decreased incidence of graft failure ? Reduced incidence of cardiac tamponade Closed Protective from sternal adhesions in redo-operations Might not have control over how the pericardium is handled, but knowing how it was handled is important for patient management Pericardial Effusion Excess accumulation of fluid in the pericardium May or may not be clinically significant Pericarditis Inflammation of the Cardiac Tamponade pericardium Pericardial Effusion that causes significant compression of the heart Acute Latent PPtost-PPiericardi ditotomy Synd rome 70 yo male POD #1 CABG x3 Chest tubes removed 3 hours ago Complaining of vague chest discomfort Unable to take a deep breath Pericardial friction rub LSB POD #! Inflammation of the pericardium CV patient Idiopathic Direct and/or indirect trauma Benign and self limiting Diagnosis Treatment ECG Relieve Symptoms Symptoms Analgesics Friction rub NSAIDs Corticosteriods Colchicine Symptomatic treatment Monitor for development of pericardial effusions Monitor for development of Post- Pericardiotomyyy Syndrome Prior to transfer from CVICU was started on Ibuprofen 400mg tid x 24 hours POD # 2 creatine had increased from 90 to 140 Ibuprofen D/C EKG POD#3: POD #3 Incidence as high as 85% in post-operative CV patients Insult to pericardium Manifestations dependant on the rate of fluid accumulation Many undetected /Transient / Benign Maximum size POD #10 – regress after 30% are quantified are “large” ~ 1% of larggppe effusions develop tamponade Diagnosis Treatment ECG None CXR NSAIDs TTE* Corticosteriods TEE Colchicine CT Pericardiocentesis MRI Oppgen Surgical Draina ge Supportive (usually self limiting) Monitoring for signs of decreasing cardiac output malaise, orthopnea, fatigue, dyspnea, unexplained tachycardia, hypotension, Hemodynamically pulses paradoxus, jugular venous Significant? distension, distant heart sounds, ascites, peripheral edema, progressive azotemia, gradual equalization of R atrial, PAD and wedge pressures, mediastinal widening on CXR Worsening Effusion Possibly prepare for pericardiocentesis Monitoring for decompensation post pericardiocentesis Possibly prepare for re-sternotomy Mr. S 70 year old male elective admission for Bentall Procedure Normal coronary arteries GdGrade 2 LVF on cath Bicuspid AV 3+ AI Dilated aortic root and ascending aorta Chronic Atrial Fib – On coumadin, stopped x 7/7 bridged with Lovenox ppgytt slightly elevated / remained of coa gs OK HT N Exsmoker (x 20yrs) Single presyncopal episode 8 yrs ago Experiencing increasing dyspnea OR • Bentall procedure with #27 Carbomedics Mechanical Prosthesis / #30 Valsava graft • Pericardium was closed with 2.0 silk • Total operating time 4.25 hours • Transported to CVICU in critical condition POST-OP • Uncomplicated • Trans ferre d to Car diac Spec ia l Care unit POD #1 A pericardial effusion that causes significant compression of the heart Rare, but life- Rare, but life-threatening threatening SCHIAVONE W A Cleveland Clinic Journal of Medicine 2013;80:109-116 Within 5-7 dayyps post cardiac surg er y 0.1% - 6% As a resul t of post-oper ati ve bleed in g Limited expansion of the pericardium Low pressure tamponade / regional tamponade because of loculated effusions & localized pericardial adhesions Fluid accumulation (and therefore pressure) in the pericar dium compresses the myocardildial tissue and bldblood is not able to propel forward Cardiogenic shock Know who is at risk Bleeding Pre-oppg(g) risk of bleeding (medications, bleeding hx) Hemodilution (excessive I/V fluids, prolonged pump run) HhiHypothermia Serum lab values (platelets, hgb, azotemia) Heparin rebound Post epicardial pacing wire removal Greater than 7 dayyggys following surgery –up to 1 year (30-45 days) Higher mortality rate than Early Tamponade Almost exclusively patients who have had valve surgery IdIncreased iiidncidence excessive INR values As a result of Fluid (blood /exudate) Air (pneumopericardium) Lyyp(mph (chyyplopericardium) Later that day..... (POD#1) When ambulating pre-syncopal, hypotensive eppgisode.... Recovered.....vital signs and labs stable . Over the next few days Mr. S was slow to ambulate, vital signs were stable, developed increasing peripheral edema, rhythm atrial fib wit h v. rate 100-110/ min POD#6 – still not right.. Stable.. Echo • Normal functioning Bentall with Aortic Valve functioning • LVH • Dildlated LV wit hbdlh borderline impairment o f systo lic function • Small to moderate ppjyericardial effusion with the majority of fluid located posteriorly without hemodynamic effect POD #8 – decreasing B/P , Temp increased, WBC increase to 17, lower sternum unstbltable, stlternal drainage, CXR- bilateral pleural effusions Monitoring Vital signs (HR, B/P) EKG changg(es (tachy / low voltagg)e) Mental status Leftward deviation of PA catheter on CXR Chest tube losses Sudden large volume – bleeding Sudden slowing – clotting Classic Signs Monitoring ? Pulses Paradox Decreased systolic upstoke on arterial pressure monitor SBP drop greater than 10mmHg between expiration and inspiration ElitiEqualization of the R artilterial pressure and PCWP Pulses Paradoxus Suppressed: •LV dysfunction •Regional tamponade •PPV •COPD with cor pulmonal e •Severe AI •Intracardiac shunt Quiet heart sounds Beck’s triad High JVP Low arterial pressure Distended neck veins Dx – Cardiac Tamponade - Late … ? Early too and mechanical sternal dehiscence Returned to OR for medistinal Re-exploration with the evacuation of a large pericardial effusion – relief of tamponade, drainage of bilateral pleural effusions, and sternal rewiring. Mr. S was discharged 12days later Intra op cultures were negative Follow up echo Valve fn N/ no pericardial effusion noted / CXR N EARLY Re-sternotomy to determine and alleviate the source of bleeding Support hemodynamics Correct coagulopathies Correct hypothermia Decrease metabolic demands LATE Periocardiocentesis (when possible) Re-sternotomy unable to tolerate echo failure of percutaneous drainage presence of intrapericardial hematoma Mr. B. 62 yo male with bicuspid aortic valve with critical aortic stenosis Elective admission for AVR Aortic Valve Replacement with #27 St. Jude Mechanical Prosthesis Uncomplicated post-operative course Discharge home on POD#5 On coumadin with therapeutic INR 2.5 Common complication of cardiac surgery Occurs a few days–weeks (even months) after cardiac surggyery Incidence 10-40% Prolonging and disabling Immune-mediated inflammatory process Mild(isolated pleural/pericardial involvement) to severe (hemodynamic consequences) Presentation Post cardiac surgery Pericarditis Pericardial rub Fever Leukocytosis Increased sed rate Pulmonary infiltrates +/- pleural effusion 2 weeks followinggg() discharge (POD#19) Mr. B presented to his community hospital with increasing shortness of breath, low grade fever and sign ifican t L pleura l effus ion Transferred to tertiary hospital: CXR – Large L pleural effusion TTE – Mod sized pericardial effusion without comprise - N functioning mechanical aortic valve prosthesis No vegetation INR erratic control noted by his family physician L chest tube – drained 2 liters sero-sang drainage Placed on prednisone Discharged home 3 days after CT discontinued Diagnosis Fever without alternative causes Pleuritic chest pain Friction rub Evidence of pleural effusion Evidence of a new or worsening pericardial effusion Imazio et al. propose the presence of at least 2 of these criteria for diagnosis of PPS International Journal of Cardiology 159(2012) 1-4 Management Diagnostics Treatment Echo Anti-inflammatory agents Corticosteriods CT Thoracentesis Prevention – Colchicine shown to be safe and effective Decreased occurrence of chest pppain and pleural effusions (COPPS &COPPS2 trials) 3 weeks later Mr. B ppyresented to his community hospital with increasing dyspnea Increased JVP Increased WBC Transferred to tertiary facility again - CCU CXR - Mod L pleural effusion Echo - Large pericardial effusion CT – drained L pleural effusion PiPeriocar diocentes is – large effiffusion diddrained Discharggpe home on prednisone –no further readmissions CV patients do not follow classic pictures of disease symptomatology There can be a significant delay in post- oppperative complications Manyyg signs of pericardial d ysfunction are masked by post-operative pain and “expected” recovery symptoms (fatigue / dyspnea) Low threshold for performing an echo in CV patient with atypical symptoms Pericardial dysfunction is often benign and transient, but an index of suspicion needs to be maintained when patients are not progressing just as expected ? Role of colchcine .