Keywords

FormalPara Main Messages
  1. 1.

    All variables that affect patient clinical outcomes must be considered when providing care

  2. 2.

    Modern cardiac units consist of patient care teams that are complex, interdisciplinary and rely on the expertise of every medical specialty

  3. 3.

    Integrating the expertise of surgeons, cardiologists, anesthesiologists, intensivists, radiologists, neurologists, nephrologists, technicians, nurses, and consultants from all medical sub-specialties, surgical complications can be promptly identified and managed, reducing morbidity and mortality

Improving Patient Care

The management of cardiovascular diseases continues to evolve and cardiac surgery as a therapeutic option continues to change. However, a new treatment must be better than the natural history of the disease, and better than the alternative treatments available. Clinical improvement is not always simple and many clinical investigators continue to search for the correct answer. During my surgical residency, my mentors impressed upon me the importance of recognizing the potential impact my clinical decisions would have for my patients; not only perioperatively, but during their lifetime.

I had learned a basic computer language during my training and when I started independent practice I developed an elementary program to enter pertinent clinical, hemodynamic and imaging data on each of my surgical patients, and monitored their evolution by periodically collecting information related to their health status. That database also served for quality assurance improvement, which was aimed at perfection. However, since perfection cannot be attained, we settled for excellence. This process of constant improvement in clinical outcomes continues today in our unit and I believe that it is essential in every cardiac surgical unit. Thus, a comprehensive database containing all variables that affect clinical outcomes and patient satisfaction is indispensable and periodical reviews and analyses are necessary to measure and improve quality.

Multi-disciplinary Cardiac Units

Cardiac surgical patient care has become increasingly more complex and dependent on a dedicated team as opposed to one individual. The days of a single discipline approach in surgical treatment has been replaced by a multitude of committed experts in the modern cardiac unit. Surgeons, cardiologists, anesthesiologists, intensivists, dedicated nurses and technicians as well as a cadre of teams of radiologists and intervention radiologists, neurologists, nephrologists, and consultants from every sub-specialty in medicine are now part of this complex medical enterprise.

There is no substitute for an operation perfectly and expeditiously performed but when complications occur, prompt corrective management reduces mortality and morbidity. An electrocardiogram that suggests myocardial ischemia soon after discontinuation of cardiopulmonary bypass must be taken very seriously unless an intraoperative echocardiogram shows no new wall motion abnormality. If there is new wall motion abnormality, the mechanism for segmental ischemia must be readily determined and corrected. The same applies for a postoperative new electrocardiographic abnormality which should prompt at least an echocardiogram and possibly immediate coronary angiogram. This aggressive and effective management has been facilitated by the creation of teams of cardiac interventionalists that treat acute myocardial infarction and are continuously available to manage patients with acute cardiac syndromes. The availability and the appropriate use of intra-aortic balloon pump, ECMO and ventricular assist devices may further reduce mortality, but the root cause of acute cardiac dysfunction should be determined and corrected whenever possible. ECMO is also useful for acute pulmonary failure that cannot be managed by conventional methods of assisted ventilation.

Acute stroke teams now can intervene and reduce the devastating effects of cerebral thromboembolism and arterial thrombosis. Here, time is crucial and “fast-track anesthesia” has improved the timing to assess neurologic outcomes in cardiac surgery. The benefit of neurovascular interventions is reduced when the stroke occurred more than 3 h duration.

The main reason cardiac surgical patients are nursed in an intensive care unit during the first hours or days after surgery is to closely monitor vital signs, electrocardiogram, mediastinum bleeding and have periodical assessment of all organs: heart, lungs, brain, kidneys, liver and gastrointestinal, and musculoskeletal systems. Nurses are often the first ones to detect changes and their experience is invaluable. An intensivist must be physically present in the intensive care unit and start immediate management of any complication.

Aiming for perfection we will attain excellence. This manual was written to assist you in providing care to cardiac surgical patients in the operating room, interventional suite, intensive care unit, and ward in the modern era.