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The initial management of most patients after cardiac surgery occurs in specialized intensive care units (ICUs). The unique pathophysiologic alterations associated with hypothermia and cardiopulmonary bypass (CPB) mandate that a specialized environment, including sophisticated electrophysiologic and hemodynamic monitoring along with intensive attention and supervision by specially trained critical care nurses, be available. Although CPB is no longer universally applied in cardiac surgery, the multiple management problems posed by cardiac patients continue to demand specialized treatment.

The patient typically arrives in the ICU or postcardiac surgery recovery area from the operating room with the necessary apparatus for monitoring the following parameters: heart rate and rhythm; systemic arterial, central venous, pulmonary artery, and pulmonary artery occlusion pressures (PAOPs); cardiac output; urinary output; mediastinal drainage; body temperature; arterial oxygen saturation (SpO2); mixed venous oxygen saturation (SvO2); and end-tidal carbon dioxide (ETCO2) tension.

Most of the apparatus attached to the patient on arrival in the ICU serves multiple purposes. A pulmonary artery catheter allows monitoring of pulmonary artery pressures and can also be used to estimate the filling pressure of the left ventricle, cardiac output, and body core temperature. The pulmonary artery catheter allows for measurement of the SvO2, which is used as an indirect index of tissue oxygenation. The peripheral arterial cannula provides a continuous pulse-wave tracing of systemic blood pressure and ready access to arterial blood sampling for laboratory analysis. Regular periodic assessments of arterial blood gases, especially after a major change in ventilator settings, are essential unless continuous ETCO2 and SpO2 by pulse oximetry are being monitored. ETCO2 and SpO2 are reliable in guiding the weaning of mechanical ventilation and removal of the endotracheal tube. Monitoring of these parameters has been used very effectively in "fast-track" protocols, the notion that rapid extubation can lead to lower pulmonary complications from longer periods of mechanical ventilation. Assessment of volume loss is based on chest and mediastinal tube drainage plus urine output. The endotracheal tube secured in the correct position with an appropriately inflated cuff is essential for positive-pressure ventilation of the lungs. Confirmation of bilateral breath sounds and absence of tracheal air leak versus cuff inflation should be made upon the patient's arrival in the ICU. The endotracheal tube's position should be ascertained on the initial chest radiograph. The endotracheal tube also allows for suctioning of bronchial secretions and reduces (but does not completely eliminate) the risk of oropharyngeal and gastric reflux secretions entering the trachea and bronchi. The endotracheal tube can often be removed the evening of surgery if the patient is conscious, is able to protect the airway, has good ventilatory mechanics and muscle strength, and is able to take on the work of breathing. Most patients can have the pulmonary artery catheter removed within 12 to 24 hours if intravenous (IV) vasopressor and inotropic drug therapy is at minimum levels. The peripheral arterial cannula can be removed when cardiovascular ...

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