Perioperative Considerations in Cardiac Surgery Edited by Cuneyt Narin PERIOPERATIVE CONSIDERATIONS IN CARDIAC SURGERY Edited by Cuneyt Narin INTECHOPEN.COM Perioperative Considerations in Cardiac Surgery http://dx.doi.org/10.5772/1455 Edited by Cuneyt Narin Contributors Zacek, Jan Harrer, Alessandro Taddei, Yavuz Bilgin, Andrea Székely, Tamás Breuer, Béla Merkely, Maria Carmona, Luiz Malbouisson, Matheus Fachini Vane, Luminita Iliuta, Roxana Enache, Meral - Kanbak, Filiz Uzumcugil, Theofani Antoniou, Mohammad Hamid, Susanne Picker, Gideon Paret, Vered Molina Hazan, Robert Wagner, Andrew Westbrook, Philip Johnson, Martin Martínez, Eduardo Wilfrido Goicoechea Turcott, Pastor Luna Ortiz, Benito Anton Palma, Alberto Salazar, Leal, Sara Ferrando-Martinez, Mª Angeles Muñoz-Fernández, John Heijmans, Ranasinghe, Robert Bonser, Anne Q.N. Nguyen, André Y. Denault, Alain Deschamps, France Varin, Louis P. Perrault, Thomas Kenny, Martin Ashton-Key, Wasowicz © The Editor(s) and the Author(s) 2012 The moral rights of the and the author(s) have been asserted. All rights to the book as a whole are reserved by INTECH. The book as a whole (compilation) cannot be reproduced, distributed or used for commercial or non-commercial purposes without INTECH’s written permission. Enquiries concerning the use of the book should be directed to INTECH rights and permissions department (permissions@intechopen.com). Violations are liable to prosecution under the governing Copyright Law. Individual chapters of this publication are distributed under the terms of the Creative Commons Attribution 3.0 Unported License which permits commercial use, distribution and reproduction of the individual chapters, provided the original author(s) and source publication are appropriately acknowledged. If so indicated, certain images may not be included under the Creative Commons license. 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Printed in Croatia Legal deposit, Croatia: National and University Library in Zagreb Additional hard and PDF copies can be obtained from orders@intechopen.com Perioperative Considerations in Cardiac Surgery Edited by Cuneyt Narin p. cm. ISBN 978-953-51-0147-5 eBook (PDF) ISBN 978-953-51-6847-8 Selection of our books indexed in the Book Citation Index in Web of Science™ Core Collection (BKCI) Interested in publishing with us? Contact book.department@intechopen.com Numbers displayed above are based on latest data collected. For more information visit www.intechopen.com 3,250+ Open access books available 151 Countries delivered to 12.2% Contributors from top 500 universities Our authors are among the Top 1% most cited scientists 106,000+ International authors and editors 112M+ Downloads We are IntechOpen, the first native scientific publisher of Open Access books Meet the editor Dr. Cuneyt Narin is currently Associate Professor and director of Cardiovascular Surgery Department at Uni- versal Ege Saglik Hospital in Izmir, Turkey. He grad- uated from Uludag University Medical School, Bursa, Turkey in 1994. He completed his surgical training in the field of cardiovascular surgery at Dokuz Eylul Universi- ty Medical School, Izmir, Turkey in 2000. After becoming a Consultant Cardiovascular Surgeon, he gained his surgical skills at Uni- versal Ege Saglik Hospital in Izmir until 2004. He continued his surgical career in an academic position at Selcuk University Meram Medical School in Konya, Turkey between 2004 and 2011. He worked as a Research Fellow and Surgical Assistant at Texas Heart Institute at St. Luke’s Hospital, Cardiovascular Surgical Research Laboratory and Department of Trans- plantation and Mechanical Circulatory Support, Houston, Texas between 2008 and 2009. He has been working in his current position since August 2011. He has 140 scientific publications including book chapters. His major interests are minimal invasive cardiac surgery, pediatric cardiac surgery and experimental researches. Contents Preface X I Chapter 1 Data Integration and Management in Cardiac Surgery 1 Alessandro Taddei, Maurizio Mangione, Paolo Marcheschi and Stefano Dalmiani Chapter 2 Anesthesia in Cardiac Surgery 15 Meral Kanbak and Filiz Üzümcügil Chapter 3 Anaesthetic Considerations for Congenital Heart Disease Patient 57 Mohammad Hamid Chapter 4 Monitoring Outcomes in Highly Specialised Cardiac Surgery 75 Thomas Kenny and Martin Ashton-Key Chapter 5 Perioperative Organ Protection in Cardiac Surgery 91 Maria Carmona, Matheus Vane and Luiz Malbouisson Chapter 6 Perioperative Management of Pulmonary Hypertension 109 Theofani Antoniou and Kassiani Theodoraki Chapter 7 Early Postoperative Care After Cardiac Surgery 125 Paul M. H. J. Roekaerts and John H. Heijmans Chapter 8 Cardiac Surgery and Allogeneic Blood Transfusions 147 Yavuz M. Bilgin Chapter 9 Hemotherapy in Cardiac Surgery 167 Robert Wagner X Contents Chapter 10 Coagulation Measurement and Optimisation in Cardiac Surgery 179 Philip Johnson and Andrew Westbrook Chapter 11 Heparin Induced Thrombocytopenia: Its Significance in Cardiac Surgical Patient 211 Marcin Wąsowicz Chapter 12 Antiplatelet Drugs in Coronary Artery Disease 221 Susanne Maria Picker Chapter 13 Glycemic Control in Cardiac Surgery 247 Martín Martínez Rosas, Eduardo Wilfrido Goicoechea-Turcott, Pastor Luna Ortiz, Alberto Salazar and Benito Antón Palma Chapter 14 Thyroid Hormone Therapy for the Cardiac Surgical Patient 265 Aaron M. Ranasinghe and Robert S. Bonser Chapter 15 A Pathophysiological Approach to Understanding Pulmonary Hypertension in Cardiac Surgery 277 Anne Q. N. Nguyen, Alain Deschamps, France Varin, Louis P. Perrault and André Y. Denault Chapter 16 The Physiology and the Clinical Significance of Postoperative Hyperlactatemia After Pediatric Cardiac Surgery 307 Vered Molina-Hazan and Gideon Paret Chapter 17 Relationship Between Natriuretic Peptides and Hemodynamic Parameters Following Heart Surgery in Infancy 325 Andrea Székely, Tamás Breuer and Béla Merkely Chapter 18 Sticking Up for the Immune System Integrity: Should the Thymus Be Preserved During Cardiac Surgery? 339 Sara Ferrando-Martínez, M. Ángeles Muñoz-Fernández and Manuel Leal Chapter 19 Ivabradine Versus Beta-Blockers in Patients with Conduction Abnormalities or Left Ventricular Dysfunction Undergoing Coronary Artery Bypass Grafting 355 Luminita Iliuta and Roxana Enache Chapter 20 Amyloidosis and Cardiac Surgery 369 Pavel Zacek and Jan Harrer Preface The perioperative period is vitally important in outcomes of patients undergoing cardiac surgery. The proper evaluation of preoperative period, as well as improvement in standards of perioperative care of these patients have been helping to reduce mortality and morbidity rates following the cardiac surgery. Accordingly, the content of present textbook mainly covers various topics related to perioperative period in cardiac surgery. In order to organize the content, two books have been created. The first book focuses on topics both in preoperative and early postoperative periods of cardiac surgery. The book covers not only classical chapters such as anesthesia for pediatric heart surgery and management of pulmonary hypertension in intensive care unit, but also currently “hot” topics consisting of strategies of blood conversation and heparin induced thrombocytopenia. The second book covers miscellaneous issues such as fungal endocarditis after cardiac surgery, off pump versus on pump coronary artery bypass surgery and arrhythmia after cardiac surgery. This book should prove to be a useful reference for trainees, senior surgeons and nurses in cardiac surgery, as well as anesthesiologists, perfusionists, and all the related health care workers who are involved in taking care of patients with heart disease which require surgical therapy. This book aims to improve the knowledge and understanding of readers with regard to the background of perioperative period in cardiac surgery. I hope these internationally cumulative and diligent efforts will provide patients undergoing cardiac surgery with meticulous perioperative care methods. Numerous international authors have participated in the creation of this book. I have compiled their valuable experiences and contributions about critical issues in the field of cardiac surgery. I greatly acknowledge the precious assistance of Ms. Molly Kaliman of InTech Publisher. I also would like to thank Ilker Kiris, MD, for his productive ideas in the course of preparing this book. X Preface Finally, upcoming decades should see even greater advances in the field of care of patients undergoing cardiac surgery. I assure that improvements in technologies and surgical skills will help to accomplish this goal. To my wife, Gokce and to our children, Kaya and Kayra. Assoc. Prof. Cuneyt Narin, MD Department of Cardiovascular Surgery, Selcuk University Meram Medical School, Konya, Turkey 1 Data Integration and Management in Cardiac Surgery Alessandro Taddei 1,2 , Maurizio Mangione 1 , Paolo Marcheschi 1 and Stefano Dalmiani 1 1Medical Informatics, Gabriele Monasterio CNR / Tuscany Region Foundation, 2 CNR Institute of Clinical Physiology, G. Pasquinucci Heart Hospital, Massa Italy 1. Introduction Today information and communication technology is widely applied in health care. A variety of Information Systems for management of both administrative, government and clinical tasks have been developed and largely implemented in hospitals. Cardiac surgery setting is peculiar in terms of complexity of health-care information management, involving in addition to general tasks related to hospital patient care (ADT, DRG billing, cost evaluation, multimodality diagnostic examinations, laboratory tests, ward and nursing care, anesthesia and surgical interventions, follow-up) specific procedures for cardiac function evaluation and care (cath-lab, radiology), heart surgery (from minimal invasive to open heart operations with assisted circulation), intensive care unit monitoring. Given the huge amount of different heterogeneous sources of patient data, both administrative and clinical, integration is crucial to allow comprehensive medical decision making, effective care planning and proper resource control. Actually few systems achieve this objective even if interoperability in health care has been promoted by many international initiatives (HL7, ANSI, CEN, DICOM). Aim of this paper is to report our experience in developing an integration system to manage health care in its technological, administrative and clinical aspects, in respect of high quality care and cost-effectiveness evaluation. Almost 15 years ago the Hospital Information System (HIS) was first developed at National Research Council (CNR), Institute of Clinical Physiology (IFC), in Pisa by the SPERIGEST project (supported by Italian National Health Ministry, 1995-98) (Macerata, 1995) for the integration of resources in Cardiology. Later, extension of HIS at G.Pasquinucci Heart Hospital (GPH), IFC-CNR’s section in Massa, 60 kilometers from Pisa, specialized in Cardiology and Cardiac Surgery (both adult and pediatric), required both adaptation and development. In 2007 IFC-CNR health-care activities converged into the “G.Monasterio Foundation” (FGM) by the joint effort of CNR, Tuscany Region and Universities. A networked computer-based information systems was implemented, based on three levels of data archiving (administration, clinical system and functional units, i.e. diagnostic laboratories, care units, Operating Rooms) and on two modalities for data exchange Perioperative Considerations in Cardiac Surgery 2 Fig. 1. Gabriele Monasterio CNR / Tuscany Region Foundation, Pisa and Massa, Italy (middleware data integration into the central clinical database ARCA and Web distribution of health care information over the HIS network). PACS was set up using Open Source DICOM utilities. The computer-network infrastructure, interconnecting GPH with the head institution in Pisa, allows achieving full access to patient information from any workstation. Secure Web technology was applied for distribution of health care information within hospital Intranet and also outside by Extranet. The project of the information system was aimed at collecting, archiving and integrating all data related to patient care, from the visit in ambulatory to hospital admission, diagnostic procedures, cardiac surgery intervention and finally discharge and follow-up. The different Fig. 2. The clinical information system: patient data flows sources of patient information were integrated by middleware into the central hospital database (ARCA) which represents the clinical repository. Network connection between GPH and IFC is currently fast enough (8 Mb/s and recently up to 200 Mb/s) to guarantee Data Integration and Management in Cardiac Surgery 3 effective access to patient data, archived in the ARCA repository located in Pisa (SQL IBM DB2/2, recently migrated into Oracle DB). 2. Electronic medical record Transition from conventional paper-based towards electronic medical record (EMR) required, first, to set up regular and comprehensive patient information flow from health care units into ARCA repository (Taddei et al., 2003). Each diagnostic or care unit (ECG, echocardiography, cath lab, chemical lab, nursing system) as well as the Operating Room Theatre and the Intensive Care Unit were provided with computer-based systems for recording patient data and transferring reports into EMR. Structured data entry was generally implemented in addition to free text. Standard ICD9-CM codes of diagnoses and Fig. 3. The main GUI of the Electronic Medical Record Fig. 4. Accessing the medical record in the ward by Wi-Fi connected laptop procedures were applied for filling in DRG forms. EMR user interface was set up extending the model already used in Cardiology departments of IFC-CNR in Pisa (Carpeggiani et al., Perioperative Considerations in Cardiac Surgery 4 2000). Use of Java language allowed to deploy EMR on any platforms (MS-Windows, Mac, Linux). Safe wireless networks were installed in the wards of both adult and pediatric cardiac departments to allow use of mobile EMR workstations at patient bed. 3. Operating room theatre Development of HIS at GPH started with the set up of the Anesthesia Information Management system (Taddei et al., 2000) for documentation of anesthesia procedure during cardiac surgery operations. Commercial software (OTIS by Dedalus Inc.) for anesthesia data entry with on-line acquisition from OR equipment was adapted and integrated with HIS. Three phases were distinguished: preoperative patient identification and characterization, importing data from ARCA repository; intra-operative data entry (drugs, events, notes) and automatic data capture from OR equipment; post-operative ICU ordering, anesthesia record printing and data exporting to ARCA repository. Material data entry system was developed for resource management during operations. For each anesthesia record a surgery record was created automatically (by trigger on intervention start) in order to facilitate reporting by operators and to achieve OR register. Fig. 5. Anesthesia Information System integrated with Hospital Information System Recently a new Anesthesia Information Management System has been developed at the Heart Hospital in Massa (Cossu et al., 2011). It was specialized for recording anesthesia- related perioperative patient data during cardiac surgery on either adult or pediatric patients. The system was aimed at integrating patient data (clinical, instrumental and administrative) partly filled in by operator (anesthetist or anesthesia technician) through the Graphical User Interface, partly SQL-retrieved from Hospital Information System (Oracle), repository of patient electronic medical records, and partly gathered, by HL7, from Operating Room instrumentation (monitors, anesthetic machine and blood gas analyzer). Software was created in Java, achieving reliability and cross-platform capability. First, it was crucial to define requirements by interaction with anesthetists and later by cycles of test, revising and correction. GUI, designed to better ergonomics, was divided into modules, each for a corresponding task or phase of anesthesia. Specific forms are provided for documentation of induction phase, for recording staff, drug administrations (bolus or drip), Data Integration and Management in Cardiac Surgery 5 Fig. 6a. The main GUI of the new Anesthesia Information System: the diary (middle), the event counters (right), the tags for access to data views (top), the diary filters (bottom) Fig. 6b. Data entry and printing Perioperative Considerations in Cardiac Surgery 6 Fig. 7. Recording bolo/drip drug administrations and computing dosages and quantities Fig. 8. Printout of anesthesia record