CT ICU checklist

NSTEMI, off-pump CABG.

Rounds with CT surgery around 6-6:15 AM. Things to monitor:

  • Pacemaker settings – if being paced, turn down HR to 50 to see what underlying rhythm is. If rhythm NSR, HR is appropriate, and BP tolerating, then leave patient on backup (usually VVI 60 or lower than patient’s intrinsic rate).     - If HR appropriate (>60s-70s), start beta blockers, typically metoprolol tartrate.

  • Chest tube output – if <100 in 8 hours, consider placing to bulb, removing, etc.

  • Chest x-ray and I/Os – assess for volume overload; if BP tolerating, if renal function okay, start diuresis as soon as possible after surgery.

  • Post-op medications – from the picture I sent previously (also taped to many of the walking workstations in the unit), i.e. POD 0 aspirin; POD 1 statin, beta blocker; POD 2 heparin, Plavix if indicated.         - Indications for Plavix: NSTEMI, off-pump CABG.         - Remember: on-pump CABG leads to bleeding problems, off-pump CABG leads to clotting problems.         - Indications for beta blocker: CAD (goal-directed medical therapy) OR biomechanical or mechanical AV replacement or MV replacement (prevention of atrial fibrillation).         - Contraindications for beta blocker: superior septal approach for mitral valve surgery (risk of damage to heart’s conduction system, i.e. risk of AV node block).

  • When patient is ready for bedboard:         - Not requiring drips (pressors, inotropes, clevidipine, etc.); not requiring BiPAP or OptiFlow; stable enough to “go to a closet and not be checked on for 4 hours”.

Pre-round from 6:30-ish to 8:30-ish.

  • If you are working without an APP present, be sure to sign out to the multidisciplinary floor team/APP (conference room behind nursing station on 5 Reynolds) at 8:15 AM.
  • Wednesday 8 – 9 AM: CT grand rounds. Rounds typically start after this.

Rounds: depending on attending, you will be leading! This is proper medical rounds, system-based, multi-disciplinary.

Afternoon: new admissions.

  • Go to bedside as soon as patient comes up – the anesthesia/surgery team gives hand-off at bedside. Key pieces of information to note down:     - Past medical history     - Chief problem and surgery performed (with qualifiers such as superior septal approach, presentation with NSTEMI, etc. which change post-op management)     - Drains (ex: pleural, pericardial)     - Airway (easy mask? Grade view? MAC or Miller or Glidescope?)     - Cardiopulmonary bypass time, aortic cross-clamp time     - Pre-op echo results, post-op echo results (especially LV and RV function)     - Products given, specifically cell saver, crytalloid/albumin, blood products, etc.     - Cardiac index and SvO2 at end of case     - Drips that the patient was started on (especially inotropes and pressors)     - Basically, pull up a note template, it will tell you all the info you need to track from hand-off.

  • Track chest tube output for first couple of hours.

  • When to call surgeons back (i.e. when to be worried about excess bleeding and need to re-open in OR):

    • 100 cc in 20 minutes

    • 150 cc in 30 minutes

    • 300 cc in 1 hour

  • Reversal of paralytics: generally recommended for most patients, even if paralytic was given a long time ago, just to be careful.

  • Neostigmine (reversal): 0.07 mg/kg or 5 mg total (whichever is lower).

Glycopyrrolate (to cholinergic effects of neostigmine, especially bradycardia): 0.02 mg per every mg of neostigmine.

Basically, if a patient is 70 kg or over, give 1 mg (5 cc) of glycopyrrolate followed by 5 mg (5 cc) of neostigmine followed by a flush. The cc to cc count of glyco and neo are the same (i.e. if you give 3 cc of neo, you give 3 cc of glyco).

  • After reversal, tell nursing staff to start weaning sedation.

Check back within ~20 min, make sure patient is responding to commands appropriately, SBT (short, 15-min SBT is appropriate if soon after surgery; do longer 1-hour if intubated for a long time), extubate.