Guidelines for MANAGEMENT OF LEFT HEART FAILURE in Cardiac Surgery PATIENTS

Posted by e-Medical PPT Thursday, December 26, 2013
Indicators of cardiocirculatory failure:
Cardiac index < 2.0 L/min/m2
SvO2 < 60%
Mean arterial pressure < 60 mmHg
Urine output < 0.5 ml/h, existing for longer than an hour
Plasma lactate > 2.0 mmol/L
Peripheral vasoconstriction with delayed capillary refill and cool extremities

When LAP/PAD/CVP decrease :

Evaluate response to an increase in preload.
Autotransfusion by means of passive leg raising.
Administration of colloid or crystalloid solution
    (maximum of 10 ml/kg body weight).

If a preload increase does not lead to hemodynamic
    stabilization, an echocardiogram is indicated.

In unstable patients, a 12-lead ECG to rule out acute
    ischemia, and lactate level should be obtained.

Goal directed therapy:
Increase preload
Optimize heart rate & rhythm (avoid tachycardia & arrhythmias)
Vasodilating agents (NTG, nicardipine, nesiritide)
Inotropic agents (milrinone or dobutamine)
Mixed vasoactive agents (epinephrine, norepinephrine)
Drug combinations (inotropic + vasopressor agents)

Treatment of LV diastolic dysfunction:

Optimize preload (LAP 14-18 mmHg)
Avoid tachycardia
Optimize heart rate (80/min) & increase AV delay (180 ms)
Aggressive treatment of atrial fib & tachyarrhythmias
Milrinone (0.5 mcg/kg/min) ± Vasopressin (0.04 units/min)
    or phenylephrine (1-2 mcg/kg/min)  [avoid tachycardia]
Levosimendan (if MAP > 60 mmHg)
IABP
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