الفهرس 
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Abstract
Postoperative morbidity after cardiothoracic surgery is
common, and many of the complications are caused by the
exaggerated systemic proinflammatory response to
cardiopulmonary bypass (CPB). Intensive care has become a
standard component of postoperative treatment for most cardiothoracic
patients. The post-operative care extends beyond the
immediate post-extubation period to ensure adequate
monitoring for potential complications.
A low cardiac output state results from decreased left
ventricular preload, decreased contractility, arrhythmias,
increased afterload or diastolic dysfunction. Right ventricular
dysfunction produces inadequate filling of the left heart
resulting in a low cardiac output state. When these persist,
inotropic therapy must be used such as dopamine, dobutamine,
epinephrine, norepinephrine, and milrinone. After cardiac
surgery, atrial fibrillation, sinus bradycardia, and varying
degrees of heart blockage can occur. Simple atrial pacing (at a
rate of 80 to 100 beats per minute) for the treatment of sinus
bradycardia effectively augment cardiac output (CO).
Postoperative lung injury remains an important morbidity
cause, and its genesis is related to anesthesia, cardiopulmonary
bypass (CPB) and surgical trauma. Postoperative circulatory
shock and the number of transfusions during surgery are
considered acute lung injury and Acute respiratory distress
synderome (ARDS) triggering factors. The mechanical ventilation (invasive and noninvasive) is ordered routinely in
intensive care units, where it has demonstrated its effectiveness
to treat acute respiratory failure, especially in patients with
chronic obstructive pulmonary disease (COPD), acute heart
failure and immuno depression.
Post-operative delirium is common following cardiac
surgery, and leads to adverse events and longer hospital stays.
Maintaining patients with delirium in a stable environment with
familiar caregivers and providing reassurance are important.
Identifying and treating any modifiable underlying cause, such as
pain, hypoxia, electrolyte abnormalities, or postoperative
infection remain the mainstay of treatment. There is little
evidence to support drug treatment, in which case 0.5 to 5.0 mg of
haloperidol is provided.
Acute kidney injury (AKI) is prevented by correction of
the factors leading to pre-renal azotemia such as treatment of
volume depletion and congestive heart failure before cardiac
surgery, perioperative hydration and the use of hemodynamic
monitoring and inotropic agents to optimize cardiac output.
Hypophosphatemia is common after cardiac surgery, and is
associated with significant respiratory and cardiac morbidity.
Phosphate replacement is initiated in the postoperative period
for serum phosphate levels below 8.64 mg/dl.
Chronic pain is more common than other morbidities of
cardiac surgery such as mediastinitis, renal dysfunction, and
neurologic deficits. This persistent pain interferes with daily
activities and quality of life. Patient-controlled epidural analgesic techniques, with opioids and/or local anesthetics,
have been proved reliable, effective, and safe.
Ventilator-associated pneumonia (VAP) is the main
infectious complication in cardiac surgery. The most frequent
microorganisms are P aeruginosa, S aureus, E coli, and K
pneumonia. Rapid institution of an appropriate broad-spectrum
antibiotic regimen is cornerstone of therapy.
Antifibrinolytic therapy reduces perioperative blood loss
in cardiac operations. Tranexamic acid prevents plasmin
formation and inhibits fibrinolysis. Incidence of postoperative
thrombotic complications such as myocardial infarction, acute
renal failure, stroke, pulmonary artery thrombembolism is
decreased when tranexamic acid is administrated.
Enteral nutrition (EN) is initiated within the first 24-48
hours in the intensive care unit (ICU). This approach is not
appropriate for those patients with hypotension, hypoperfusion,
and low-flow states, though providing at least some EN may
still have salutary, trophic effects on the intestinal mucosa. The
use of parenteral nutrition (PN) is recommended for critically
ill patients unable to tolerate EN within a window of 0-7 days,
depending on the nutritional assessment. Parenteral nutrition is
delivered alone, or in combination with EN, depending on the
status of the gasterointestinal tract.
Thus, cardiothoracic surgery is not without risk, and, for
better outcome, it’s of paramount importance to do every effort
to avoid, early suspect and treat properly the complications.