8042NRS Clinical Reasoning: Postoperative Cardiac Management Synopsis

This synopsis delves into the critical aspects of postoperative cardiac management, focusing on strategies to mitigate complications following cardiovascular surgery. It highlights the importance of hemodynamic monitoring and management, including the use of vasoactive agents to address abnormalities in blood pressure and circulation. The literature review methodology is outlined, emphasizing the use of databases like PubMed and MEDLINE to gather relevant articles. Key findings reveal common postoperative problems, such as hemodynamic instability and septic shock, and the corresponding management techniques, including fluid resuscitation and the administration of inotropic agents. The discussion underscores the significance of hemodynamic management in reducing mortality and morbidity risks, while acknowledging the limitations of the research in not fully addressing aspects like rewarming and ventilator management. The synopsis concludes that postoperative complications, whether general or specific, are primarily managed through hemodynamic interventions and the strategic use of vasoactive agents.

Running head: SYNOPSIS
Synopsis of postoperative cardiac management
Name of the Student
Name of the University
Author Note

1SYNOPSIS
Introduction- Cardiovascular surgery or cardiac surgery refers to surgery that is
performed in the heart or the blood vessels by cardiac surgeon, with the aim of treating cardio
vascular complications. It is often used for curing ischemic heart disease, correcting congenital
heart diseases or valvular heart diseases that might arise due to a range of factors. Furthermore,
cardiac operation also involves treatment of atherosclerosis, rheumatic heart disease, and heart
transplantation. Showing similarity with other surgical procedures, cardiac surgery also requires
postoperative precautions, with the aim of avoiding complications. There is a need to maintain
appropriate insertion care, for avoiding infections and minimising complications (Hausenloy et
al., 2015). Further complications are also associated with loss of appetite and swelling.
Postoperative cardiovascular complications have always been associated with an increase in
morbidity and mortality during the postoperative period. They also result in an increase in the
length of hospitalization and lead to higher healthcare-associated treatment cost (Sutton, Bailey,
Bellomo, Eastwood & Pilcher, 2014).
Hypertension and tachycardia often arise from pain, surgical stress or interruption of beta
blockers therapy that lead to an increase in myocardial oxygen demand. Research evidences state
that the immune system of some patients is present in a prime susceptible stage, before
conduction of the surgery that increases the likelihood to subsequently suffer from postoperative
cardiac complications. The gastrointestinal tract also acts as a source of inflammation that leads
to release of endotoxin, systemically from bacteria and lowers the cardiovascular performance of
the patients, thereby leaving the cardiac tissue at a risk of hypoxia and under perfusion (Imazio
& Hoit, 2013). Hence, there is a need to prevent postoperative complications, with the aim of
reducing rates of mortality and associated morbidity among such patients.

2SYNOPSIS
Methods- A literature review was conducted in order to gain exhaustive information from
academic oriented literature that focused on postoperative cardiac management and formed the
basis of research. The methodology focused on recognition retrieval and recollection of articles,
relevant to postoperative cardiac management, followed by comprehension of the materials that
has been collected and read (Aveyard, 2014). This was followed by gaining a sound
understanding of the conceptual framework methodology and new terminologies that were
present in the retrieved articles. Research question was formulated that acted as the fundamental
code of this review of literature or research project. The question was kept comprehensive and
specific and focused on the study and determined the methodology. This question guided all the
stages of literature review that includes enquiry, analysis, followed by reporting of the key
findings. The Research question for this literature review was as follows:
What are the management strategies for postoperative cardiac complications?
This Research question helped in specifying the major objectives of the research, and
helped in guiding the research and assisted in construction of logical arguments. The research
started by identifying the search terms and key concepts within the research question. Each
component was treated as a separate concept and the keywords were derived from the research
question, along with their synonyms that were found in preliminary research. With the aim of
identifying potential relevant articles that pertains to the topic, two databases namely PubMed
and MEDLINE were searched. The search terms were ‘cardiac’, ‘heart’, ‘operation’, ‘surgery’,
‘postoperative’, ‘therapy’, ‘management’, and ‘intervention’. The search terms were used in
combination with several Boolean operators AND, NOT and OR that helped in broadening on
narrowing down the search results. The operator ‘AND’ retrieved results that contained all the
keywords. On the other hand, ‘OR’ helped in broadening the search results, by retrieving articles

3SYNOPSIS
that contained either of the keywords (McGowan, Sampson, Salzwedel, Cogo, Foerster &
Lefebvre, 2016).
The inclusion criteria are given below:
 Articles published in English
 Articles published not prior to 2013
 Articles that contain information on postoperative cardiac management in humans
The exclusion criteria were as follows:
 Articles that contain research conducted on animal models
 Articles published before 2013
 Unpublished manuscripts
 Abstracts
 Foreign language articles
Results/findings- According to research findings the common postoperative problems that
are seen among cardiac patients, hemodynamics was identified as an aspect of cardiovascular
physiology, concerned with the forces that the heart generates, thereby resulting in movement of
blood through the cardiovascular system (Salzwedel et al., 2013). The basic management
techniques identified from the literature focused on measuring the hemodynamics state of the
patient, followed by classifying it as hypertension, hypotension or a hyperdynamic and
hyperdynamic state, on finding abnormalities (Ji et al., 2013). The management procedure

4SYNOPSIS
generally involves identification of the causes that lead to abnormal hemodynamics. This is
generally followed by administration of a therapy such as, a vasoactive or cardioactive agent that
is able to mend the deviation that has been identified (Nielsen et al., 2013). According to
research evidences, continuous monitoring of the hemodynamic states of the patient includes
conduction of electrocardiogram, monitoring the pulse oximetry, invasive arterial pressure, and
endtidal carbon dioxide concentration (Peretto, Durante, Limite & Cianflone, 2014). A
pulmonary artery catheter or central venous pressure monitor is generally used for the preload
assessment. The myocardial performance determines the insertion of pulmonary artery catheter,
which in turn helps to better assist the performance of the patient, during heart manipulation
(McLaughlin et al., 2013).
Similar findings were also reported by other research articles that focused on monitoring the
hemodynamics of the patient followed by administration of pharmaceutical drugs or endogenous
agents, commonly called vasoactive substances that have been conferred the ability of bringing
about an increase or decrease in blood pressure depending on the hemodynamic abnormality
(Nishimura et al., 2014). These have been found to adjust vascular resistance and vascular
compliance, typically by bringing about vasoconstriction or dilation, which in turn helps to
maintain the homeostatic mechanism of the body under control. Evidences have been provided
by researchers for the use of bradykinin, angiotensin, histamine and vasoactive internal peptide,
when the patient shows abnormalities in heart rate and blood pressure, following a cardiac
surgery (Beylin et al., 2013). Researchers also said that the dosage of such vasoactive substances
are typically titrated by adjusting them upwards or downwards, with the aim of achieving a
desired effect or specific range of values as a determined by competent cardiac surgeons.

5SYNOPSIS
Similar findings were also reported by other articles that illustrated the mechanism of
administering vasoactive drugs, with the use of any intravenous pump, or volumetric in fusion
device (Prys-Picard, Shah, Williams, Cardenas Jr & Sharma, 2013). These research articles also
elaborated on the use of ionotropic agents that increase the myocardial contractility. Moreover,
ionodilators are also used in the form of vasoactive agents owing to their ionotropic effects that
lead to vasodilation, and result in decreasing pulmonary and systemic vascular resistance (Gaies
et al., 2014). Cardiovascular complications are often related to the development of septic shock
that occurs in response to certain infection, and results in hypertension and other abnormalities in
cellular metabolism. Universal agreement was obtained from all the articles, related to use of
aggressive fluid resuscitation, as the initial intervention for supporting patients having
experienced septic shock. Similarities were obtained related to implementation of vasoactive
drug therapy either through use of ionotropic agents and vasopressors or by administering drugs
that directly increase the blood pressure (Vincent & De Backer, 2013). Most commonly used
ionotropic agents have been found to increase MAP, by bringing about an elevation in the
cardiac index, along with limited impacts on systemic vascular resistance. Moreover, research
evidences also established dobutamine as the drug of choice for increasing cardiac output among
such patients. The drug acts as another ionotropic agent and stimulates the β-1 and β-2 receptors,
during septic shock, thereby increasing cardiac index, in combination with heart rate and stroke
volume (Mallat et al., 2014).
Discussion- Most patients having undergone cardiac surgery include hypertension risks of
bleeding pacing, atrial fibrillation and flutter. Moreover, in such patients the lungs are found to
be not optimally ventilated, and they often report renal impairment. Severe pain is another
postoperative complication that patients experience, which in turn affects postoperative recovery.

6SYNOPSIS
Hemodynamic management was identified as the basic therapeutic intervention related to
addressing such postoperative complications. Hence, the research evidences identified
hemodynamic management as the primary therapeutic management procedure among patients
who have undergone high risks of cardiac surgery. Monitoring the hemodynamic even provides
extensive information about the adequacy of circulation oxygenation and perfusion.
Administration of vasoactive agents therefore helps in stabilizing the abnormal hemodynamics,
and facilitates elimination or reduction of the chances of mortality and morbidity.
The major strength of the research lies in the fact that it focused on one aspect of
management of postoperative cardiac complications, thereby providing distinct information that
pertain to the topic. However, attention to rewarming, fluid resuscitation and appropriate
ventilator management are the key components that are generally administered, while being
involved in critical care of cardiac patients, following cardiac surgery (Thiele, Ohman, Desch,
Eitel & de Waha, 2015). Hence, consideration of the aforementioned three aspects in the
literature review would have helped in gaining a deeper understanding of postoperative cardiac
management.
Conclusion- Postoperative complications can be general or specific, to the kind of cardiac
surgery undertaken and is generally treated by hemodynamic management. General
postoperative complications include atelectasis, postoperative fever, wound infection, deep vein
thrombosis, and embolism. Vasoactive agents should be used for treating postoperative cardiac
complications, with the aim of reducing or eliminating abnormalities in blood pressure and
circulation of blood in the blood vessels, and septic shock. Thus, it can be stated that vascular
activity of these drugs pertains to their effect on the blood vessel.

7SYNOPSIS
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8SYNOPSIS
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9SYNOPSIS
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10SYNOPSIS
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