Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2
➤ Gửi thông báo lỗi ⚠️ Báo cáo tài liệu vi phạmNội dung chi tiết: Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2
Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2
CHAPTER 9Mediastinal BleedingOverview.......................................................347Etiology of Mediastinal Bleeding....................... Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2.............348Prevention of Perioperative Blood Loss: Blood Conservation Measures.351Assessment of Bleeding in the ICU..................................356Management of Mediastinal Bleeding..................................363Blood Transfusions: Red Cells.......................................367B Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2lood Components, Colloids, and Blood Substitutes..................369Mediastinal Reexploration for Bleeding or Tamponade................371Technique oEbook Manual of perioperative care in adult cardiac surgery (5/E): Part 2
f Emergency Resternotomy................................373Overview 347Ộ Mediastinal BleedingI.OverviewA.The use of cardiopulmonary bypass (CPB) durinCHAPTER 9Mediastinal BleedingOverview.......................................................347Etiology of Mediastinal Bleeding....................... Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2addition to hemodilution from a crystalloid prime, which reduces levels ofclotting factors and platelets, contact of blood with the extracorporeal circuit activates platelets and the extrinsic and intrinsic coagulation systems, and triggers fibrinolysis. In fact, systemic heparinization alone causes Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2 platelet dysfunction and induces fibrinolysis.2 In addition, cell-saving devices that are routinely used for red cell salvage eliminate platelets andEbook Manual of perioperative care in adult cardiac surgery (5/E): Part 2
coagulation factors from the blood.B.Off-pump coronary artery bypass surgery (OPCAB) avoids hemodilution and minimizes platelet activation, and is asCHAPTER 9Mediastinal BleedingOverview.......................................................347Etiology of Mediastinal Bleeding....................... Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2s still present. Although a coagulopathy after OPCAB is very unusual, it may occur in patients who have sustained substantial blood loss with blood scavenged in and returned from the cell-saving device. This will result in depletion of coagulation factors and platelets, rhe occurrence of substantial Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2 bleeding after an OPCAB procedure generally indicates a surgical source.c. Either 28—32 Fr PVC or silicone malleable chest tubes or 24 Fr silastic flEbook Manual of perioperative care in adult cardiac surgery (5/E): Part 2
uted (Blake) drains arc placed in the mediastinum and opened pleural cavities. They arc connected to a drainage system and placed to —20 cm of H2O sucCHAPTER 9Mediastinal BleedingOverview.......................................................347Etiology of Mediastinal Bleeding....................... Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2 may be more comfortable for the patient.'5,61Some surgeons do not obligatorily place chest tubes into widely opened pleural spaces, especially after off-pump surgery'. 1 lowever, any bleeding that occurs in the pleural space will tend to accumulate and not be drained by the mediastinal tubes. This Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2can produce a deceptive picture with insidious bleeding that can only be detected by chest x-ray.2Following minimally invasive surgery, the number andEbook Manual of perioperative care in adult cardiac surgery (5/E): Part 2
location of tubes may van', /liter MIDCABs, only one pleural chest tube is placed, so blood could potentially accumulate around the heart and not be CHAPTER 9Mediastinal BleedingOverview.......................................................347Etiology of Mediastinal Bleeding....................... Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2 right thoracotomy approaches to the aortic or mitral valve, one mediastinal and one pleural tube are placed. Chest-tube positioning is difficult and348 Mediastinal Bleedingnot ideal after these procedures, so the potential for undetected blood accumulation around the heart or in the pleural spaces Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2is enhanced. Thus, extra vigilance for undrained blood in the unstable patient is imperative.D.Postoperative bleeding gradually tapers over the courseEbook Manual of perioperative care in adult cardiac surgery (5/E): Part 2
of several hours in the majority of patients, but about 1 -3% of patients will require reexploration in the operating room for persistent mediastinalCHAPTER 9Mediastinal BleedingOverview.......................................................347Etiology of Mediastinal Bleeding....................... Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2stent or increasing amounts of bleeding should prompt early exploration (see section V1H, pages 373-374).E.Bleeding invariably requires use of various blood products to maintain normovolemia and adequate hemodynamic parameters, correct anemia to ensure adequate tissue oxygen delivery’, and correct a Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2 coagulopathy to help arrest the bleeding. Transfused blood is not benign and can cause a variety’ of complications that may increase operative mortalEbook Manual of perioperative care in adult cardiac surgery (5/E): Part 2
ity.7-9 The safe lower limit for hematocrit (1 ICT) is not precisely defined, but in the bleeding patient in the early postoperative period, hemodynamCHAPTER 9Mediastinal BleedingOverview.......................................................347Etiology of Mediastinal Bleeding....................... Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2od comjjonent therapy ideally should he selected based upon identification of specific coagulation abnormalities by point-of-care testing and treatment algorithms, although clinical judgment remains essential in making prompt therapeutic decisions.F.Mediastinal bleeding can be a highly morbid and le Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2thal problem. Although hypovolemia can be corrected by volume infusions, the bleeding patient tends to be hemodynamically unstable out of proportion tEbook Manual of perioperative care in adult cardiac surgery (5/E): Part 2
o the degree of bleeding and fluid replacement. Most importantly in the immediate postoperative period is the potential for blood to accumulate aroundCHAPTER 9Mediastinal BleedingOverview.......................................................347Etiology of Mediastinal Bleeding....................... Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2iac arrest. Constant attention to the degree of bleeding and to trends in hemodynamic parameters should allow steps to be taken to avert tills problem. If profound hypotension or a cardiac arrest develop, emergency’ sternotomy in the 1CU is indicated.II.Etiology of Mediastinal Bleeding (Table 9.1)Me Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2diastinal bleeding is somewhat arbitrarily categorized as “surgical” or “medical” in nature. Significant bleeding after uneventful surgery is usuallyEbook Manual of perioperative care in adult cardiac surgery (5/E): Part 2
“surgical”, especially when initial coagulation studies arc fairly normal. However, persistent bleeding depletes coagulation factors and platelets, caCHAPTER 9Mediastinal BleedingOverview.......................................................347Etiology of Mediastinal Bleeding....................... Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2th abnormal coagulation studies and is considered “medical”. However, even after correction of coagulation abnormalities, discrete bleeding sites may be present that will not stop without recxploration. Thus, the initial approach to bleeding is to try to identify any contributing factors that might Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2account for the degree of bleeding and then take the appropriate steps to correct them.1A. A number of risk factors have been identified that increaseEbook Manual of perioperative care in adult cardiac surgery (5/E): Part 2
perioperative bleeding and/ or the requirement for transfusions (Table 9.2).7 Aside from stopping antiplatelct or anticoagulant medications prcopcratCHAPTER 9Mediastinal BleedingOverview.......................................................347Etiology of Mediastinal Bleeding....................... Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2' of utilizing blood conservation measures, and the importance of earlyEtiology of Mediastinal Bleeding 349Table 9.1 • Etiology of Mediastinal Bleeding1Surgical bleeding sites2Heparin effect - residual or rebound3Excessive protamine administration4Platelet dysfunction5Thrombocytopenia6Clotting facto Ebook Manual of perioperative care in adult cardiac surgery (5/E): Part 2r deficiencyCHAPTER 9Mediastinal BleedingOverview.......................................................347Etiology of Mediastinal Bleeding.......................CHAPTER 9Mediastinal BleedingOverview.......................................................347Etiology of Mediastinal Bleeding.......................Gọi ngay
Chat zalo
Facebook