Authors: Yoan Lamarche, Demetrios Sirounis, Rakesh C. Arora
Reference: Can J Cardiol 2010 (26) Suppl SD. 135.
Patients undergoing surgical coronary revascularization procedures typically recover in either a general or dedicated cardiac critical care units. It has been shown that many aspects of patient care in an intensive care unit (ICU) can be standardized according to clinical care protocols. While the utilization of protocols in the general ICU has been associated with improved patients outcomes, implementation continues to be inconsistent. Furthermore, there is little data on rates of clinical care protocol utilization in the postoperative cardiac surgery setting. It was hypothesized that the use of standardized management strategies are widely variable between ICUs.
A survey of 30 Canadian cardiac surgical ICUs was conducted to define utilization of postoperative care protocols. Management strategies following coronary bypass surgery were obtained and compared to identify areas of variability. RESULTS. Twenty-eight units responded (93%) of which 26 sites (87%) were using formal postoperative protocols. All responding units, except one, had specific orders for CABG patients (96%). Orders for allogenic RBC transfusion threshold, postoperative extubation pathway, analgesia and atrial fibrillation management were present in 40%, 74%, 60% and 57% of the responding units, respectively. A standing order for aspirin administration within 6 and 24 hours of surgery was present in 52% and 91% of the centers, respectively. Statin administration was mentioned in the orders in 41% of the units. A protocolized trigger to notify the surgeon was specified for bleeding and hypotension in 75% and 35% of the centers. The most frequent vasopressor ordered was norepinephrine (35%) and the most frequent inotropes were dobutamine (31%) and milrinone (25%). Nitrates were used after CABG with a mammary artery in 41% of the units.
A large number of Canadian centres utilize at least one formal protocol for the care of the postoperative coronary revascularization patient. There is, however, a broad spectrum of management protocols in those units. Many protocols do not mandate physician’s notifications in case of complication and therefore, rely on experience from the housestaff and nursing for appropriate notification of the surgeon. Future studies will examine if implementation of standardized protocols improve outcomes in the postoperative cardiac patient.