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Hypotension and low cardiac output

Labs and tests

Electrocardiogram

  • ? changed from pre-op ( new RBBB is not uncommon, usually temporary and of little clinical significance; Shifts of the axis are also common and usually benign)
  • Rhythm – post-operative bradycardias, blocks, or atrial fibrillation
  • ST-T changes – diffuse non-specific changes are not uncommon and may reflect pericardial inflammation; ST elevation in two or more contiguous leads in a territory that was grafted can indicate an acute graft failure – notify the ICU fellow or Attending immediately; ST segment elevation across the anterior leads can represent LIMA spasm if the LIMA was grafted to the LAD – notify the ICU fellow or Attending immediately.

Chest X-Ray

  • Verify correct position of the ETT. Ideally half way between the glottis and the carina. Should be at least one cm above the carina.
  • Verify correct position of the Swan-Ganz catheter. The tip should not be too peripheral – no more than 1 to 2 fingerbreadths beyond the lateral mediastinal shadow.
  • Check the position of all other tubes and drains. The ng tube, chest tubes, and mediastinal sumps.
  • Check for pneumothorax.
  • Check for lobar collapse, atelectasis, effusions, pulmonary edema.

Laboratory Results

  • Hemoglobin
  • Coagulation parameters (PLT, PT, PTT, INR, ACT)
  • Potassium, magnesium – a vigorous diuresis is common in the first few hours after the OR. This can lead to significant hypokalemia and hypomagnesaemia which increases the likelihood of post-operative dysrhythmias. Standing orders are in place to replace these electrolytes.
  • Glucose – tight glycemic control post-operatively reduces morbidity. Use an insulin drip or sliding scale to keep the blood glucose between 6 and 10mMol/L.
  • Cardiac markers – elevations of CPK, CPK-MB, and troponins are non-specific. They should be assessed as part of the overall clinical picture including the hemodynamic status of the patient and the EKG.