Intensive Care voor de hartchirurgie patiënt J.G. van der Hoeven Geen belangenverstrengeling Hartchirurgie 10% kleine complicaties Hartoperatie Ongecompliceerd beloop (80%) 10% grotere problemen Ontslag 24 72 uur Ontslag < 24 uur Langdurige IC opname Mortaliteit 1% Mortaliteit hartchirurgie UMCN Landelijk 8 Percentage 6 6,7 Herstart 4 2 2,8 2,9 2,8 2 0 0 2004 2005 2006 0,9 2007 0,7 2008 2009 2,8 2,4 2,3 1,2 2010 0,9 2011 2,5 0,9 2012 APACHE IV gecorrigeerde SMR SMR hartchirurgie UMCN Landelijk *** *** 1 0,88 0,8 *** *** 0,81 Landelijke invoering APACHE IV 0,6 0,72 0,71 0,63 0,56 0,53 0,4 0,42 0,27 0,2 0,21 0,12 0 2004 2005 2006 2007 2008 2009 2010 2011 0,09 2012 Ingrediënten van de crisis • Geen veiligheidscultuur • Ontbreken van leiderschap op meerdere niveaus • Falen van interne- en externe controle De veranderingen • Keten organisatie • Dagelijks bestuur • Controle op de kwaliteit • Cultuurverandering De ontwikkelingen • TAVI • Mitraclip • LVAD en va-ECMO • TEVAR en TAAA In de praktijk Medisch protocollair Hartoperatie Klinisch pad Ongecompliceerd beloop (80%) Ontslag < 24 uur In de praktijk The new england journal of medicine Once dark-red, nonpulsatile blood is aspirated, remove the syringe and insert the guidewire through the needle. Use the scalpel to stab the skin adjacent to the needle, and then remove the needle. While holding the guidewire to ensure that it remains accessible and does not embolize, insert the sheath and internal obturator over the guidewire until the hub fills the wound. Remove the obturator and guidewire from the sheath, and then attach a sterile flush to the port to ensure brisk flow. Attach the distal port of the pulmonary-artery catheter to the main pressure monitor. Place the catheter tip level with the patient’s heart, and set the pressure to zero. Orient the catheter so that its curvature follows its expected path, and then insert it into the sheath. Advance the catheter to 15 cm (i.e., halfway between the first two thin marks), at which point its tip will lie outside the sheath, and then inflate the balloon. Continue to advance the catheter until a right-atrial-pressure waveform is transduced. The distance to the right atrium is typically 15 to 20 cm from an internal jugular or subclavian vein, and approximately 40 to 50 cm from a femoral vein. The right atrial waveform has several identifiable components (Fig. 3): an a wave, which indicates atrial contraction; an x descent, which indicates atrial relaxation; a small c wave, which indicates closure of the tricuspid valve; a v wave, which indicates passive atrial filling during right ventricular systole; and a y descent, which indicates passive atrial emptying following the opening of the tricuspid valve. Instruct an assistant to write down the mean right atrial pressure. Advance the catheter another 5 to 10 cm until a right-ventricular-pressure waveform is transduced (Fig. 3). This sinusoidal waveform contains a swift upstroke and downstroke, representing ventricular systole, and a slower upstroke, representing passive ventricular filling during diastole followed by right atrial contrac- 10% kleine complicaties Right Atrial Pressure Pulmonary-Artery Pressure Pressure (mm Hg) 20 10 a x 0 c v y Normal Range Mean: 1–5 mm Hg 20 10 a 0 Normal Range Systolic: 15–30 mm Hg Diastolic: 1–7 mm Hg 20 d 10 0 Normal Range Systolic: 15–30 mm Hg Diastolic: 4–12 mm Hg Mean: 9–19 mm Hg Pulmonary-Capillary Wedge Pressure Pressure (mm Hg) Right Ventricular Pressure Pressure (mm Hg) Hartoperatie Cardiointensivisten Pressure (mm Hg) Medisch protocollair 20 10 0 Normal Range Mean: 4–12 mm Hg Figure 3. Pressure Waveforms in the Right Heart and Pulmonary Artery. The right-atrial-pressure waveform is notable for an a wave, which represents atrial contraction; an x descent, which represents atrial relaxation and contains a small c wave, corresponding to tricuspid valve closure; a v wave, which represents passive atrial filling during ventricular systole; and a y descent, which represents passive atrial emptying during ventricular diastole. The right-ventricularpressure waveform is notable for an a wave, which represents atrial systole, followed by a large Ontslag 24 72 uur Samenwerking a N 7 a N 2 en r uu uu r da g 24 a N tie f ra pe Pr eo Ejectiefractie (%) Kernproblemen 60 50 40 30 20 Langdurige daling EF • Lage uitgangswaarde EF • Duur en ernst van de hypothermie • Perioperatieve ischemie • CPB tijd > 120 minuten Medicamenteuze en mechanische ondersteuning Diastolisch hartfalen Postoperatief Druk Preoperatief Voor AVR Volume 24 uur na AVR Hartchirurgie Samenwerking Hartoperatie Medisch protocollair 10% grotere problemen Cardiointensivisten Innovatie IC Langdurige IC opname Mortaliteit 1% Innovatie op thorax IC CRM training Complicaties / 1000 patiënten Reanimaties op de IC p=0·03 60 6 40 4 20 2 0 0 Im ta Im pl em en Ba sis r tj aa Ef fe c pl em en ta Ba sis tie tie 0 8 r 20 80 tj aa 40 10 Ef fe c 60 Succes percentage (%) Incidentie / 1000 patiënten 80 Innovatie op thorax IC Ontwennen van beademing Lung$volume$ TLC$ ac9ve$inﬂa9on$ (lung$elas9c$recoil)$ passive$inﬂa9on$ $(relaxed$chestwall)$ Vt$ resis9ve$inspiratory$WOB$ Vt$ elas9c$inspiratory$WOB$ PEEPi$inspiratory$WOB$ PEEPi expiratory$WOB$ FRC$ FRC$ -$ 0$ Ppl$/$Pes$ +$ Innovatie op thorax IC Ontsteking Ondervoeding Bedrust Verlies van spiermassa - myopathie/neuropathie Eikermann M. Intensive Care Med 2013;39:2200-2203 Verbeteren spierfunctie • Vroegmobilisatie • Spiertraining • Voeding • Medicatie • Specifieke maatregelen Innovatie op de thorax IC ECMO team • Beperkt aantal intensivisten / verpleegkundigen • In samenwerking met perfusionisten • Volledig geprotocolleerd • Intensieve training • Prospectieve risico analyse • Man - 35 jaar • Massale longembolus • Chirurgische trombectomie • 2 × reanimatie • Rechter ventrikel falen • Postoperatieve VA-ECMO • Uitkomst: herstel Conclusies • Nog altijd groot deel „routine zorg” • Postoperatief o.h.a voorspelbare fysiologie • Minimaal invasieve chirurgie & katheter gestuurde ingrepen nemen toe • Hoog complexe chirurgie (TAAA) toenemend succesvol • va-ECMO vaak eerste keus bij low CO syndroom