The Cardiothoracic Surgical Patient

This is a hunt for complications. Of these, there may be many.

Additionally, it would be useful to determine whether the surgery was elective or emergent (the examiners may give this as a part of their introductory statement)

Previous hot cases with this sort of theme to them can be found below.

Examination of the Post-op Cardiothoracic Patient

The standard introduction

  • The examiner will give you a history.

The prelude to the dance

  • Wash hands.
  • Gown and glove.
  • Ask, if relevant:
    • "Can I turn on all the lights?"
    • "Are there any movement restrictions? Can I sit them up, or roll them on their side?"
    • "Is there a language barrier?"
  • Introduce yourself: “Hi Mr or Mrs Bloggs, I’m Dr So-and-so. I’m going to examine you.”

The Monitors

  • Rhythm
  • Rate
  • Morphology: QRS width, ST changes, etc.
  • MAP and abnormal morphology of the arterial waveform
  • CVP and abnormal morphology of the CVP waveform
    • there may be TR
  • Ancillary waveforms eg. the PA catheter waveform
    • Make sure it is properly transduced;
    • Assess the waveform - there may be MR.
  • Oxygen saturation measurement, and the quality of the waveform
  • End-tidal CO2 waveform and level

A pacing box?

  • Pacing mode
  • Set rate

Sensitivity and pacing threshold are probably important. Ask wbout these settings. One should also enquire as to what the underlying rhythm is, and whether one may see it by disconnecting the leads.

The Ventilator

One can ask the examiners the following questions:

  • How are we oxygenating this patient?
  • How are we ventilating this patient?
 

One should ask about the following parameters:

  • FIO2
  • PEEP
  • Peak pressure
  • Plateau pressure
  • Tidal volume and minute volume

One should ask to look at the pressure-volume loops.

Urine catheter

  • Unusual colour, eg. the blue urine of methylene blue
  • Anuria

Drains (surgical, intercostal, etc)

There may be surgical drains (what is in them? How much of it?). Asking how much has been coming out may be relevant in a hot case which focuses on the diagnosis of a shock state.

The pleural catheters are also interesting. One should make a mental note of whether the ICCs are on free drainage or on suction. The content of these drains could be informative, especially if one notices blood or chyle.

Dialysis

A CVVHDF or SLEDD process may be in progress. The savvy candidate may wish to ask the following questions:

  • Which modality is being used?
  • What is the dose of dialysis?
  • What is the rate of fluid removal?
  • How is the circuit anticoagulated?
  • How long has this filter lasted?

These questions may go unanswered.

IABP / ECMO

The patient you are examining may have some sort of extra gadget hooked up. If ECMO is in progress, one may wish to ask about the following parameters:

  • VA or VV?
  • Flow rate
  • Fresh gas flow
  • Any recent problems with the circuit

The use of VA ecmo means the patient has failed to come off bypass. This would be an interesting hot case.

If IABP counterpulsation is in progress, it raises additional questions. One may wish to ask the examiners whether one may be able to switch it to 1:2, to assess the efficacy of augmentation.

Infusions

This stage is critically important. The drug and fluid infusions which are currently in progress give a clue as to what problem is currently being addressed. One should not neglect the labelled bags; the choice of antibiotics gives one some idea of where the source of sepsis is thought to be.

Interesting drugs may include the following:

  • Vasopressors and inotropes
  • Vasodilators (eg. GTN or nitroprusside)

EVD

The post-ardiotomy patient should not have an EVD. If there is an EVD, that means something went horribly wrong with anticoagulation during bypass.

One should observe the following features of an EVD:

  • Set height
  • Whether it is open or closed
  • The CSF colour - eg. is it full of blood?

The physical examination

Expose and observe

Ideally, one should get the patient sitting up to 30-45°. This may not be possible. However, one should still ask for it.

Ideally, the patient should be exposed from the waist up. The candidate can then stand back and look for anything externally obvious:

  • Skin colour, eg. jaundice or the discolouration of chronic renal failure
  • Muscle wasting, obesity
  • The wound dressings
  • The pattern of breathing (eg. whether there is a characteristic chest flail)

GCS

Performing the GCS should be the first step, unless you notice that a neuromuscular junction blocker is among the infusions. The level of consciousness then determines how you go about examining the rest of the patient.

A traditionalist, who is examining Mr Bloggs, would approach the GCS in the following manner:

  • Grab hold of both of the patient's hands.
  • "Mr Bloggs!" One pauses to observe for eye opening.
  • "Can you squeeze my hands?"
  • If hand squeezing and eye opening is not observed, one administers a painful nail bed stimulus to both hands, to observe the response to pain.

Hands, nail signs, pulse and the arterial line.

One has just performed a GCS assessment; one is still holding the hands.

Now, time to look at them more closely.

First, one should spent a second assessing whether they are warm or cold.

Then, one can focus on the nails. Nail signs are numerous and deserve their own page.

In brief, the nail signs one could look for are as follows:

Done with the nails, one may want to briefly consider (and maybe even comment upon) the presence of any sort of characteristic deformities, eg. assymetrical wasting of the small muscles, or the joint changes of rheumatoid arthritis.

Next comes the pulse. While one still has both of the patient's hands, one ought to try to compare the radial pulses. It would be worthwhile to look up at the arterial line trace at this stage; abnormalities such as the widened pulse pressure of aortic regurgitation may not have been noticed until this stage.

Arms

Look for the graft sites. Don't try to palpate a radial artery which is not there.

Tone of the upper limbs

Move up from the hands. While you are still holding the hands, you can perform a sort of gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows.

Asterixis

In the conscious patient, it may be possible to assess asterixis by asking the patient to hold both their arms up with the wrists dorsiflexed.

Cubital fossa

Examine the cubital fossa for

  • Peripheral lines
  • Evidence of multiple venepunctures
  • Lymph nodes
  • Brachial pulse
  • The presence of an obvious AV fistula

One should then palpate the axillary lymph nodes.

The Neck

  • Inspect any central lines
  • Look again at the CVP

Palpate the neck:

  • Trachea: is it midline? Is there a new tracheostomy there?
  • Thyroid gland
  • Cervical lymph nodes
  • Carotid pulse - one side at a time!
  • Submandibular lymph nodes
  • Pre- and post-auricular lymph nodes

Pupils and the higher cranial nerves

A detailed examination of the cranial nerves will probably not be required. However, one may have already discovered a hemiparesis r (due to intraoperative stroke), or one might have discovered one later in which case one should return to this part of the examination.

In the absence of obvious stroke features, one can limit oneself to the following brief review:

Light reflex

Ask the examiners to dim the room lights.

Open both eyes. Each eye is exposed to light. The opposite pupil should constrict consensually.

This tests CN II (afferent) and CN III (efferent).

Facial pain sensation

Typically, this is performed by putting some pressure on the superior orbital notch.

The patient should either open their eyes or localise.

This tests CN V.

Gag reflex

The Yankeur sucker is used to probe the posterior pharynx, on both sides. A gag reaction should result from this.

This collectively tests CN X and IX.

During the cranial nerve examination, one will inevitably end up tripping over the endotracheal tube. One should note whether there is anything unusual there; for instance, is there a dual-lumen tube, or a bronchial blocker?

Chest palpation, percussion and auscultation

Palpation:

One puts both their hands on the chest to assess the symmetry of chest expansion.

At this stage, it is worthwhile to examine the integrity of the sternotomy wound, and to ask the examiners to peel off the dressings.

Percussion:

One might wish to percuss the chest. If this is done in a slick fashion, it can be forgiven.

Changes in percussion resonance may be worth commenting on.

Auscultation:

One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. In a supine ICU patient, one might gain access to the contralateral chest by grabbing the opposite arm and pulling the shoulder forward, thus pulling the patient's opposite side slightly off the bed. The money is in the bases.

Palpation and auscultation of the praecordium

Palpation:

The clever candidate will make a big show of palpating both the apex and the right sternal edge.

Auscultation:

One should auscultate in the following sequence:

  • Apex
  • Left sternal edge, lower
  • Left sternal edge, upper
  • Right sternal edge, lower
  • Left sternal edge, upper
  • Both carotids

The various clicks and murmurs one encounters are discussed elsewhere.

Abdominal palpation, percussion and auscultation

For this, one should ask to lay the patient flat.

Abdominal observation

  • Take a moment to behold the abdomen. One may ask the examiners to look under any surgical dressings; one is likely to be denied this part of the examination (they will tell you the wound looks clean and dry).

Abdominal palpation

  • All quadrants should be palpated.
  • Then, feel for the liver edge; observe respiratory excursion
  • Then, feel for the spleen.
  • Then, try to ballot the kidneys. Enquire about renal tenderness.

There may be abdominal distension and peritonism due to mesentric ischaemia from emboli.

Abdominal percussion

  • This can double as a test for peritonism.
  • If there is some suspicion of ascites, one may ask to roll the patient, so shifting dullness can be better appreciated. The examiners may not permit this test.

Abdominal auscultation

  • One should spend a good length of time on this, if one suspects bowel obstruction or ileus.

Examination of the pelvis and groins

The pelvic content would have been palpated during the abdominal examination.

The more important part of this examination is the groin.

At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.

Observation and palpation of the pelvis:

  • There may be a rash of thrush, or a groin haematoma, or an external fixation device.
  • The posterior pelvis and sacrum should ideally be palpated for pitting oedema.

Examination of the lines

  • One should take notice of anything going into or coming out of the femoral vessels.
  • There may be a vascath, a PiCCO catheter or some sort of angiography sheath. These are important clues. Why did this patient get an angiogram? What is the PiCCO for?

Examination of the genitals and rectum

  • A complete examination would call for the palpation of the testes, and a comment on their size. However, this may not be practical.
  • One should take note of any sort of waste management devices, eg. rectal tube, SPC or IDC.
  • One should definitely ask about performing a PR - this is likely to be denied by the examiners, not only for practical reasons of turning the patient, but also because the typical exam patient would end up being examined by numerous candidates, each of whom want to do a PR - and that's not cool.
  • If one is forbidden from performing the PR, one should ask about the following features:
    • Anal sphincter tone
    • Size and quality of the prostate
    • Presence of melaena or hard stool

Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.

Examination of the lower limbs

One should ask to remove TEDs and compression stockings.

  • One should observe whether the lower limbs are mottled, and whether they are of the same size (assymetrical swelling leads one to suspect lymphoedema or DVT)
  • One should palpate the larger muscles. Muscle wasting - especially of the quads- is an important feature of malnutrition. Additionally, one gets to appreciate the temperature difference between the limbs, which could be important in the assessment of peripheral vascular disease.
  • Pitting oedema should be palpated.

Leg muscle tone

The best way to test muscle tone is by holding the knee. Roll the knee gently to distract the patient; then try to lift it off the bed. In the presence of increased tone, the leg will remain straight and the whole thing will lift up; with normal or decreased tone, only the knee will bend

Calf tenderness

In the conscious patient, one might be able to assess whether a gentle calf squeeze produces the characteristic pain which suggests a DVT may be present.

This brings one to the feet, and to the beginning of the neurological examination.

Feet and the Babinsky reflex

The feet would have already been palpated to assess their temperature, and to look for pitting oedema.

Observation of the feet

One should look specifically for changes suggestive of chronic diabetic foot disease, or chronically poor vascular supply.

Palpation of the feet

This should consist of palpating the dorsalis pedis and posterior tibial pulse.

Babinsky reflex

One should test the Babinsky bilaterally.

Clonus

One should attempt to assess clonus in both feet.

Power in the limbs

Now is the time to perform a brief neurological examination of this patient.

Power of the muscle groups may be tested in the following sequence:

  • Ankle dorsi and plantarflexion
  • Knee flexion and extension
  • Hip flexion, extension, adduction and abduction.
  • Hand grip
  • Wrist dorsiflexion/palmarflexion
  • Elbow flexion/extension
  • Shoulder adduction / abduction

Reflex testing

Now that one is back to the upper limb, one may as well start their reflex tests there.

The reflexes may be tested in the following order:

  • Brachioradialis
  • Biceps
  • Triceps
  • Knee jerk
  • Ankle jerk

The measured observations

Ask to see the obs chart. If it is not allowed, ask for the following:

  • Trends of blood pressure and heart rate
  • Temperature
  • Drain output
    • ask about the position of the drains
  • Urine output

One may also wish do demonstrate an interest in the trends of any sort of advanced haemodynamic monitoring, eg. cardiac index as measured by PAC or PiCCO

The laboratory investigations

One needs to show an interest in the following labs:

  • ABG
  • Routine bloods - especially the coags, platelet count, and FBC.
    • One may wish to view the TEG readout.
  • Urinalysis
  • Culture results
  • CK, troponin, LFTs, pancreatic enzymes, inflammatory markers...

Imaging and other investigations

One should always ask for the following:

  • ECG
  • CXR
  • TTE

You sometimes want to see the following:

  • CSF analysis
  • CT or MRI results

 

Case presentation and discussion

"Mr Bloggs is recovering from [insert type of surgery]."

"His recovery is complicated by [x, y, z]"

"I have come to this conclusion on the basis of the following findings: [insert clinical findings here]"

"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"

"The current management issues are as follows: [a brief list of management priorities]"

"I would approach the management of these issues in the following manner: [list of management strategies; it helps to organise this into an A,B,C,D,E approach if one has a complex multisystem problem to manage]"

Number of previous hot cases in this topic: 23

2015, Paper 2

Unspecified hospital in Adelaide

75-year-old female, day 2 post emergency coronary artery grafting for severe left main disease and NSTEMI with persisting low cardiac output state. Background included type 2 diabetes and hypertension. She was intubated and ventilated with cardiovascular support including an intra-aortic balloon pump, nor-adrenaline and milrinone.

Candidates were directed to review her and outline their plan of management for the day. Discussion points also included management of the IABP and weaning and extubation.

2014, paper 2

Unspecified hospital in Sydney

  • 52-year-old male, day 3 in the ICU following elective CABG x 3. He remained ventilated with hypoxic respiratory failure. On examination he was obese, febrile, had high ETCO2, moderate PEEP and FiO2, reduced breath sounds at both bases. There were no focal neurological issues but he was heavily sedated. His chest x-ray showed bilateral infiltrates.
  • Candidates were asked to assess him with regards to the barriers weaning sedation and attempting extubation.

Unspecified hospital in Sydney

  • 69-year-old lady Day 2 ICU. Post coronary artery grafts and mitral valve repair. Background history of connective tissue disease. Clinical findings included sclerodactyly reduced radial pulse and brisk carotids, absent JVP, pedal oedema, paced cardiac rhythm, pansystolic murmur audible at the left sternal edge.
  • Candidates were informed she was day 2 following emergency cardiac surgery. They were asked to examine her cardiovascular system and overall state, and outline plans for ongoing management and ICU discharge.
2014, Paper 1

Princess Alexandra Hospital

  • 42-year-old male, day 6 ICU, following admission with shock, with type A thoracic aortic dissection, right CVA and severe aortic regurgitation, and now post Bentall's procedure. Clinical signs included on sedation and muscle relaxants, sternotomy scar, right groin wound, prosthetic aortic valve, bronchial breath sounds at left base and decreased air entry right base. o Candidates were directed to examine his cardiovascular system with a view to finding the cause for his initial collapse.
2013, Paper 1

Royal Adelaide Hospital

  • 57-year-old man, day 16 in ICU post AVR and CABG. Post-operative course complicated by cardiac failure and leg ischaemia. Candidates were asked to identify the nature of surgery, current issues and to formulate a management plan for the day.
2012, Paper 2

Royal Melbourne Hospital

  • 69-year-old female post complicated coronary artery graft surgery who failed extubation. Clinical signs included vasoplegic shock state, oliguria and raised lactate. Candidates were asked to address the key issues and formulate a management plan.

Monash Medical Centre

  • 70-year-old man with inflammatory response post coronary artery graft surgery. Clinical findings included bilateral lung crepitations, pericardial rub, groin haematoma, saphenous vein harvest site and milrinone infusion. Discussion related to the management of heart failure.
2012, Paper 1

Princess Alexandra Hospital

  • 59-year-old female with ESKD day 5 post cardiac surgery complicated by cardiogenic shock, dysrhythmias and ischaemic liver injury, with a cold foot and IABP still in situ. Candidates were asked to identify the major issues and discuss ongoing management.

Princess Alexandra Hospital

  • 51-year-old male with MSSA endocarditis and ESKD, day 9 post MVR, AVR and aortic root replacement, complicated by bleeding, persisting pneumothorax and ongoing septic shock. Candidates were asked to determine why post-operative progress had been slow, give a differential diagnosis for post-operative hypotension, give a differential diagnosis for the new onset fever and interpret the post-op CXR.

Prince Charles Hospital

  • A male patient day 6 post CABG and AVR complicated in the post-operative period by delirium and cardiorespiratory failure requiring re-intubation. Candidates were asked to assess the patient and discuss the main clinical issues and causes of respiratory failure following cardiac surgery.

Prince Charles Hospital

  • 53-year-old man day 2 post MVR for Staph aureus endocarditis complicated by vasoplegic shock, lactic acidosis and right heart dysfunction managed with vasopressors, inotropes, renal replacement therapy and nitric oxide. Candidates were asked to identify the clinical issues and discuss the causes of shock in this patient
2011, Paper 2

St George Hospital

  • 62-year-old male post re-do CABG with persisting low cardiac output state on IABP with background ESRF on peritoneal dialysis. Candidates asked to assess patient and make a management plan

Royal North Shore Hospital

  • 79-year-old male 3 days post CABG, failed extubation for respiratory failure, AF treated with amiodarone and cardioversion, acute on chronic renal impairment.

Royal North Shore Hospital

  • 78-year-old female post emergency CABG for NSTEMI with ongoing inotropic support, right frontal subacute infarct with left hemiplegia, fluid overload, slow wean from ventilatory support.

Prince of Wales Hospital

  • 85-year-old female day 3 post elective AVR and CABG complicated by bleeding, vasoplegic shock and pulmonary hypertension. Candidates were asked to identify the current issues and formulate a management plan
2011, Paper 1

Westmead Hospital

  • 56-year-old male post CABG x 5 with ischaemic cardiomyopathy and acute on chronic renal failure, now dialysis dependent.
2010, Paper 2

Royal Adelaide Hospital

  • A 73 year old man with DM and dialysis dependent CRF. In ICU following elective AVR and CABG. Candidates were asked to discuss glycemic control, fluid management in dialysis dependant cardiac surgery and complications following cardiac surgery.

Royal Adelaide Hospital

  • An 82 year old male admitted with NSTEMI and APO secondary to severe AS and CAD. He required emergent cardiac surgery. Discussion centred around management of cardio-respiratory wean, post op AF and role of levosimendan.
2010, Paper 1

Austin Hospital

  • 41 year old male in ICU following an emergency valve replacement for bacterial endocarditis of a pulmonary valve (previous Ross procedure). Had clear signs of peripheral emboli with significant R lung consolidation and lung abscesses. The patient was fully conscious and extubated on 40% inspired oxygen. Candidates were told the patient had had emergency valve replacement and were required to evaluate his current clinical situation.

Austin Hospital

  • 55 year old man with diabetic ESRF and peripheral vascular disease (a-v fistula insitu). Day 1 post CAGS. Making good progress. Vascath in situ but not being used. Not intubated. Candidates told post CAGS and were asked to formulate a management plan.
2009, Paper 2

St George Hospital

  • Post elective CAGS in an 83 year old man who had experienced early complications and slow progress. Ongoing inotrope requirement, marked oedema in the face of intravascular volume depletion. Significant sedation. Marked transaminitis. Candidates asked to outline a plan of management.

Royal Prince Alfred Hospital

  • A 76 year old man who presented with unstable angina and had an urgent CABG 4 days ago.  
    Bedside findings were:

    a) Sternotomy and saphenous venotomy scars
    b) Raised A-a gradient
    c) PAFC
    d) Haemodynamic data
    e) CVVHDF on citrate anticoagulation
    f) High dose inotrope requirement

    Current issues were:
    a) vasodilatory shock
    b) Discussion of hypoxia
    c) ARF – causes and management

Royal North Shore Hospital

  • A 76 year old gentleman who had had cardiac surgery 3 weeks ago, has had a complicated post op course. Candidates asked to assess him and provide a plan of management.