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• W1963925314 abstract "•New advances in core critical care therapies such as mechanical ventilation have allowed physicians to deliver supportive care in a less harmful and more sustainable way.•Advances include low(er) tidal volume ventilation, prioritizing airway pressure over maximal Po2, and selective use of sigh breaths in place of higher tidal volumes for sustaining oxygenation.•Advances in techniques for hemodynamic monitoring and central line insertion have dramatically reduced complications referable to invasive monitoring.•The increased diagnostic complexity of patients with ventricular assist devices has made the diagnosis of low cardiac output more challenging. In addition to right ventricular failure, tamponade, bleeding, sepsis, and aortic insufficiency must all be considered. •New advances in core critical care therapies such as mechanical ventilation have allowed physicians to deliver supportive care in a less harmful and more sustainable way.•Advances include low(er) tidal volume ventilation, prioritizing airway pressure over maximal Po2, and selective use of sigh breaths in place of higher tidal volumes for sustaining oxygenation.•Advances in techniques for hemodynamic monitoring and central line insertion have dramatically reduced complications referable to invasive monitoring.•The increased diagnostic complexity of patients with ventricular assist devices has made the diagnosis of low cardiac output more challenging. In addition to right ventricular failure, tamponade, bleeding, sepsis, and aortic insufficiency must all be considered. As the spectrum of cardiac surgeries has grown, the diversity and complexity of postoperative cardiac surgical care has also increased. Cardiac surgery in 2012 now involves not only traditional revascularization and valve procedures but also ventricular assist device (VAD) implantation, transplant, percutaneous valve insertions, and extracorporeal approaches to cardiopulmonary support. In addition, advanced minimally invasive and robotic techniques have allowed cardiac surgery to be performed on patients formerly considered too ill to survive. The combination of these novel procedures, and an overall sicker patient population, have challenged intensivists caring for cardiac surgery patients to develop new care strategies to adapt to the changing patient population and surgical environment. A comprehensive review of postoperative critical care for cardiac surgery is beyond the scope of this article, which instead examines 4 areas in critical care where clinical practice is evolving rapidly. Among these are management of mechanical ventilation, thresholds for blood transfusion, strategies for hemodynamic monitoring, and processes for central line insertion. In addition, current approaches to common dilemmas in postoperative cardiac care are reviewed: diagnosis of tamponade, and the diagnosis and management of low cardiac output states in patients with a VAD. The development of the multi-institution ARDSnet research network in 1994 has led to a much richer understanding of the epidemiology of lung injury and the value of specific therapeutic approaches. Although the most widely publicized finding from ARDSnet research is the correlation between tidal volume and mortality in patients with lung injury,1ARDSnet investigators Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network.N Engl J Med. 2000; 342: 1301-1308Crossref PubMed Scopus (9553) Google Scholar several other observations relating to mechanical ventilation have led to modifications in current clinical practice. Taken together, these results have noticeably altered ventilator management of patients with lung injury and have contributed to lower mortality in this patient population. The most surprising epidemiologic observation from multiple studies of patients with acute respiratory distress syndrome (ARDS) is that partial pressure of oxygen (Po2) is not a risk factor for adverse outcome.2Nuckton T.J. Alonso J.A. Kallet R.H. et al.Pulmonary dead-space fraction as a risk factor for death in the acute respiratory distress syndrome.N Engl J Med. 2002; 346: 1281-1286Crossref PubMed Scopus (587) Google Scholar, 3Brun-Buisson C. Minelli C. Bertolini G. ALIVE Study Group et al.Epidemiology and outcome of acute lung injury in European intensive care units. Results from the ALIVE study.Intensive Care Med. 2004; 30: 51-61Crossref PubMed Scopus (533) Google Scholar In the original ARDSnet study comparing 6 mL/kg and 12 mL/kg tidal volumes, for example, mortality was decreased in the 6-mL/kg group whereas Po2 was the same in both tidal volume groups.1ARDSnet investigators Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network.N Engl J Med. 2000; 342: 1301-1308Crossref PubMed Scopus (9553) Google Scholar This finding is counterintuitive, as known causes of hypoxemia are clearly present in ARDS, and derangements in lung function such as pulmonary edema appear to be markers for greater severity of disease.4ARDS Definition Task Force Ranieri V.M. Rubenfeld G.D. Thompson B.T. et al.Acute respiratory distress syndrome: the Berlin Definition.JAMA. 2012; 307: 2526-2533PubMed Google Scholar When viewed in light of other empiric observations about ARDS, however, the lack of relationship between Po2 and outcome becomes clearer. One common strategy for improving Po2 in patients with lung injury is by increasing positive end-expiratory pressure (PEEP). However, although PEEP improves oxygenation, several high-profile trials have found no outcome benefit of high (13–15 cm H2O) over low (5–7 cm H2O) PEEP levels.5Brower R.G. Lanken P.N. MacIntyre N. National Heart, Lung, and Blood Institute ARDS Clinical Trials Network et al.Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome.N Engl J Med. 2004; 351: 327-336Crossref PubMed Scopus (1727) Google Scholar, 6Briel M. Meade M. Mercat A. et al.Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis.JAMA. 2010; 303: 865-873Crossref PubMed Scopus (973) Google Scholar This lack of outcome benefit with PEEP may result in part from the inhomogeneous effect of ARDS on lung tissue. Because damaged alveoli are also less compliant, adding PEEP may overdistend normal, functional alveoli, ultimately inducing lung damage and worsening outcomes. A similar “unintended consequences” argument can be made for prone ventilation and the use of nitric oxide. Both interventions improve oxygenation, but the increased complexity involved in their use may limit any benefit resulting from higher Po2, resulting ultimately in no effect on mortality.7Pelosi P. Brazzi L. Gattinoni L. Prone position in acute respiratory distress syndrome.Eur Respir J. 2002; 20: 1017-1028Crossref PubMed Scopus (205) Google Scholar, 8Adhikari N.K. Burns K.E. Friedrich J.O. et al.Effect of nitric oxide on oxygenation and mortality in acute lung injury: systematic review and meta-analysis.BMJ. 2007; 334: 779Crossref PubMed Scopus (328) Google Scholar One possible explanation for the absence of a relationship between Po2 and outcome may be that any benefit from greater oxygenation is almost completely offset by detrimental effects of the ventilator strategies needed to generate a higher Po2. Exotic ventilator modes such as pressure control or airway pressure release ventilation have thus become less common as intensive care unit (ICU) physicians move away from blood gas values to target ventilator parameters such as airway pressure and compliance. One current question is whether the combination of ventilator settings resulting in barely adequate oxygenation and intermittent “recruitment maneuvers” affects outcome. Such maneuvers involve periodic, scheduled, large tidal volume breaths occurring throughout the day to boost oxygenation by “recruiting” alveoli that collapse during low tidal volume ventilation. In principle, because the newly recruited tidal volumes are intermittent, a benefit from chronically low tidal volumes may be harnessed without unacceptably low oxygenation. Existing literature, however, is mixed. Although recruitment maneuvers clearly improve oxygenation, no strong outcome signal has yet been found.9Fan E. Wilcox M.E. Brower R.G. et al.Recruitment maneuvers for acute lung injury: a systematic review.Am J Respir Crit Care Med. 2008; 178: 1156-1163Crossref PubMed Scopus (253) Google Scholar For patients in the cardiac surgery ICU, ARDS is an infrequent complication. The incidence of ARDS after cardiac surgery is 0.4% versus 24% in a mechanically ventilated mixed surgical/medical ICU population.10Milot J. Perron J. Lacasse Y. et al.Incidence and predictors of ARDS after cardiac surgery.Chest. 2001; 119: 884-888Crossref PubMed Scopus (138) Google Scholar, 11Gajic O. Dara S.I. Mendez J.L. et al.Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation.Crit Care Med. 2004; 32: 1817-1824Crossref PubMed Scopus (559) Google Scholar Nevertheless, patients status post cardiopulmonary bypass with aortic cross-clamp have by definition sustained some degree of lung injury merely by excluding the lung from the circulation. Cardiac surgery patients also frequently receive blood and undergo large positive fluid shifts. Both interventions increase the incidence of ARDS. One important question is thus whether cardiac surgery patients should routinely be ventilated with low tidal volume strategies. Such a strategy would not only involve reducing tidal volumes to 6 mL/kg (or even lower) but also the relatively high respiratory rates (∼30 breaths/min) needed to maintain CO2 homeostasis and increased PEEP levels to maintain oxygenation. Potential downsides to such a ventilator strategy include derangements in acid-base balance, a greater need for sedation owing to the rapid shallow breathing pattern and high levels of partial carbon dioxide pressure (Pco2), and greater complexity for ICU caregivers. Because of such concerns, literature-reported compliance with low tidal volume ventilation hovers at approximately 30% to 50%.12Walkey A.J. Wiener R.S. Risk factors for underuse of lung-protective ventilation in acute lung injury.J Crit Care. 2012; 27: 323.e1-323.e9Abstract Full Text Full Text PDF Scopus (40) Google Scholar In light of the relatively brief periods of postoperative mechanical ventilation required by most cardiac surgery patients, the benefits of a low tidal volume strategy are unclear. Existing studies in patients without lung injury are equivocal. Whereas some find a shorter time to extubation after cardiac surgery,13Sundar S. Novack V. Jervis K. et al.Influence of low tidal volume ventilation on time to extubation in cardiac surgical patients.Anesthesiology. 2011; 114: 1102-1110Crossref PubMed Scopus (92) Google Scholar others find no benefit.14Determann R.M. Royakkers A. Wolthuis E.K. et al.Ventilation with lower tidal volumes as compared with conventional tidal volumes for patients without acute lung injury: a preventive randomized controlled trial.Crit Care. 2010; 14: R1Crossref PubMed Scopus (346) Google Scholar Further work in this area to identify potential high-risk groups may clarify whether aggressive low tidal volume strategies can meaningfully affect cardiac surgery outcomes. Changes in clinical practice, however, do provide some information for the ICU physician caring for cardiac surgery patients. In part as a result of aggressive education regarding tidal volumes, most critical care physicians are setting tidal volumes lower than 10 mL/kg and finding no adverse effects.15Checkley W. Brower R. Korpak A. Acute Respiratory Distress Syndrome Network Investigators et al.Effects of a clinical trial on mechanical ventilation practices in patients with acute lung injury.Am J Respir Crit Care Med. 2008; 177: 1215-1222Crossref PubMed Scopus (91) Google Scholar Such an “intermediate” tidal volume setting (7–8 mL/kg) may provide most of the benefit of lower tidal volumes without the technical challenges of managing hypercarbia, high respiratory rates, and agitation. Existing evidence suggests considerable heterogeneity with respect to transfusion practice in cardiac surgery.16Bennett-Guerrero E. Zhao Y. O'Brien S.M. et al.Variation in use of blood transfusion in coronary artery bypass graft surgery.JAMA. 2010; 304: 1568-1575Crossref PubMed Scopus (344) Google Scholar The likelihood of receiving blood during cardiac surgery may vary as much as 3- to 4-fold from one institution to another.17Karkouti K. Wijeysundera D.N. Beattie W.S. Reducing Bleeding in Cardiac Surgery (RBC) Research Group et al.Variability and predictability of large-volume red blood cell transfusion in cardiac surgery: a multicenter study.Transfusion. 2007; 47: 2081-2088Crossref PubMed Scopus (80) Google Scholar Survey data also support a wide variation in transfusion practice among cardiac surgery caregivers, with different protocols and thresholds for product use.18Likosky D.S. FitzGerald D.C. Groom R.C. et al.Effect of the perioperative blood transfusion and blood conservation in cardiac surgery clinical practice guidelines of the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists upon clinical practices.Anesth Analg. 2010; 111: 316-323Crossref PubMed Scopus (54) Google Scholar These observations suggest that identifying an optimal strategy for the management of blood products is a frustratingly elusive goal. Even the (apparently) simple question of what hemoglobin trigger to use for transfusion in patients with coronary artery disease is extremely difficult to answer. Early studies19Carson J.L. Duff A. Poses R.M. et al.Effect of anaemia and cardiovascular disease on surgical mortality and morbidity.Lancet. 1996; 348: 1055-1060Abstract Full Text Full Text PDF PubMed Scopus (769) Google Scholar found an adverse effect of low hematocrit on outcome in patients with known coronary artery disease, suggesting a different hematocrit threshold for such patients. A large 2002 multicenter trial in critically ill patients20Hébert P.C. Wells G. Blajchman M.A. et al.A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group.N Engl J Med. 1999; 340: 409-417Crossref PubMed Scopus (3888) Google Scholar found worse outcomes for patients transfused to hemoglobin (Hb) levels between 10 and 12 g/dL versus 7 to 9 g/dL, but no difference in the subgroup with coronary artery disease, also raising the possibility that patients with coronary artery disease may have unique hematocrit requirements. In 2007 a large retrospective trial evaluating the relationship between preoperative anemia and outcome after coronary bypass grafting found increased morbidity and mortality, with preoperative anemia starting at a surprisingly high Hb level (11 g/dL)21Kulier A. Levin J. Moser R. Investigators of the Multicenter Study of Perioperative Ischemia Research Group Ischemia Research and Education Foundation et al.Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery.Circulation. 2007; 116: 471-479Crossref PubMed Scopus (348) Google Scholar Although an emerging consensus exists today that critically ill patients without coronary artery disease do not need an Hb level of 10 mg/dL to optimize critical care outcomes, a target Hb for those with coronary artery disease is less clear. Recent literature fails to completely resolve this lack of clarity. A recent comparison of high (10 g/dL) versus low (8 g/dL) Hb in patients undergoing hip replacement with known coronary disease and low hematocrit found no benefit to maintaining a higher hematocrit.22Carson J.L. Terrin M.L. Noveck H. FOCUS Investigators et al.Liberal or restrictive transfusion in high-risk patients after hip surgery.N Engl J Med. 2011; 365: 2453-2462Crossref PubMed Scopus (924) Google Scholar Other recent studies in patients with acute coronary syndrome or those undergoing urgent/emergent stenting for acute coronary syndrome are similarly mixed. While anemia before percutaneous coronary intervention appears to predict adverse outcome,23McKechnie R.S. Smith D. Montoye C. Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) et al.Prognostic implication of anemia on in-hospital outcomes after percutaneous coronary intervention.Circulation. 2004; 110: 271-277Crossref PubMed Scopus (136) Google Scholar transfusion for low hematocrits during acute coronary syndromes also appears to worsen outcomes,24Garfinkle M. Lawler P.R. Filion K.B. et al.Red blood cell transfusion and mortality among patients hospitalized for acute coronary syndromes: a systematic review.Int J Cardiol. 2012; ([Epub ahead of print])PubMed Google Scholar even showing worsened outcomes for patients receiving blood transfusion. One recent study in cardiac surgery patients, however, found an inverse relationship between nadir hematocrits during bypass and perioperative mortality, with higher hematocrits corresponding to lower mortality. This relationship was particularly strong in patients with EuroSCOREs higher than 4.25Loor G. Li L. Sabik 3rd, J.F. et al.Nadir hematocrit during cardiopulmonary bypass: end-organ dysfunction and mortality.J Thorac Cardiovasc Surg. 2012; 144: 654-662Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar Although the mechanisms leading to such diverse outcomes are unclear, a paradigm similar to that for oxygenation during mechanical ventilation may be partly responsible. Although augmenting oxygen-carrying capacity by transfusing blood may benefit some patients, adverse immunologic effects from blood transfusion may counteract this benefit in others. Another recent propensity-adjusted Korean study in critically ill surgical patients found a benefit to blood transfusion that increased with lower pretransfusion Hb.26Park D.W. Chun B.C. Kwon S.S. et al.Red blood cell transfusions are associated with lower mortality in patients with severe sepsis and septic shock: a propensity-matched analysis.Crit Care Med. 2012; 40: 3140-3145Crossref PubMed Scopus (78) Google Scholar This study, possibly done with a more genetically homogeneous population than is typical in the United States, may suggest that immunologic effects of blood transfusion account in part for their adverse effects on survival. Overall, these data suggest that centers using more blood than is normal during cardiac surgery may be able to modestly reduce their transfusion thresholds without significantly affecting outcome in either direction. Further work is needed to better identify the relevance of Hb level and blood transfusion to outcomes in critically ill patients. Because of the frequent need for vasopressors and invasive hemodynamic monitoring, cardiac surgery patients often require a central line during the postoperative period. Fortunately, techniques for insertion and management of central lines have evolved dramatically in the past 10 years. Widespread use of ultrasonography for central line placement and the increasing use of checklists have both contributed to a dramatically lower incidence of central line complications and central line–associated bloodstream infections. Since the 2006 multicenter study validating the use of checklists to reduce central line infections,27Pronovost P. Needham D. Berenholtz S. et al.An intervention to decrease catheter-related bloodstream infections in the ICU.N Engl J Med. 2006; 355: 2725-2732Crossref PubMed Scopus (3014) Google Scholar checklists have been adopted in some form by many hospitals to reduce the incidence of line infections. Although the mechanism(s) linking checklist use to improved rates of central line infection are unclear, one clear accomplishment of the original 2006 validation study was to demonstrate to clinicians that it was possible to dramatically reduce the rates of central line infection. Whether because of or despite checklists, it is clear that since 2006 the rates of central line infection have fallen dramatically, so much so that the Centers for Disease Control and Prevention dedicated the March 4, 2011 issue of the Morbidity and Mortality Weekly Report to this success story about quality and safety.28Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report. 2011. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm?s_cid=mm6008a4_w. Accessed December 1, 2012.Google Scholar The use of ultrasonography for central line insertion has also allowed clinicians more freedom to steer clear of situations whereby central line infections are most likely. Because the pre-ultrasonography risk of inserting a new central line was higher relative to the risk of central line infection, clinicians would be more likely to leave an old central line in place rather than replace it with a new stick. In fact, studies of routine line changes in the pre-ultrasonography era frequently found no benefit.29Cook D. Randolph A. Kernerman P. et al.Central venous catheter replacement strategies: a systematic review of the literature.Crit Care Med. 1997; 25: 1417-1424Crossref PubMed Scopus (261) Google Scholar However, with ultrasonography the risk and difficulty of new central line placement has gone down significantly, allowing clinicians to reduce the risk of a new insertion, particularly in difficult patients with thick necks, prior neck surgery, or other examples of difficult anatomy. Other advances have also contributed to safer strategies for venous access, including the use of ultrasonography to identify peripheral veins, an increasing use of peripherally inserted central lines,30Gunst M. Matsushima K. Vanek S. et al.Peripherally inserted central catheters may lower the incidence of catheter-related blood stream infections in patients in surgical intensive care units.Surg Infect (Larchmt). 2011; 12: 279-282Crossref PubMed Scopus (62) Google Scholar hemodynamic monitoring strategies that do not require central lines,31Marik P.E. Cavallazzi R. Vasu T. et al.Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature.Crit Care Med. 2009; 37: 2642-2647Crossref PubMed Scopus (834) Google Scholar and better techniques for maintenance of central line dressing. Taken together, these approaches have significantly improved the use of central access in cardiac surgery patients. Considerable debate exists regarding how best to identify the optimal fluid balance or choice of vasoactive agent for critically ill patients.32Chong P.C. Greco E.F. Stothart D. et al.Substantial variation of both opinions and practice regarding perioperative fluid resuscitation.Can J Surg. 2009; 52: 207-214PubMed Google Scholar Postoperative cardiac surgery patients increase the complexity of this task by adding uncertainty regarding cardiac function. Against this background, clinicians have most commonly relied on pulmonary artery (PA) catheterization and invasive arterial monitoring. In light of accumulating evidence that traditional interpretations of PA catheter data may mislead,33Kumar A. Anel R. Bunnell E. et al.Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects.Crit Care Med. 2004; 32: 691-699Crossref PubMed Scopus (604) Google Scholar however, and to address monitoring needs of newer surgeries such as left ventricular assist device (LVAD) insertion, new strategies for hemodynamic monitoring after cardiac surgery are becoming available. One ongoing challenge is the differential diagnosis of a postoperative state of low cardiac output. Both the diagnosis of the low-output state and its cause can be difficult to ascertain. Traditional indicators such as perioperative urine output and mentation may not accurately reflect cardiac output, particularly if the surgery itself has caused kidney injury and/or the patient remains intubated. Similarly, use of vasoconstrictors may produce a seemingly normal blood pressure while obscuring an inadequate cardiac output. Finally, many patients with advanced cardiac disease present for surgery already in a low-output state, and may remain so well into the postoperative period. For this reason, ICU clinicians caring for complex cardiac surgery patients have historically measured cardiac output directly using PA catheterization. Although thermodilution cardiac output remains the most common approach to cardiac output monitoring in cardiac surgery patients, physicians are increasingly supplementing direct measurements of cardiac output with dynamic, arterial waveform–derived cardiac output and volume responsiveness measurements, and lactate and venous oxygen saturation monitoring. One area where new hemodynamic monitoring tools have contributed to the clinical diagnosis has been the diagnosis of low cardiac output immediately after cardiac surgery. In this time frame, potential causes of low cardiac output states include hypovolemia, systolic and diastolic heart failure, ischemia, valvular dysfunction, and cardiac tamponade. Of these, one of the most difficult challenges with traditional monitoring is distinguishing tamponade from acute postoperative right ventricular dysfunction. In tamponade, external compression of the heart limits diastolic filling, causing stroke volumes and cardiac output to decrease. In right ventricular failure, transient right ventricular systolic dysfunction due to intracoronary air or debris, hypotension, or inadequate preservation during cross-clamp leads to inadequate left ventricular filling. In both situations, cardiac output and blood pressure are low, and the patient is only intermittently responsive to fluid. In addition, PA and right atrial pressures are high, consistent with either right ventricular dysfunction or external compression of the heart. Not infrequently, acute right ventricular dysfunction can present with the same equalization of pressures that signals cardiac tamponade. Clarifying whether tamponade or right ventricular dysfunction is the cause of hemodynamic compromise after cardiac surgery is important because of the consequences. Although the only definitive treatment for tamponade is operative reexploration, current evidence suggests that a take-back is associated with a higher incidence of infection and worsened outcomes.34Biancari F. Mikkola R. Heikkinen J. et al.Estimating the risk of complications related to re-exploration for bleeding after adult cardiac surgery: a systematic review and meta-analysis.Eur J Cardiothorac Surg. 2012; 41: 50-55Crossref PubMed Scopus (95) Google Scholar If the cause is right ventricular failure, however, a conservative approach using vasoconstrictors to support blood pressure may suffice without the need to explore. One new solution for this diagnostic dilemma is the use of surface or transesophageal echocardiography. Simple 2-dimensional echocardiography machines are now frequently used for vascular access, and may be easily repurposed for rapid diagnostic evaluation of the heart. Although complex Doppler analysis is usually beyond the scope of these devices, a quick 4-chamber view of the heart can often distinguish between tamponade and right ventricular failure. Although pericardial effusions are common after cardiac surgery, and may not by themselves be diagnostic for cardiac tamponade,35Rose E.A. Gelijns A.C. Moskowitz A.J. Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) Study Group et al.Long-term use of a left ventricular assist device for end-stage heart failure.N Engl J Med. 2001; 345: 1435-1443Crossref PubMed Scopus (3227) Google Scholar other echocardiographic signs (diastolic collapse of the right atrium or ventricle) can add diagnostic clarity. In addition, visualizing both a large, poorly contracting right ventricle and a small, normally contracting left ventricle in the setting of equalization of pressures is strongly suggestive of right ventricular failure and may thus make tamponade less likely. Surface echo is currently more readily available than transesophageal echocardiography (TEE) for emergent hemodynamic diagnosis, although its images can often be insufficiently clear for diagnostic purposes. TEE, however, is also becoming increasingly more accessible to critical care physicians, with newer probes able to remain in the esophagus for days at a time. For most patients after complex cardiac surgery, cardiac output measurement via a PA catheter remains a critical tool in hemodynamic monitoring. No other monitor affords the ability to simultaneously measure right and left ventricular filling pressures and cardiac output. In addition to incremental improvements in postoperative critical care, ICU physicians have also adapted to a new spectrum of cardiac surgical procedures. The most prominent of these is the use of cardiac assist devices. Over the past decade, the role of VADs has transitioned from rescue therapy to mainstay in the surgical treatment of heart failure. Early versions of these devices were pneumatically driven pumps that withdrew blood from the left (or right) ventricle and pumped it into the aorta (or PA) in a pulsatile fashion. More recent “axial-flow” devices are continuous, nonpulsatile, magnetic rotor-driven devices that continuously pump blood from the ventricle to the aorta. Both devices add complexity to hemo" @default.
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