Postoperative care after cardiac surgery

INTRODUCTION — The immediate postoperative period after cardiac surgical procedures such as coronary artery bypass grafting and valve replacements is characterized by a pattern of myocardial injury and recovery. Understanding this pathophysiology allows anticipation of physiologic derangements and early recognition and avoidance of complications. This topic discusses routine postoperative care of the cardiac surgical patient.

Intraoperative problems that can occur immediately after cardiopulmonary bypass (CPB) may be transient or may persist after transport to the intensive care unit (ICU), as discussed in a separate topic. (See "Intraoperative problems after cardiopulmonary bypass".)

Monitored transportation from the operating room and the formal handoff process to ICU personnel are also discussed separately (table 1). (See "Anesthesia for cardiac surgery: General principles", section on 'Transport and handoff in the intensive care unit' and "Handoffs of surgical patients", section on 'Operating room to intensive care unit'.)

Specific complications that may occur after cardiac surgery are discussed in other UpToDate topics:

●(See "Postoperative complications among patients undergoing cardiac surgery".)

●(See "Early cardiac complications of coronary artery bypass graft surgery" and "Atrial fibrillation and flutter after cardiac surgery".)

●(See "Atrial fibrillation and flutter after cardiac surgery".)

●(See "Neurologic complications of cardiac surgery".)

INITIAL STABILIZATION AND RESUSCITATION

Pathophysiologic considerations of cardiac surgery — In the early postoperative period after cardiac surgery with cardiopulmonary bypass (CPB), patients often exhibit hemodynamic instability lasting approximately 6 to 12 hours, typically followed by a period of recovery (figure 1). Two factors influence this trajectory in an individual patient:

●Severity of the patient's underlying cardiac disease (eg, biventricular dysfunction)

●Key intraoperative events (eg, degree of hemodilution, need for blood product transfusion, duration of CPB and aortic cross-clamping, quality of myocardial protection)

Specific pathophysiologic consequences after cardiac surgery with CPB include:

●Water and sodium overload – The circuit priming volume of the CPB machine, as well as perioperative administration of crystalloid and/or colloid solutions and blood product transfusions result in a net positive sodium and water balance despite efforts to avoid excessive fluid administration and hemodilution (see "Blood management and anticoagulation for cardiopulmonary bypass", section on 'Avoiding excessive fluid administration' and "Blood management and anticoagulation for cardiopulmonary bypass", section on 'Strategies to minimize further hemodilution'). While total body water is increased, intravascular volume may remain relatively low during the early postoperative period such that patients typically require ongoing preload augmentation to achieve adequate cardiac output (CO). This increases total body fluid; thus, there is often a need for diuresis during the recovery phase (typically beginning on postoperative day one or two).

●Systemic inflammatory response – Surgical trauma coupled with the direct contact of blood on the foreign surfaces of the CPB circuit results in the systemic inflammatory response with inflammation, coagulopathy, and organ dysfunction (see "Management of cardiopulmonary bypass", section on 'General principles'). Widespread activation of thrombin, complement, cytokines, neutrophils, mast cells, and other inflammatory mediators occurs. As a consequence, patients exhibit a worsening of organ dysfunction and coagulopathy during the initial 12 to 24 postoperative hours that is generally proportional to the duration of CPB. Studies noting an association between CPB duration and morbidity include:

•A 2012 meta-analysis that included nine studies with 12,466 patients noted that 6.06 percent developed acute kidney injury (AKI), and longer mean CPB times were noted in patients with AKI compared with those who did not develop AKI (mean difference 25.65 minutes) [1].

•A 2019 meta-analysis that included 13 studies with 989 patients noted that duration of CPB was the most strongly correlated variable associated with duration of postoperative mechanical ventilation [2].

•A retrospective study that included >5000 patients noted that postoperative death, pulmonary, renal, and neurologic complications, multiorgan failure, multiple blood transfusions, and reoperation for bleeding were associated with CPB duration (analyzed in 30-minute increments) [3].

●Myocardial dysfunction – Myocardial ischemia and dysfunction is common and is a consequence of pre-existing disease and superimposed perioperative factors:

•Traumatic myocardial injury – Surgical trauma occurs during cardiotomy and manipulation of the heart.

•Myocardial ischemia and ischemia-reperfusion injury – Cardiac surgery with CPB involves separation of the heart from the circulation during aortic cross-clamping, which results in a period of ischemia that is partially mitigated by myocardial protection using cardioplegia solution and hypothermia (see "Management of cardiopulmonary bypass", section on 'General principles'). This ischemic injury is further aggravated by reperfusion occurring upon release of the aortic cross clamp [4]. The ischemic insult and ischemia-reperfusion injury may cause or worsen any preexisting myocardial dysfunction during the first 12 to 24 postoperative hours after ICU admission.

We assess high-sensitivity troponin levels to quantify the degree of myocardial injury in selected cases when there is significant concern for myocardial injury in the postoperative period, particularly if repeat revascularization is being considered. Clear consensus regarding the relationship of troponin levels to clinical endpoints is lacking. A 2019 consensus statement defines acute myocardial infarction (MI) in the setting of coronary surgery as a troponin level that is 10 times the upper reference limit (URL) [5]. Notably, different troponin assays and assessment protocols are used in different institutions, but values associated with increased risk for mortality after cardiac surgery are consistently much higher than those associated with increased risk after noncardiac surgical procedures. For example, a prospective cohort study of high-sensitivity troponin I measurements in 13,862 cardiac surgical patients noted that only very high troponin levels of 5670 ng/L (95% CI 1045-8260 ng/L) measured on the first postoperative day were associated with an increased risk of death within 30 days; this threshold troponin level was 218 times higher than the upper reference limit [6]. A post-hoc analysis of 1,206 patients noted that high-sensitivity troponin T (hs-TnT) assays obtained 6, 12, 24, 48, and 72 hours after cardiac surgery reported that optimal sensitivity and specificity for prediction of all-cause one-year mortality was a threshold hs-TnT >50 times the URL obtained 12 hours postsurgery [7].

Endpoints of resuscitation

Adequate oxygen delivery — A primary goal is ensuring adequate oxygen delivery (DO₂), which is determined by CO and arterial oxygen content (CaO₂) according to the following formula (see "Oxygen delivery and consumption", section on 'Oxygen delivery'):

CO is determined by heart rate (HR) x stroke volume (SV), while CaO₂ is determined by the hemoglobin (Hgb) concentration and the arterial oxyhemoglobin saturation (SaO₂) and arterial oxygen tension (PaO₂) according to the following formula: CaO₂ = (1.34 x Hgb x SaO₂) + (0.0031 x PaO₂). The dissolved oxygen (0.003 x PaO2) is generally ignored as this contributes little to the oxygen content and delivery (typically <0.3 ml/dL). For clinical purposes, we approximate CaO₂ by using the most recently measured Hgb concentration and continuously monitored SpO₂, a noninvasive measurement of the percent of saturated hemoglobin in the capillary bed using co-oximetry with a pulse oximeter.

Therefore, therapeutic targets to maintain adequate oxygen delivery include:

●Hgb concentration – We aim to maintain a Hgb concentration of 7.5 to 8 g/dL (hematocrit 21 to 24 percent) after routine cardiac surgery with CPB. (See "Indications and hemoglobin thresholds for RBC transfusion in adults", section on 'Cardiac surgery'.)

Prevention and management of postoperative bleeding after cardiac surgery are discussed elsewhere. (See "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Bleeding'.)

●Hgb saturation – We typically target a continuously monitored SpO₂ of >90 percent in the immediate postoperative period. As a general principle, hyperoxia should be avoided and oxygenation goals should be individualized.

●Cardiac output – Although a pulmonary artery catheter (PAC) is not commonly used for routine cardiac surgical cases, intermittent or continuous measurements of CO can be obtained if a PAC is available. We maintain cardiac index (CI; calculated as the CO/body surface area) >2 L/minute per m², which is generally sufficient to maintain adequate oxygen delivery. Administration of fluid therapy and/or combinations of inotropes and vasoactive drugs are used to achieve this hemodynamic goal. Management of common postoperative hemodynamic derangements such as inadequate preload, excessive afterload or poor inotropy is discussed in a separate topic. (See "Novel tools for hemodynamic monitoring in critically ill patients with shock" and "Pulmonary artery catheterization: Interpretation of hemodynamic values and waveforms in adults".)

In patients without a PAC, CO may be inferred using surrogates of adequate oxygen delivery such as degree of extremity perfusion, acid base status, central venous oxygenation (S_cVO₂), urine output, and hemodynamic parameters. In patients with signs of inadequate oxygen delivery unresponsive to typical resuscitative measures (eg, volume expansion and administration of low dose inotropic support), we typically insert a PAC to monitor CO. Alternatively, point-of-care ultrasound, transesophageal echocardiography, or transthoracic echocardiography is used to assess cardiac function. (See "Overview of perioperative uses of ultrasound", section on 'Point-of care ultrasound (POCUS)' and "Overview of perioperative uses of ultrasound", section on 'Echocardiography'.)

Hemostasis — Another primary goal is ensuring adequate hemostasis. Blood loss measured by chest tube output should be <400 mL/hour in the first postoperative hour, and <200 mL/hour during the first two hours [8]. Management of excessive chest tube output includes correcting any coagulopathy while maintaining an adequate Hgb level (see 'Adequate oxygen delivery' above). Details regarding management of bleeding after cardiac surgery are discussed in a separate topic. (See "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass", section on 'Achieving hemostasis and management of bleeding'.)

SEDATION — Patients are typically sedated upon arrival to the postoperative intensive care unit (ICU). We plan for extubation within six hours of arrival in the intensive care unit (ICU) for most patients undergoing routine cardiac surgery, particularly those participating in enhanced recovery after cardiac surgery (ERACS) protocols. (See "Anesthetic management for enhanced recovery after cardiac surgery (ERACS)".)

●Preferred sedative agents – Short-acting intravenous (IV) sedatives (eg, propofol, dexmedetomidine) are used to facilitate early extubation (table 2). If supplemental sedation is needed, particularly in a patient with pain, we administer an opioid. (See 'Analgesia' below and "Sedative-analgesia in ventilated adults: Medication properties, dose regimens, and adverse effects".)

•Dexmedetomidine – Dexmedetomidine is an alpha-2 adrenergic agonist with sedative, analgesic, anxiolytic, and sympatholytic properties, commonly used to sedate patients after cardiac surgery [9-11].

Weaning from mechanical ventilation is possible during sedation with lower dose infusions of dexmedetomidine, typically 0.2 to 0.4mcg/kg per hour. Also, dexmedetomidine is associated with less respiratory depression than propofol and other sedative/hypnotic regimens [12,13]. One observational study reported shorter ICU length of stay and decreased hospital charges with dexmedetomidine compared with propofol [14]. Although a lower incidence of delirium has been reported in some studies, in cardiac surgical patients [15-19], data are not consistent [20-22]. Given its minimal impact on respiratory drive, we typically use dexmedetomidine as a first line sedative agent after cardiac surgery, especially in situations where rapid extubation is preferable. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with lower risk'.).

Although dexmedetomidine infusion is associated with hypotension and bradycardia when administered at higher infusion rates, these adverse effects are rarely seen in cardiac surgical patients because epicardial cardiac pacing wires are typically inserted at the end of the procedure and prevent bradycardia. (See "Sedative-analgesia in ventilated adults: Medication properties, dose regimens, and adverse effects", section on 'Dexmedetomidine'.)

•Propofol – Propofol is a potent IV anesthetic agent with a very short half-life that is commonly used as a continuous infusion in the ICU setting. We typically select propofol sedation for cardiac surgical patient who may have a more prolonged duration of mechanical ventilation or for patients with severe hemodynamic instability who require deeper levels of sedation. Typical propofol dosing is 10 to 50 mcg/kg per minute. At this lower end of the dose range, hemodynamic side effects are minimized.

Notably, propofol has no analgesic properties. Thus, a multimodal analgesic regimen including an IV opioid is typically necessary. (See 'Analgesia' below and "Sedative-analgesia in ventilated adults: Medication properties, dose regimens, and adverse effects", section on 'Propofol'.).

●Agents to avoid – We avoid benzodiazepines in the postoperative setting after routine cardiac surgery due to their association with delirium, especially when delivered as a continuous infusion, as well as increased duration of mechanical ventilation and length of ICU stay [23]. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with higher risk'.)

ANALGESIA

General considerations

●Multimodal pain management – Multimodal pain management is a critical component of routine early postoperative management for cardiac surgical patients [24-32]. The Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) Society [24] and the Society of Cardiovascular Anesthesiologists (SCA) [32] recommend perioperative multimodal, opioid-sparing age-adjusted pain management planning, similar to enhanced recovery after other major surgical procedures. Nonopioid systemic analgesic agents, regional and local anesthetic techniques, and judicious use of opioids are included in a multimodal pain management plan [24-26,32-35]. Implementation of such multimodal pain management programs before, during, and after cardiac surgery has reduced perioperative opioid use by as much as 30 percent [9,36]. (See "Anesthetic management for enhanced recovery after cardiac surgery (ERACS)", section on 'Multimodal pain management'.)

●Importance of adequate analgesia – Pain assessment tools are used at regular intervals for both intubated and nonintubated patients to allow early identification and treatment of acute pain after cardiac surgery (see "Pain control in the critically ill adult patient", section on 'Assessment for pain'). Notably, failure to achieve appropriate levels of analgesia has been associated with complications after cardiac surgery that include:

•Pulmonary complications – Respiratory splinting secondary to pain after median sternotomy or thoracotomy leads to pulmonary insufficiency and inadequate pulmonary toilet, predisposing the patient to pneumonia and possible reintubation.

•Cardiovascular complications – Pain is associated with increased sympathetic outflow through increased levels of circulating catecholamines. After cardiac surgery, this state of elevated sympathetic outflow has the deleterious effects of both increasing myocardial oxygen demand and predisposing patients to arrhythmias (eg, atrial fibrillation) [37].

•Delirium – Although administration of analgesics and sedatives are associated with delirium, acute pain is also an associated precipitating factor, especially in older or frail patients [17].

•Development of persistent postoperative pain – Patients who experience moderate to severe pain on the third postoperative day are at higher risk of developing persistent pain syndromes [32,38,39].

Specific agents and techniques — Preferred agents include limited use of opioids and administration of acetaminophen.

Opioids — For patients with pain, we administer an intravenous (IV) opioid (eg, hydromorphone 0.5 mg) to provide both analgesia and supplemental sedative effects [40]. Some centers administer a single dose if intravenous methadone during the intraoperative period as part of a multimodal regimen to limit postoperative opioid dosing [32]. For patients who are not candidates for early extubation, a continuous infusion of fentanyl is reasonable. Following extubation when oral intake has been established, an oral opioid such as oxycodone is initiated. Judicious opioid use is necessary to minimize or avoid prolonged intubation due to excessive sedation and respiratory depression [41]. Postoperative nausea and vomiting (PONV) are promptly treated [25,27]. Other adverse effects of opioids include ileus, particularly when used at higher doses. (See "Pain control in the critically ill adult patient", section on 'Opioid analgesics'.)

Notably, cardiac and other major surgery is a significant contributor to persistent opioid use (POU) [42-46], defined as ongoing utilization of opioid prescriptions more than 90 days after surgery. POU occurs in 8 to 15 percent of patients undergoing cardiac surgery, including coronary artery bypass grafting and major valve procedures [43-46]. Risk of POU is associated with several factors including gender, age, geographical location, presence of certain comorbidities, and perhaps most importantly, the absolute amount of opioids (morphine milliequivalents) prescribed on discharge. For this reason, nonopioid analgesic agents and techniques are important to minimize use of opioids. (See "Anesthesia for cardiac surgery: General principles", section on 'Higher-dose opioid technique' and "Perioperative uses of intravenous opioids in adults: General considerations", section on 'High-dose opioid induction technique'.)

Nonopioid systemic analgesics — Nonopioid analgesics that may be used during and after cardiac surgical procedures include dexmedetomidine as noted above (see 'Sedation' above). Other agents include acetaminophen, gabapentinoids, and ketamine [9,24-26,33,36,47].

●Acetaminophen – We schedule postoperative administration of an acetaminophen dose between 650 to 1000 mg every six to eight hours based on liver function and provider discretion [48-50]. Doses greater than 3 g per day are avoided due to potential for hepatotoxicity. Such scheduled postoperative administration of acetaminophen (650 to 1000 mg every eight hours) improves pain scores, reduces reliance upon opioid-based analgesia, and potentially reduces delirium. In one small randomized study of 67 patients undergoing cardiac surgery, acetaminophen reduced perioperative opioid use and improved overall pain scores [48]. Opioid consumption expressed in morphine equivalents in the first 24 postoperative hours was lower in the acetaminophen group (45.6±29.5 mg) compared with the placebo group (62.3±29.5 mg). In another small randomized study of 121 older adults, postoperative scheduled administration of IV acetaminophen was combined with postoperative sedation for up to six hours using IV propofol or IV dexmedetomidine [49]. Opioid consumption for breakthrough pain was lower in the first 48 postoperative hours, and the incidence of in-hospital delirium was lower in patients receiving acetaminophen rather than placebo in their analgesic/sedative regimen (10 versus 28 percent; hazard ratio [HR] 2.8, 95% CI 1.1-7.8).

While the route of administration (ie, oral, rectal, or IV) does not seem to impact postoperative pain scores, vasoplegia requiring intervention in critically ill patients has been reported with administration of IV acetaminophen [51].

●Other agents

•Nonsteroidal anti-inflammatory drugs (NSAIDs) – NSAIDs are generally avoided in the United States due to the Food and Drug Administration (FDA) black box warning regarding the potential for adverse cardiovascular events (eg, myocardial infarction, cardiac arrest, stroke, pulmonary embolism) [52-54]. Also, NSAIDs have caused transient reductions in early postoperative renal function in noncardiac surgical patients, although this effect is unlikely to be clinically relevant in those with normal preoperative renal function [55,56].

However, if pain is refractory to opioids and acetaminophen, an NSAID with combined cyclooxygenase (COX) 1 and COX-2 activity may be used for a limited duration in selected patients who have good renal function and are not at risk for significant bleeding or acute kidney injury [53,57-60]. We typically use ketorolac 15 mg every six hours for only 24 hours. However, use of NSAIDs after coronary artery bypass grafting surgery remains controversial due to concerns regarding increased risk for thrombotic complications [52].

•Dexmedetomidine – In addition to its sedative properties (see 'Sedation' above), dexmedetomidine is considered to be part of a multimodal analgesic strategy for acute pain management when it is used. Care must be taken to avoid oversedation [32].

•Ketamine – Ketamine is administered at subanesthetic doses at some centers since this agent has profound opioid-sparing effects, a stable hemodynamic profile, absence of respiratory depression, and a low incidence of PONV [9,61-64]. However, ketamine is associated with increased risk for hallucinations, especially at higher infusion rates. When more conservative analgesic measures have failed and the benefits of ketamine outweigh potential risks, the authors initiate ketamine as an infusion at a rate of 0.1 to 0.25 mg/kg per hour. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with higher risk'.)

•Gabapentinoids – We avoid gabapentinoids in most cardiac surgery patients, and always avoid them in patients >70 years of age and those with glomerular filtration rate <30 mL/minute. Adverse effects include excessive sedation, respiratory depression, dizziness, and visual disturbances, especially if an opioid is coadministered [65-69]. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with higher risk'.)

Some centers do administer a gabapentinoid (eg, gabapentin, pregabalin) during the perioperative period in selected patients participating in an enhanced recovery after cardiac surgery (ERACS) protocol in order to limit opioid exposure. (See "Anesthetic management for enhanced recovery after cardiac surgery (ERACS)", section on 'Multimodal pain management'.)

Neuraxial and regional anesthetic techniques

●Neuraxial techniques – Neuraxial analgesic techniques are not generally employed after cardiac surgery in the United States due to concerns regarding risk of spinal epidural hematoma (SEH) in patients who received systemic anticoagulation required for cardiopulmonary bypass (CPB). However, these techniques are used more commonly in some other countries [70]. (See "Continuous epidural analgesia for postoperative pain: Benefits, adverse effects, and outcomes".)

•Thoracic epidural analgesia (TEA) – A 2023 meta-analysis that included 51 randomized trials noted a shorter length of stay (LOS) in the intensive care unit (ICU) by -6.9 hours (95% CI -12.5 to -1.2 hours) and shorter LOS in the hospital by -0.8 days (95% CI -1.1 to -0.4 days) in 2112 cardiac surgical patients who received TEA compared with 2220 patients who did not [71]. Lower pain scores and incidences of delirium, transfusions, arrhythmias, and pulmonary complications were also noted in patients who received TEA. No cases of SEH were reported in any of the trials included in this 2023 meta-analysis [71]. A 2019 meta-analysis of 69 randomized trials compared TEA with other analgesic techniques in 2404 patients undergoing cardiac surgery with or without CPB [72]. TEA was associated with lower risk of pain (at rest and with movement), as well as lower incidence of some adverse outcomes (respiratory depression, atrial fibrillation or flutter, myocardial infarction) compared with other techniques that included systemic analgesia, peripheral nerve block, intrapleural analgesia, or wound infiltration. No cases of SEH were reported in any of the trials in this 2019 meta-analysis. However, a higher overall incidence of hypotension was noted in patients who received TEA (risk difference [RD] 0.21, 95% CI 0.09-0.33; 17 trials with 870 participants) [72].

•Intrathecal morphine analgesia (ITMA) – Although not commonly used in the United States, ITMA has been used for decades to decrease the need for systemic opioid and sedative agents with improved pain scores after cardiac surgery [73]. Use of ITMA may also reduce risk of postoperative pulmonary complications [74]. (See "Approach to the management of acute pain in adults", section on 'Regional anesthesia techniques' and "Post-cesarean delivery analgesia", section on 'Hydrophilic opioids (morphine and hydromorphone)'.)

●Thoracic nerve blocks – Bilateral thoracic paravertebral blocks (PVB) and various truncal fascial plane blocks are used in some institutions, as described below [75]. Expertise in placement and management of these regional anesthetic techniques to control postoperative pain is necessary. (See "Thoracic nerve block techniques".)

•Bilateral thoracic PVB – Bilateral thoracic PVBs provide similar analgesic efficacy and less risk of SEH compared with neuraxial techniques [76,77]. Continuous bilateral PVB is associated with improved pain scores, reduced need for rescue opioids during the postoperative period, and decreased ICU and hospital lengths of stay compared with no use of a regional anesthetic technique in cardiac surgical patients [78]. Also, PVB has been shown to be a safe and effective strategy for pain control and early extubation compared with TEA in these patients [79]. (See "Thoracic paravertebral block procedure guide".)

•Fascial plane thoracic nerve blocks – Other thoracic regional techniques include serratus anterior plane (SAP), pectoral nerves (PECs), erector spinae plane (ESP), transverse thoracic muscle plane (TTMP), and intercostal nerve blocks, or parasternal infiltration of local anesthetic (table 3) [32,80-86]. These regional and local anesthetic techniques are relatively easy to perform, reduce pain scores, and limit perioperative opioid use without incurring the risk of side effects associated with neuraxial techniques such as epidural or spinal analgesia (eg, hypotension, SEH). (See "Thoracic nerve block techniques", section on 'Fascial plane blocks of the chest wall'.)

A 2020 systematic review concluded that use of a single-injection SAP block or PECs block reduced pain scores and opioid consumption compared with systemic analgesia alone after cardiothoracic surgery, although the data were heterogeneous (51 studies [nine randomized trials] with 637 total patients) [83]. The authors also noted that the duration of action of these blocks was longer than that of intercostal nerve blocks, but likely shorter than bilateral thoracic PVB.

Small nonrandomized studies of the use of continuous bilateral thoracic ESP blocks have also reported decreased perioperative opioid consumption [87,88]. One randomized trial of the efficacy of preoperative parasternal plane block to reduce opioid consumption noted that median concentrations of both remifentanil and propofol were significantly reduced during sternotomy in patients receiving the block [89]. Also, postoperative concentrations of several inflammatory cytokines were lower during the first seven postoperative days.

MANAGEMENT OF MECHANICAL VENTILATION — After cardiac surgery with cardiopulmonary bypass (CPB), most patients arrive in the intensive care unit (ICU) tracheally intubated with planned temporary mechanical ventilation.

●Imaging considerations – Typically, a chest radiograph is obtained shortly after arrival in the ICU, or in the operating room before transport to the ICU; this is reviewed to diagnose problems such as incorrect endotracheal tube or vascular line placement, pulmonary edema, atelectasis, or pneumothorax. In addition, lung ultrasound can be employed in the ICU to diagnose suspected pneumothorax, atelectasis, pneumonia, pulmonary embolism, diaphragmatic motion abnormalities, and other postoperative problems [90]. (See "Overview of perioperative uses of ultrasound", section on 'Lung ultrasound'.)

●Implementing mechanical ventilation – Initial settings for fraction of inspired oxygen concentration (FiO₂) are based on requirements in the operating room, then are adjusted as necessary to target continuously monitored arterial hemoglobin saturation (SpO₂) >90 percent, and to target normocarbia with continuously monitored end-tidal carbon dioxide (EtCO₂). Also, we intermittently measure arterial blood gases to assess arterial oxygen tension (PaO₂) and arterial carbon dioxide tension (PaCO₂), as well as acid-base status. (See 'Adequate oxygen delivery' above.)

We apply a lung-protective ventilation strategy as a continuation of intraoperative management, which may reduce the incidence of postoperative pulmonary complications (see "Anesthesia for cardiac surgery: General principles", section on 'Prebypass ventilation strategies' and "Mechanical ventilation during anesthesia in adults", section on 'Lung protective ventilation during anesthesia') [91,92]:

•Low tidal volume (TV) starting at 6 to 8 mL/kg ideal body weight

•Respiratory rate (RR) 10 to 14. We adjust RR based on EtCO₂ monitoring and PaCO₂ measurements. (See "Overview of initiating invasive mechanical ventilation in adults in the intensive care unit".)

•Positive end-expiratory pressure (PEEP) 5 to 8 H₂O. However, implementation of higher PEEP levels may be necessary to improve oxygenation in patients with pulmonary edema or altered lung mechanics.

•Plateau pressure (PP) maintained at <20 cm H₂O with adjustments of TV

•Low driving pressure (PP-PEEP) at <15 cm H₂O

In a 2019 retrospective study that included 4694 patients undergoing cardiac surgery with CPB, 10.9 percent experienced pulmonary complications (pneumonia, prolonged mechanical ventilation, need for reintubation, and/or poor oxygenation with a ratio PaO₂/FiO₂ <100 mmHg within 48 postoperative hours while intubated) [92]. Fewer pulmonary complications were noted in 6.6 percent of 1913 patients managed with intraoperative lung-protective ventilation that included TV <8 mL/kg ideal body weight, modified driving pressure (peak inspiratory pressure - PEEP) <16 cmH₂O, and PEEP ≥5 cmH₂O, compared with 13.9 percent in 2781 patients managed with other ventilation strategies (adjusted odds ratio [OR] 0.56, 95% CI 0.42-0.75). A sensitivity analysis revealed that use of modified driving pressure <16 mmHg, but not PEEP or low TV, was also independently associated with fewer pulmonary complications (adjusted OR 0.51, 95% CI 0.39-0.66) [92]. However, implementation of higher levels of PEEP may be necessary in patients with pulmonary edema to improve oxygenation.

●Weaning from mechanical ventilation – Routine early extubation within six hours after arrival in the ICU is typical for patients participating in enhanced recovery after cardiac surgery (ERACS) protocols; this has not been associated with increased risk for adverse outcomes [24,36,93-95]. Prolonged endotracheal intubation and controlled ventilation are associated with increased morbidity, mortality, and cost [96,97].

Also, to facilitate early extubation, appropriate preoperative and intraoperative management strategies are continued in the postoperative period. These include multimodal opioid-sparing pain management, limited use of benzodiazepines, reversal of neuromuscular blocking agents at the end of the procedure, use of lung-protective ventilation, temperature control, ensuring hemostasis, and careful management of fluid administration.

We typically avoid reversing residual neuromuscular blockade until the patient has been rewarmed to >36°C in order to avoid shivering with associated increased oxygen consumption. Once rewarming is complete, neuromuscular blockade is reversed with either neostigmine administered together with glycopyrrolate or with sugammadex (see "Clinical use of neuromuscular blocking agents in anesthesia" and "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Reversal of neuromuscular block'). Sedation is then weaned. Once the patient is awake and following commands, pressure support ventilation is initiated for a spontaneous breathing trial. (See "Initial weaning strategy in mechanically ventilated adults", section on 'Readiness testing'.)

We typically extubate within four to six hours after arrival in the ICU so that early mobility can be achieved (see 'Mobility' below). In low-risk patients, weaning from mechanical ventilation and extubation may occur as early as two to three hours following arrival in the ICU. Following extubation, patients are typically placed on nasal cannula oxygen, even individuals receiving low-dose inotropic or vasoactive drug support. Attention to rewarming and early extubation strategies are associated with improved outcomes [8]. Patients with baseline preoperative hypoxemia or severe chronic obstructive lung disease may require either high-flow nasal cannula or noninvasive ventilation after extubation [98,99]. Those with severe obstructive sleep apnea may need to use continuous positive airway pressure (CPAP) guided by home CPAP settings.

HEMODYNAMIC MANAGEMENT

Circulatory support

●Inotropic support and vasoactive therapy – Inotropes, vasopressors, and/or vasodilators are often necessary, particularly in the initial 6 to 12 hours following intensive care unit (ICU) admission and then weaned if hemodynamic goals are maintained (table 4 and table 5). In general, these drugs are used to treat left ventricular and/or right ventricular dysfunction, and/or vasoplegia. Typically, therapy is initiated in the intraoperative postbypass period, as discussed in a separate topic:

•(See "Intraoperative problems after cardiopulmonary bypass", section on 'Left ventricular dysfunction'.)

•(See "Intraoperative problems after cardiopulmonary bypass", section on 'Right ventricular dysfunction'.)

•(See "Intraoperative problems after cardiopulmonary bypass", section on 'Vasoplegia'.)

Selection of specific inotropic and vasoactive agents and dosing are adjusted in the ICU as necessary. As the pathophysiologic consequences of cardiopulmonary bypass (CPB) resolve, these medications are weaned, allowing removal of invasive monitors to facilitate mobility. (See 'Mobility' below.)

●Mechanical circulatory support – Postcardiotomy cardiogenic shock occurs in 0.2 to 6.0 percent of patients after cardiac surgery with CPB [100,101]. Temporary mechanical circulatory support (eg, intraaortic balloon pump [IABP] counterpulsation, percutaneous or implantable ventricular assist devices, or extracorporeal membrane oxygenation) may be employed in cases of refractory ventricular dysfunction resulting in persistently low cardiac output (CO) [100]. These devices are typically inserted in the intraoperative postbypass period. Selection of a circulatory assist device depends on individual patient hemodynamic factors, surgical preferences, and institutional resources (table 6). Details are discussed in separate topics:

•(See "Intraoperative problems after cardiopulmonary bypass", section on 'Short-term mechanical circulatory assist devices'.)

•(See "Intraoperative problems after cardiopulmonary bypass", section on 'Extracorporeal membrane oxygenation'.)

Management of arrhythmias — Normal sinus rhythm is ideal to maintain optimal CO because it provides an atrial contribution to ventricular filling and normal, synchronized contraction of the ventricles. However, both supraventricular and ventricular arrhythmias are common during and after weaning from CPB. (See "Intraoperative problems after cardiopulmonary bypass", section on 'Arrhythmias'.)

Atrial fibrillation (AF) is the most common arrhythmia after cardiac surgery, usually developing two to five days postoperatively. Although no single intervention has been shown to dramatically reduce incidence of postoperative AF, we focus on the early use of a beta blocker. Typically, we administer metoprolol 12.5 to 25 mg two or three times daily on the first postoperative day or as soon as hemodynamics allow. Subsequent doses are titrated upward to achieve a heart rate between 70 and 90 beats per minute (bpm) while maintaining normotension and adequate cardiac output. Other preventive and management strategies are discussed separately. (See "Atrial fibrillation and flutter after cardiac surgery".)

Management of cardiac arrest — Although cardiac arrest may occur at any time in the postbypass or postoperative period after cardiac surgery, most occurrences are in the first five postoperative hours [102,103]. The incidence was 0.7 percent in the first 24 hours after surgery in one series of nearly 4000 patients [104]. Causes include myocardial ischemia (eg, due to delayed entry of air into the coronary circulation or graft inadequacy), significant bleeding, impediments to cardiac function (eg, cardiac tamponade, tension pneumothorax), and arrhythmias (eg, ventricular fibrillation [VF], pulseless ventricular tachycardia [VT], loss of temporary pacemaker capture in a pacer-dependent patient) [102-104]. In the first few hours after CPB, most of these causes are reversible.

There are critical differences in management of cardiac arrest in the intraoperative or ICU setting after open cardiac surgical procedures compared with standard advanced cardiac life support (ACLS) management protocols (see "Advanced cardiac life support (ACLS) in adults"). These include:

●External cardiac compressions are not initiated immediately due to concern for disruption of the surgical repair, particularly the avulsion of a coronary graft anastomosis or dehiscence of a prosthetic valve.

●Administration of a full standard 1 mg ACLS dose of epinephrine is avoided since this may lead to extremely high blood pressure that could disrupt arterial suture lines. Rather, 50 mcg increments of epinephrine are administered as needed, with continuous reassessment.

●Administration of atropine for asystole or severe bradycardia is avoided. Rather, pacing is initiated.

The following specific management strategies are employed (algorithm 1) [103]:

●Identify the cardiac rhythm:

•If VF or pulseless VT is identified, three successive defibrillation shocks are administered. Defibrillation has a success rate of 78 percent after the first shock compared with 35 and 14 percent after the second and third shocks, respectively [105]. Amiodarone 300 mg intravenous (IV) should also be given.

•If asystole or severe bradycardia is identified, pacing is initiated. The pacemaker is set for dual chamber pacing (DDD mode (see "Modes of cardiac pacing: Nomenclature and selection")) at 80 to 100 bpm at maximum output voltage 20 milliamps atrial and 25 milliamps ventricle [103].

●If pulseless electrical activity (PEA) is noted, pacing is interrupted to ensure that the underlying rhythm is not VF. If PEA is confirmed, proceed with external cardiac compressions while opening the chest as described below.

●If VF, VT, asystole, severe bradycardia, or PEA is present and unresponsive to initial defibrillation or pacing after one minute:

•Initiate external cardiac compressions while the chest is opened through the existing fresh sternotomy as expeditiously as possible (within five minutes).

•During manual cardiac massage, mechanical ventilation and sedation medications are discontinued and manual ventilation with an Ambu bag is employed, using a fraction of inspired oxygen (FiO₂) set at 1.0 and a rate of two breaths for every 30 compressions [105].

•Administer epinephrine boluses at doses of only 50 mcg rather than standard ACLS doses of 1 mg, which may lead to extremely high blood pressure that could disrupt arterial suture lines after restoration of spontaneous circulation.

●Once the chest is reopened:

•Initiate two-handed internal cardiac massage at a rate of 100 to 120 bpm. The two-handed internal cardiac massage technique involves pressing the heart like a pancake with two flattened hands and straightened fingers to avoid pushing a thumb into an atrial chamber [103]. In patients with an IABP in place, the triggering mode may be switched during cardiac massage from use of the electrocardiogram to the arterial pressure tracing.

•Use internal defibrillation at 20 J/s during each attempt to treat VF.

•Continue resuscitation with internal cardiac massage, epinephrine, internal defibrillation, and/or pacing as indicated until the heart begins to contract or until resuscitation efforts are terminated due to futility.

Survival rates after cardiac arrest are higher in the early postoperative period after cardiac surgery compared with other settings (79 versus <25 percent) as they occur in the operating room or ICU location where clinicians with expertise in resuscitation are either at the bedside or immediately available [105,106]. Also, the arrest is likely to be a witnessed event, and is often anticipated in patients with a low cardiac index (CI), electrolyte abnormalities, arrythmias or after a steady decline in hemodynamics unresponsive to usual treatments. However, if cardiac arrest occurs after the 10^th postoperative day, survival is less likely since the pericardium starts to develop adhesions and the heart is technically more difficult to access for performing urgent open cardiac massage in this later postoperative period [106].

DETECTION AND MANAGEMENT OF DELIRIUM OR STROKE — Screening for postoperative delirium is commonly performed as part of routine postoperative care after cardiac surgery [24,25]. Susceptible patients include those with risk factors such as older age, frailty, or obstructive sleep apnea [107-110].

●Delirium – Evaluation for postoperative delirium is commonly performed as part of early recovery following routine cardiac surgery as well as for patients in an enhanced recovery after cardiac surgery (ERACS) protocol. Factors such as older age, frailty, or obstructive sleep apnea confer particular risk. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Postoperative anesthetic management'.)

In addition to treating pain (see 'Analgesia' above), we employ nonpharmacologic interventions as the first line of prevention and treatment to manage delirium (see "Delirium and acute confusional states: Prevention, treatment, and prognosis", section on 'Prevention') [25]:

•Ensuring appropriate sensory input (eg, use of hearing aids, glasses)

•Providing cognitive stimulation

•Encouraging normal sleep patterns

•Encouraging mobility (see 'Mobility' below)

•Providing adequate hydration and nutrition (see 'Diet' below)

•Investigating known treatable causes of delirium (eg, pain, medication-induced delirium, substance intoxication or withdrawal, other medical conditions) (see "Diagnosis of delirium and confusional states")

Pharmacologic interventions (eg, dexmedetomidine, quetiapine, olanzapine, haloperidol) may be employed in some centers for selected patients [25,111]. Details regarding management of delirium are discussed separately. (See "Delirium and acute confusional states: Prevention, treatment, and prognosis", section on 'Management'.)

●Stroke – Although asymptomatic stroke is common after cardiac surgery, occurring in approximately half of patients studied with magnetic resonance imaging, this finding has not been associated with worse neurocognitive outcomes [112]. Management of overt acute ischemic stroke occurring in the postoperative period after cardiac surgery, including endovascular thrombectomy with or without intra-arterial thrombolysis, is discussed separately [113]. (See "Neurologic complications of cardiac surgery".)

GLYCEMIC CONTROL — We maintain a blood glucose (BG) of 140 to 180 mg/dL (7.7 to 10 mmol/L) with a continuous intravenous (IV) insulin infusion titrated with a nomogram according to results of frequent (ie, hourly) BG measurements, similar to glycemic control in the postbypass period during cardiac surgery and other critical care settings [114]. (See "Glycemic control in critically ill adult and pediatric patients" and "Intraoperative problems after cardiopulmonary bypass", section on 'Hyperglycemia'.)

Poor perioperative glycemic control has been associated with increased morbidity and mortality [115,116]. Hyperglycemia is extremely common during and after CPB, particularly in patients with diabetes. However, non-diabetic patients develop "stress-induced hyperglycemia," and most also require insulin therapy. However, attenuating the hyperglycemic response after cardiac surgery can be challenging, and tight control can be harmful due to risk of hypoglycemia [117]. Patients with a Hgb A1c of >8 percent are particularly likely to develop hypoglycemia.

Specific institutional protocols for insulin use to achieve glycemic control in the early postoperative period vary. For example, detemir or glargine insulin is administered during the evening of the day of surgery and on postoperative day one at one of our institutions, allowing significant reduction of the regular insulin infusion. Dosing of these long-acting agents is guided by the preoperative Hgb A1c. Typically, 0.1 units/kg is administered to nondiabetic patients with a normal Hgb A1c (<5.7 percent). For patients with HgbA1c in the prediabetic or diabetic range, 0.2 units/kg is administered. In many patients, particularly if the insulin infusion requirement is >4 units/hour, one additional dose of detemir is administered on the first postoperative morning after consumption of clear liquids. Subsequently, an insulin sliding scale is used. Notably, patients who required high doses of a long-acting insulin agent at home are not placed on their usual chronic dose regimen since considerably less insulin is typically required during adherence to a carbohydrate controlled diet in the hospital. (See "General principles of insulin therapy in diabetes mellitus", section on 'Basal insulin analogs'.)

DIET — We typically initiate an oral diet in the intensive care unit (ICU) shortly after tracheal extubation. This is consistent with professional society recommendations for initiation of enteral nutrition within 24 hours of major surgery, targeting 25 to 30 kcal and 1.5 to 2.5 g protein per kg per day of ideal body weight [118,119]. For patients unable to consume at least 80 percent of their daily required caloric intake by postoperative day two to three (eg, those with gastroparesis or hemodynamic instability), we initiate enteral nutritional support with bedside placement of a nasoenteral feeding tube. Although hemodynamic instability and/or a high vasopressor requirement has previously been regarded as a contraindication, data suggest that enteral nutrition should be initiated in the euvolemic patient without tissue malperfusion [120]. (See "Overview of perioperative nutrition support" and "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription" and "Nutrition support in intubated critically ill adult patients: Enteral nutrition".)

Only a small subset of patients may require nutritional supplementation with parenteral formulations. The optimal timing for initiating parenteral nutrition in critical illness is uncertain. However, some data suggest that early initiation (within 24 to 36 hours of critical illness) is less harmful than previously believed due to advances in catheter management, glycemic control, and avoidance of overfeeding [121]. (See "Nutrition support in intubated critically ill adult patients: Parenteral nutrition".)

MOBILITY — We begin active range of motion and chest physiotherapy activities with sternal precautions within a few hours following extubation in hemodynamically stable patients. Typically, patients are transferred to a chair on the first postoperative day and begin ambulation with assistance three times per day after an initial physiotherapy evaluation. (See "Strategies to reduce postoperative pulmonary complications in adults", section on 'Lung expansion' and "Strategies to reduce postoperative pulmonary complications in adults", section on 'Early mobilization'.)

While labor-intensive to implement, early mobility protocols have been shown to reduce nosocomial infections, delirium, venous thromboembolism (VTE), and other complications [122]. Patients who remain sedated and immobile for a prolonged period suffer deleterious effects such as rapid and long-lasting loss of muscle mass, reductions in circulating blood volume, insulin resistance, and alterations in the sleep pattern [123].

VENOUS THROMBOEMBOLISM PROPHYLAXIS — Cardiac surgery patients have moderate risk for development of venous thromboembolism (VTE) due to the duration of intraoperative immobility during surgery and/or preoperative exercise limitations due to cardiovascular disease. One retrospective study that included 331,950 patients undergoing coronary artery bypass graft surgery noted that although the incidence of VTE was low (1.3 percent), it was associated with increased mortality, morbidity, and hospital length-of-stay [124].

We emphasize getting the patient out of bed on the night of surgery and early ambulation by the morning after surgery, as well as mechanical prophylaxis (see 'Mobility' above and "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Selecting thromboprophylaxis'). We typically add pharmacologic prophylaxis for VTE on the night of surgery once postoperative hemostasis has been attained by starting unfractionated heparin 5000 units subcutaneous twice daily. This is preferred over low molecular weight heparin in advanced age patients (>80 years old) and patients with renal failure or who are at risk for development of renal insufficiency. However, professional society guidelines and institutional protocols for pharmacologic prophylaxis after cardiac surgery vary [125,126].

Additional details are available in a separate topic. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

CRITERIA FOR DISCHARGE FROM INTENSIVE CARE — Extubation after a few hours, early oral intake, prevention and treatment of nausea and vomiting, use of multimodal analgesia, delirium screening, and early ambulation are the focus of intensive care unit (ICU) care during the first 24 hours. Invasive monitors and urinary catheter are removed on the first postoperative day. Although institutional practices vary, pleural and mediastinal drains are typically removed if output is <100 mL in an eight hour shift for two shifts.

If the criteria noted in the table are met (table 7), most cardiac surgical patients are able to transfer to a lower level of monitored care on the first postoperative day. Risk factors for readmission to the ICU include low left ventricular ejection fraction, frailty, renal failure, surgical re-exploration for bleeding, and need for controlled ventilation overnight [8,127].

ENHANCED RECOVERY AFTER CARDIAC SURGERY — Many institutions have adopted protocols for enhanced recovery after elective cardiac surgery (ERACS) involving standardized multidisciplinary approaches that span the entire perioperative period to achieve early extubation, shortened intensive care and hospital stays, and potentially improved outcomes. Further details are discussed in a separate topic. (See "Anesthetic management for enhanced recovery after cardiac surgery (ERACS)".)

SUMMARY AND RECOMMENDATIONS

●Pathophysiologic considerations – In the early postoperative period after cardiac surgery with cardiopulmonary bypass (CPB), patients often exhibit hemodynamic instability lasting approximately 12 to 24 hours, typically followed by a period of recovery (figure 1). Specific pathophysiologic consequences after cardiac surgery include (see 'Pathophysiologic considerations of cardiac surgery' above):

•Water and sodium overload

•Systemic inflammatory response to CPB

•Myocardial dysfunction due to pre-existing disease and superimposed perioperative factors:

-Myocardial injury due to surgical trauma

-Myocardial ischemia-reperfusion injury

-Reduced blood flow due to hypoperfusion or microemboli

●Endpoints of resuscitation – Goals for resuscitation include:

•Oxygen delivery – Ensure adequate oxygen delivery by (see 'Adequate oxygen delivery' above):

-Maintaining hemoglobin (Hgb) at 7.5 to 8 g/dL (hematocrit 21 to 24 percent)

-Maintaining arterial oxygen saturation (SpO₂) >90 percent

-Maintaining normal acid-base status and normocarbia

-Maintaining cardiac index (calculated as the cardiac output/body surface area) >2 L/minute per m²

•Hemostasis – Ensure adequate hemostasis. Blood loss measured by chest tube output should be <400 mL/hour in the first postoperative hour, and <200 mL/hour over the first two hours. Management includes correcting coagulopathy. (See 'Hemostasis' above.)

●Routine postoperative critical care

•Sedation – We plan for extubation within six hours of arrival in the intensive care unit (ICU) for most patients; thus, short-acting intravenous (IV) sedatives such as dexmedetomidine or propofol are used (table 2). (See 'Sedation' above.)

•Analgesia – We use opioids judiciously to treat pain (eg, bolus dose of IV hydromorphone 0.5 mg) while avoiding excessive sedation and respiratory depression. We suggest administration of acetaminophen 650 to 1000 mg every six to eight hours in patients without liver dysfunction (Grade 2C). For patients who are not candidates for early extubation, continuous infusion of fentanyl is reasonable. (See 'Analgesia' above.)

•Management of mechanical ventilation – We suggest using a lung-protective ventilation strategy (Grade 2C) that includes (see 'Management of mechanical ventilation' above):

-Low tidal volume (TV) starting at 6 to 8 mL/kg ideal body weight

-Respiratory rate (RR) 10 to 14, with adjustments based on arterial carbon dioxide tension (PaCO₂) measurements

-Positive end-expiratory pressure (PEEP) at 5 to 8 H₂O

-Plateau pressure (PP) <20 cm H₂O with adjustments of TV

-Low driving pressure (PP-PEEP) <15 cm H₂O

-Fraction of inspired oxygen concentration (FiO₂) setting to maintain SpO₂ >90 percent

•Hemodynamic management

-Inotropic support and vasoactive therapy – Inotropes, vasopressors, and/or vasodilators are often necessary, particularly in the initial 6 to 12 hours after ICU admission (table 4 and table 5). (See 'Circulatory support' above.)

-Prevention and management of arrhythmias – Normal sinus rhythm is ideal to maintain optimal cardiac output (CO). Atrial fibrillation (AF) is the most common postoperative arrhythmia. (See 'Management of arrhythmias' above.)

-Management of cardiac arrest – Critical differences in management of cardiac arrest in the early postoperative period open cardiac surgical procedures compared with standard advanced cardiac life support management protocols (algorithm 1). (See 'Management of cardiac arrest' above.)

•Detection and management of delirium – We evaluate for and prevent postoperative delirium by employing nonpharmacologic strategies including treating pain and encouraging adequate hydration, nutrition, mobility, and normal sleep patterns. (See 'Detection and management of delirium or stroke' above.)

•Glycemic control – We maintain blood glucose (BG) at 140 to 180 mg/dL (7.7 to 10 mmol/L) using a continuous IV insulin infusion titrated according to results of hourly BG measurements. Specific institutional protocols for insulin use to achieve glycemic control vary. An example is administration of detemir or glargine insulin during the evening of the day of surgery and on postoperative day one. (See 'Glycemic control' above.)

•Diet – We initiate an oral diet in the ICU shortly after tracheal extubation. In patients unable to consume at least 80 percent of their daily required caloric intake by postoperative day two or three, we initiate enteral nutrition support via a nasoenteral feeding tube. (See 'Diet' above.)

•Mobility – We suggest beginning chest physiotherapy with sternal precautions (Grade 2C), and active range of motion within a few hours following extubation, followed by transfer to a chair on postoperative day one, and begin ambulation with assistance three times per day. (See 'Mobility' above.)

•Venous thromboembolic (VTE) prophylaxis – We add pharmacologic to mechanical prophylaxis for VTE on the night of surgery once postoperative hemostasis has been attained and we emphasize early mobility. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

•Criteria for discharge from intensive care – If the criteria noted in the table are met (table 7), most cardiac surgical patients transfer to a lower level of monitored care on postoperative day one. (See 'Criteria for discharge from intensive care' above.)