Cardiothoracic ICU Nursing Guide

Post-Cardiac Surgery Monitoring

Systematic assessment every 1–2 hours is mandatory in the first 24 h post-CPB. Focus on haemodynamic stability, rhythm, bleeding, and end-organ perfusion.

Surgery Types at a Glance

CABG — coronary revascularisation; watch for graft spasm, perioperative MI (new ST changes, troponin rise >10x ULN)
Valve repair/replacement — prosthetic valve dysfunction, paravalvular leak, haemolysis (LDH, haematuria)
LVAD implant — device flows, suction events, right heart failure (RVF) in 20–30% post-implant
Combined procedures — longer CPB time → higher risk of coagulopathy, LCOS, AKI

Haemodynamic Targets

Parameter	Target
MAP	> 65 mmHg
HR	60–90 bpm
CVP	8–12 mmHg
PCWP	12–18 mmHg
Cardiac Index (CI)	> 2.2 L/min/m²
SVR	800–1200 dyne·s/cm⁵
SvO₂ / ScvO₂	> 65% / > 70%
Lactate	< 2 mmol/L

Mediastinal Drain Management

Mediastinal Drain Management Algorithm ▶

Normal Drainage Expectations

First hour post-op: up to 200 mL acceptable
Hours 2–4: < 100 mL/hr each
After 4 h: < 50 mL/hr
Total 24 h: < 500 mL (most centres)

Excessive Drainage Algorithm

Confirm system integrity — tubing kinks, connections, suction level (–20 cmH₂O standard)
Check activated clotting time (ACT) and reverse residual heparin with protamine if ACT > 130 s
Check coagulation: PT/INR, APTT, fibrinogen, platelet count; thromboelastography (TEG/ROTEM) if available
Correct coagulopathy: FFP, cryoprecipitate (fibrinogen < 1.5 g/L), platelets (< 80 × 10⁹/L)
Maintain normothermia; avoid hypothermia which worsens coagulopathy
Notify surgical team if > 200 mL/hr for 2 consecutive hours — re-exploration may be needed

Sudden Cessation of Drain Output

High-risk scenario for cardiac tamponade
Assess: rising CVP, falling MAP, equalization of filling pressures, tachycardia, muffled heart sounds
Attempt gentle drain milking only if approved by unit protocol
Prepare for emergency re-exploration / pericardiocentesis

Drain Removal Criteria

Output < 25–50 mL/hr for 4 h, no air leak, haemodynamically stable
Usually 24–48 h post-op; ensure analgesia prior to removal

Epicardial Pacing

Temporary epicardial wires placed routinely intra-operatively (atrial + ventricular)
Typical settings post-op: rate 80–90 bpm, output 10–20 mA, sensitivity 2 mV
AV sequential pacing (DDD) preferred — preserves atrial kick, improves CO by ~20%
Threshold testing: reduce output until capture is lost; set output at 3× threshold
Sensing check: inhibit pacing in VVI mode, confirm patient rhythm seen
Wire removal: at 5–7 days; ensure INR < 1.5 / hold anticoagulation; monitor for 4 h post-removal
Handle with insulated gloves — microshock risk

Sternal Precautions

No pushing/pulling with arms for 6–8 weeks (sternal healing)
No lifting > 2–4 kg post-sternotomy
Log-roll technique for turning in ICU
Assess sternum daily for instability, crepitus, wound erythema
Obese patients / diabetics / bilateral IMA grafts — higher risk of sternal wound dehiscence (DSWI)
Use sternal support brace when mobilising
Coughing support: pillow splinting technique; essential post-extubation

Post-Cardiac Surgery Haemodynamic Assessment Tool

Heart Rate (bpm)

MAP (mmHg)

CVP (mmHg)

PCWP (mmHg, optional)

Cardiac Output (L/min, opt)

Lactate (mmol/L)

Urine Output (mL/hr)

Drain Output last hr (mL)

Enter drain output each hour to track trends.

Cardiac Mechanical Support Devices

CT-ICU nurses must be proficient in device monitoring, alarm management, and troubleshooting for all temporary mechanical support modalities.

Intra-Aortic Balloon Pump (IABP)

Mechanism & Indications

Counterpulsation: inflates in diastole (↑ coronary perfusion), deflates in systole (↓ afterload)
Indications: cardiogenic shock, weaning from CPB, post-CABG LV dysfunction, refractory angina
Typical augmentation ratio: 1:1 (inflate every beat), can wean to 1:2, 1:3
Insertion: femoral artery; tip at distal aortic arch (just below left subclavian)

IABP Monitoring

Confirm position on CXR: tip 2–3 cm below carina
Augmented diastolic pressure should exceed systolic by 10–15 mmHg
Check for limb ischaemia hourly: distal pulses, Doppler, colour, cap refill
Heparin infusion: maintain APTT 50–80 s or ACT 150–200 s
Helium drive gas: check level; refill if alarm triggers

IABP Timing Troubleshooting ▶

Problem	Waveform Sign	Effect	Correction
Early inflation	Inflation before dicrotic notch	↑ afterload, aortic regurgitation risk	Delay inflation trigger
Late inflation	Inflation well after dicrotic notch	Reduced diastolic augmentation	Advance inflation trigger
Early deflation	Sharp systolic drop, no assisted end-diastolic dip	Reduced afterload reduction, premature afterload return	Delay deflation trigger
Late deflation	Assisted end-diastolic pressure > unassisted; balloon still inflated at systole onset	↑ afterload, balloon impedes LV ejection	Advance deflation trigger

Weaning Protocol

Reduce ratio: 1:1 → 1:2 → 1:3 over 4–6 h, monitoring haemodynamics at each step
Remove when CI > 2.2, MAP > 65 off or minimal vasopressors, no recurrence of ischaemia
Manual pressure for ≥ 30 min post-removal; observe for haematoma, pseudoaneurysm

Impella

Overview & Purge Solution

Microaxial pump positioned across aortic valve; unloads LV directly
Models: Impella 2.5 (2.5 L/min), CP (3.7 L/min), 5.0 / 5.5 (5 L/min) — most common post-cardiac surgery: CP or 5.0
Purge solution: 5% dextrose + heparin 50 IU/mL (check local protocol); purge pressure 300–1100 mmHg depending on model
Purge flow should be 2–30 mL/hr; alerts if outside range

Alarm Management

Suction alarm — inadequate LV filling; give volume, reduce P-level, reposition
Low purge pressure — check reservoir, tubing kink, refill dextrose bag
Position alarm — device migrated; CXR/echo for position, reposition under fluoro
Motor current too high/low — thrombus or haemolysis risk; check LDH, plasma Hb, urine colour
Haemolysis markers: ↑ LDH, ↑ plasma Hb, haemoglobinuria (pink/red urine)

ECMO

VA-ECMO vs VV-ECMO

	VA-ECMO	VV-ECMO
Indication	Cardiac failure / cardiogenic shock	Respiratory failure (ARDS)
Drainage	Venous (RA/femoral vein)	Venous
Return	Arterial (aorta/femoral artery)	Venous (IJ/femoral vein)
Cardiac support	Yes — full haemodynamic	No — oxygenation only
North-south syndrome	Risk with femoral VA-ECMO	Not applicable

Circuit Checks & ACT Targets

Hourly visual circuit check: oxygenator, tubing, connections, clot presence
ACT target: 180–220 seconds (heparin infusion titrated accordingly)
Flows: usual adult VA-ECMO 3–5 L/min; alarm if < 1.5 L/min
Sweep gas (FiO₂ and flow): adjust to maintain PaCO₂ 35–45 mmHg
Membrane oxygenator: check pre/post pO₂; rising pressure gradient suggests clot
Hand-crank available at bedside at all times
Limb perfusion cannula for femoral arterial access — check distal limb hourly

Temporary & Permanent Pacemakers Post-Surgery

Temporary Transvenous PM

Inserted for perioperative complete heart block or sinus node dysfunction
Check sense/pace thresholds daily; document in notes
Secure connection to generator; avoid traction on lead
Microshock precautions: gloves when handling exposed terminals
Do not perform cardioversion without consulting cardiologist — may damage lead

Permanent Pacemaker / ICD

Inserted if AV block persistent > 5–7 days post-surgery
Post-implant: restrict ipsilateral arm elevation for 4–6 weeks
Check device function at 24 h: sensing, pacing thresholds, impedance
ICD patients: educate on shock therapy, avoid strong magnetic fields (MRI planning)
Programme change records must be documented; verify rate response settings

Arrhythmia Management in CT-ICU

Post-cardiac surgery arrhythmias are common and can critically impact haemodynamics. Prompt recognition and management are essential nursing competencies.

Post-Operative Atrial Fibrillation (POAF)

Commonest complication after cardiac surgery — occurs in 20–40% of CABG, up to 60% of valve surgery patients
Peak incidence: day 2–3 post-op; almost all POAF within 5 days
Mechanism: pericardial inflammation, sympathetic surge, electrolyte disturbances, atrial stretch
Risk factors: age > 70, prior AF, valve surgery, ↑ LA size, hypomagnesaemia, pain, hypoxia

Amiodarone Protocol (typical)

IV loading: 300 mg in 250 mL 5% dextrose over 30–60 min (central line — causes phlebitis peripherally)
Maintenance infusion: 900 mg over 24 h
Oral conversion: 200 mg TDS for 1 week → 200 mg BD for 1 week → 200 mg OD (duration per cardiologist)
Monitor: QTc prolongation, bradycardia, hypotension during IV loading
Thyroid function, LFTs, CXR at baseline (chronic use)

POAF Management Steps

12-lead ECG — confirm AF, assess ventricular rate
Check electrolytes: K⁺ target 4.5–5.0 mmol/L, Mg²⁺ > 0.8 mmol/L; correct aggressively
Assess haemodynamic stability: stable → rate control (beta-blocker, diltiazem, amiodarone); unstable → DC cardioversion
Rate control target: < 100 bpm at rest
Anticoagulation: if AF > 48 h or unknown duration — heparin bridge; discuss with cardiology for timing post-surgery
Most POAF cardioverts spontaneously within 24–48 h with rate control and electrolyte correction

Complete Heart Block (CHB)

Incidence ~1–3% after valve surgery; higher after TAVI, AV nodal procedures
Recognition: P waves without QRS, wide escape rhythm < 40 bpm, syncope/haemodynamic collapse
Immediate: activate epicardial pacing (DDD or VVI) at 80–90 bpm; ensure capture
If no epicardial wires or capture failure: transvenous temporary pacing urgently
If persistent > 5–7 days: permanent pacemaker implantation
Common post: AVR, mitral valve surgery, VSD repair, TAVI — proximity of AV node to surgical field

Ventricular Tachycardia / Fibrillation

VT/VF Recognition & Response

Pulseless VT / VF: call cardiac arrest; commence CPR; defibrillate 200 J biphasic immediately
Sternal precautions: avoid sternal compressions if sternum wired (risk of wire injury); consider open-chest CPR if < 10 days post-op
Many centres have open-chest CPR protocol for post-cardiac surgery arrest within 10 days
Amiodarone 300 mg IV after 3rd shock in pulseless arrest

Sustained VT with Pulse

Haemodynamically unstable: synchronised DC cardioversion 150–200 J
Haemodynamically stable: IV amiodarone 150 mg over 10 min, then 1 mg/min × 6 h, then 0.5 mg/min
Identify and correct reversible causes: electrolytes, ischaemia, acidosis, hypoxia
Lignocaine 1–1.5 mg/kg IV if amiodarone unavailable
Electrophysiology consultation if recurrent / incessant

QTc Prolongation Monitoring

Measure QTc on each 12-lead ECG; calculate using Bazett's formula: QTc = QT / √(RR)
QTc > 500 ms: high risk of Torsades de Pointes (TdP)
Common culprits in CT-ICU: amiodarone, ondansetron, haloperidol, azithromycin, ciprofloxacin, methadone
Correct: K⁺ > 4.5, Mg²⁺ > 0.9 mmol/L; stop offending drugs if possible
TdP treatment: IV MgSO₄ 2 g over 10 min; overdrive pacing if recurrent; isoproterenol for bradycardia-induced TdP

DC Cardioversion in CT-ICU

Procedure Points

Synchronised mode for all arrhythmias except VF
Energy: AF 120–200 J biphasic; Flutter 50–100 J; VT 150–200 J
Sedate: propofol 0.5–1 mg/kg IV or midazolam 2–3 mg ± fentanyl
Ensure synchronisation marker on R-wave before delivery
Pads: anterior-posterior positioning more effective than anterior-lateral for AF

Pre-Cardioversion Checklist

Anticoagulation status — if AF > 48 h: TOE to exclude LA thrombus or 3 weeks therapeutic anticoagulation
Remove epicardial wires from generator (or use low energy) — inform cardiac surgery team
Anaesthesia / sedation support at bedside
Resuscitation equipment available: defibrillator, intubation kit, crash drugs
Post-cardioversion: ECG, BP monitoring × 1 h minimum

Post-Cardiac Surgery Complications

Early recognition and escalation of complications is a defining CT-ICU nursing skill. Know the signs, know the actions.

Low Cardiac Output Syndrome (LCOS)

Diagnosis

CI < 2.2 L/min/m² despite adequate filling
Signs: cool/mottled peripheries, oliguria (< 0.5 mL/kg/hr), rising lactate, confusion
Occurs in 5–10% post-cardiac surgery; associated with ↑ mortality
Echo: ↓ LVEF, wall motion abnormalities, right heart failure

Management

Optimise preload: CVP 8–12, PCWP 12–18 (cautious fluids)
Correct arrhythmias: restore sinus rhythm, optimise HR (60–90)
Inotropic support: dobutamine first-line; milrinone if beta-blocked; levosimendan if available
Reduce afterload if SVR elevated: vasodilators, IABP
Escalate: IABP → Impella → VA-ECMO for refractory LCOS
Re-explore if surgical cause suspected (graft failure, tamponade)

Cardiac Tamponade

Recognition

Beck's Triad: hypotension + elevated JVP/CVP + muffled heart sounds
Pulsus paradoxus: > 10 mmHg drop in systolic BP on inspiration
Equalisation of pressures: CVP ≈ PCWP ≈ PAD (within 5 mmHg) — classic sign on invasive monitoring
ECG: electrical alternans (alternating QRS amplitude), sinus tachycardia
Echo (gold standard): pericardial effusion, RV diastolic collapse, IVC plethora (> 2 cm non-collapsing)
Post-cardiac surgery tamponade may be localised (atypical) — echo essential

Nursing Actions

Call surgical team / intensivist IMMEDIATELY — tamponade is a cardiac surgical emergency
Volume bolus as temporising measure (maintains preload)
Avoid positive pressure ventilation if possible (↓ venous return)
Prepare for pericardiocentesis or surgical re-exploration

Deep Sternal Wound Infection (DSWI)

Risk Factors & Signs

Obesity (BMI > 35), diabetes, bilateral IMA harvest, prolonged CPB, re-exploration
Signs: sternal instability/clicking, wound erythema/discharge, fever, ↑ CRP/WBC
Typically presents day 5–14; earlier = more aggressive
Organisms: Staph aureus (incl. MRSA), coagulase-negative Staph, gram-negatives

Management

Wound swab and blood cultures before antibiotics
IV antibiotics: vancomycin (MRSA coverage) ± gram-negative cover per sensitivities
Surgical debridement and rewiring or VAC (vacuum-assisted closure) therapy
Strict glycaemic control: target BGL 6–10 mmol/L in ICU
Nutritional support: adequate protein and zinc for wound healing

Renal Failure Post-Cardiopulmonary Bypass

AKI occurs in 20–30% post-CPB; 1–5% require renal replacement therapy (RRT)
Mechanism: non-pulsatile flow, inflammatory response, emboli, haemolysis, contrast nephropathy
KDIGO criteria: creatinine rise > 26 μmol/L in 48 h, or > 50% rise in 7 days, or UO < 0.5 mL/kg/hr × 6 h
Nursing: hourly urine output monitoring, daily creatinine/urea/electrolytes, avoid nephrotoxins (NSAIDs, aminoglycosides, contrast)
Optimise haemodynamics: MAP > 65 mmHg, avoid hypotension episodes
RRT indications: refractory hyperkalaemia, severe acidosis, fluid overload, uraemic symptoms

Neurological Complications

Stroke (Type I)

Incidence ~2–5% post cardiac surgery; highest risk: aortic surgery, valve surgery, AF
Mechanism: emboli (air, thrombus, atheromatous debris), hypoperfusion
Immediate: CT head, neurology consult, glucose control, BP management (avoid hypotension)
Thrombolysis generally contraindicated post-cardiac surgery — surgical bleeding risk

Cognitive Dysfunction & Delirium (Type II)

Post-operative cognitive dysfunction (POCD): subtle memory/attention deficits; common in elderly
ICU delirium: use CAM-ICU; incidence 30–50% in cardiac surgery ICU
Management: ABCDEF bundle (awaken, breathing, coordination, delirium monitoring, early mobility, family engagement)
Avoid sedative overload; haloperidol or quetiapine if pharmacological intervention needed
Orientation strategies: clock, calendar, familiar items, family visits

CT-ICU Pharmacology

Mastery of vasoactive agents, antiarrhythmics, and anticoagulation is fundamental to safe CT-ICU nursing practice and GCC licensure examinations.

Inotropes

Drug	Mechanism	Dose	Key Nursing Points
Dobutamine	β1 > β2 agonist; ↑ contractility, ↓ SVR	2–20 mcg/kg/min	Tachyarrhythmia risk at high doses; avoid if HR > 120; central line preferred
Milrinone	PDE-3 inhibitor; ↑ cAMP; inodilator	0.125–0.75 mcg/kg/min; loading 25–50 mcg/kg over 10 min	Vasodilation → hypotension; reduce dose in renal impairment (renally cleared); additive with dobutamine
Levosimendan	Ca²⁺ sensitiser + K-ATP channel opener; inodilator	0.05–0.2 mcg/kg/min × 24 h (no loading dose if hypotensive)	Effects last 7–9 days (active metabolite); significant vasodilation; thrombocytopenia risk; monitor daily FBC
Dopamine	Dose-dependent: DA <5; β1 5–10; α1 >10 mcg/kg/min	1–20 mcg/kg/min	More arrhythmogenic than dobutamine; largely replaced but still used; watch for tachycardia
Adrenaline	β1, β2, α1 — potent inotrope + vasopressor	0.01–1 mcg/kg/min	Causes hyperglycaemia; significant tachycardia; use in severe cardiogenic shock or arrest; central access only

Vasopressors

Drug	Mechanism	Dose	Key Nursing Points
Noradrenaline	Predominantly α1 (↑ SVR); mild β1	0.01–1 mcg/kg/min	First-line vasopressor; central line mandatory; extravasation causes necrosis (use phentolamine if occurs); titrate to MAP
Vasopressin	V1 receptor → vascular smooth muscle contraction	Fixed: 0.03–0.04 units/min (not weight-based)	Preserves MAP without ↑ HR; useful in vasodilatory shock post-CPB; spares noradrenaline; do not exceed 0.04 units/min
Phenylephrine	Pure α1 agonist	0.5–5 mcg/kg/min	Causes reflex bradycardia; ↑ SVR without inotropy — use cautiously in depressed LV function; rapid bolus for acute hypotension

Antiarrhythmics

Amiodarone

Class III (Vaughan-Williams); also I, II, IV actions
Broad spectrum: AF, VT, VF, junctional tachycardias
IV loading: 300 mg over 30–60 min (central); maintenance 900 mg/24 h
Prolongs QT — monitor QTc; K⁺ and Mg²⁺ correction essential
Long-term toxicity: pulmonary fibrosis, hypothyroid/hyperthyroid, corneal microdeposits, hepatotoxicity, photosensitivity

Beta-Blockers

Metoprolol IV: 2.5–5 mg over 2 min; may repeat q5 min × 3
Esmolol: ultra-short acting (half-life 9 min); titratable infusion; ideal for acute rate control
Evidence: prophylactic beta-blockers reduce POAF by ~50%
Caution: ↓ HR in bradycardia, avoid in decompensated LV failure
Resume pre-op beta-blockers as soon as haemodynamically stable

Anticoagulation Post-Cardiac Surgery

Post-Op Anticoagulation Protocols ▶

Post-CABG

Aspirin 75–100 mg within 6–24 h post-op (proven graft patency benefit)
Dual antiplatelet (aspirin + clopidogrel or ticagrelor) if off-pump CABG or recent ACS — follow cardiologist instructions
UFH thromboprophylaxis when drain output low and no major bleeding

Post-Mechanical Valve

Target INR: Aortic mechanical: 2.0–3.0; Mitral mechanical: 2.5–3.5; High-risk: 3.0–4.0
Heparin bridging: UFH infusion started when drains removed and haemostasis confirmed, targeting APTT 60–80 s
Warfarin initiated: usually day 1–2 post-op (once haemostasis confirmed)
Heparin continued until INR therapeutic for 2 consecutive days
DOAC/NOAC: NOT recommended for mechanical valves (evidence of increased valve thrombosis)

Post-Bioprosthetic Valve

Warfarin for 3 months (target INR 2.0–3.0) then aspirin long-term (some centres aspirin alone from start)
If concurrent AF: lifelong anticoagulation as per AF guidelines (DOAC acceptable)

Protamine Reversal

Protamine neutralises heparin 1:1 (1 mg protamine per 100 IU heparin remaining)
Administration: slow IV over 10 min; rapid infusion → severe hypotension, bradycardia, pulmonary hypertension
Risk: anaphylaxis (protamine allergy: fish allergy, prior protamine-containing insulin — NPH insulin)
Monitor ACT after administration; second dose if ACT remains elevated
Heparin rebound: can occur 2–4 h after protamine — monitor ACT, repeat dose if needed

GCC Context: Cardiothoracic ICU Nursing

Contextual knowledge for nurses practising in the Gulf Cooperation Council (GCC) region across DHA, HAAD, MOH UAE, SCFHS, and QCHP-regulated environments.

GCC Regulatory Competencies

DHA / HAAD (UAE) CT-ICU Competencies

Critical care nursing licensure requires 2 years ICU experience minimum
Haemodynamic monitoring: arterial line, CVP, PAC management including PCWP interpretation
Cardiac device competency: IABP management, temporary pacemaker assessment
ACLS certification mandatory; BLS instructor certification valued
DHA DataFlow verification required; HAAD CBT examination (clinical + theoretical)
Continuing Professional Development (CPD): 30 hours/2-year cycle for DHA renewal

SCFHS (Saudi Arabia) Critical Care

Saudi Commission for Health Specialties classifies critical care nursing as a specialty
Prometric examination: ~170 MCQ questions; critical care pharmacology heavily tested
NCBE (National Competency-Based Examination) includes clinical scenario assessment
Cardiothoracic nursing recognised as sub-specialty under critical care
Required: equivalency certificate for non-Saudi nurses; experience letters from previous employers
Saudi Health Council oversees scope of practice; tamponade and emergency protocols in scope

QCHP (Qatar) Standards

Qatar Council for Healthcare Practitioners — Prometric CBT for registration
Critical care specialty: separate exam from general nursing
Good Standing Certificate required from country of previous practice
Qatar National Health Strategy emphasises cardiac care excellence (Heart Hospital, Doha)
Continuing education: 20 CPD credits/year required for renewal

MOH Oman / Kuwait / Bahrain

Mutual recognition among GCC states — SCFHS or DHA registration facilitates regional mobility
Oman Nursing and Midwifery Council (ONMC): DataFlow + competency assessment
Kuwait MOH: licensing exam covers critical care scenarios
All GCC states: language proficiency (English or Arabic depending on institution)

Ramadan Considerations — Post-Cardiac Surgery

Medication Timing Challenges

Oral medications: consolidate to Iftar and Suhoor doses where clinically safe
Warfarin: consistent timing critical for stable INR — advise taking at Iftar each day
Beta-blockers: once daily formulations preferable; do not abruptly stop — rebound tachycardia risk
Antiarrhythmics: amiodarone once daily can be given at Iftar; twice-daily regimens — Iftar + Suhoor
Diuretics: furosemide at Iftar (not Suhoor — dehydration and sleep disruption risk)

Clinical Monitoring Points

Dehydration increases blood viscosity → ↑ risk of graft thrombosis and AF
Fasting patients: monitor electrolytes (K⁺, Mg²⁺) — hypomagnesaemia → AF risk
Most Islamic scholars permit medications for critically ill patients — fatwa supports treatment continuity
Non-oral routes (IV, IM, inhaled) do not break fast per most scholarly opinion
Engage hospital chaplaincy/imam for patient-centred counselling
Document Ramadan fasting status and medication adjustment plan in care notes

Heat & Climate Effects on Cardiac Output

GCC summer temperatures > 45°C: significant cardiovascular stress on discharge patients
Heat → vasodilation → ↓ SVR → compensatory tachycardia; problematic in post-CABG patients on beta-blockers
Fluid shifts in heat: dehydration → ↑ blood viscosity → graft thrombosis risk; educate on 2–2.5 L fluid intake
Air-conditioned transition: rapid vasoconstriction on entering AC environments → BP spikes; caution in hypertensive patients
Outdoor activity restriction: no exertion outdoors between 10:00–16:00 post-cardiac surgery rehabilitation
Inpatient monitoring: patients transferred from cooler OR/ICU to wards may vasodilate → hypotension — assess on ward arrival

Cardiac Surgery Tourism in GCC

UAE, Saudi Arabia, and Qatar are regional leaders for complex cardiac surgery, attracting patients from South Asia, Africa, and the wider Middle East
Nursing implications: language barriers (interpreters via language line apps — TeleLanguage common in DHA facilities), cultural dietary preferences post-op, family involvement in decision-making
International patients: discharge planning challenges — ensure stable INR, device follow-up plan, and GP/cardiologist letter in patient's country language where possible
Flying post-cardiac surgery: generally safe at 4–6 weeks for uncomplicated CABG; earlier for repatriation in stable patients with medical escort
Documentation: discharge summaries in English + Arabic; device cards for pacemakers/ICDs (essential for airport security screening)

GCC Exam Prep — CT-ICU MCQs

DHA / MOH / SCFHS / QCHP style questions. Click "Show Answer" to reveal.

Q1. A patient is 2 days post-CABG. The nurse notes the ECG shows an irregularly irregular rhythm at 130 bpm. The BP is 102/68 mmHg. What is the MOST likely diagnosis and IMMEDIATE nursing priority?

A) Ventricular tachycardia — prepare for cardioversion immediately

B) Post-operative atrial fibrillation — assess haemodynamic stability and check electrolytes

C) Sinus tachycardia — administer IV fluids

D) Second-degree AV block — activate epicardial pacing

Correct Answer: B — Post-operative AF peaks on day 2–3 post-cardiac surgery. The irregularly irregular rhythm confirms AF. With BP 102/68 the patient is borderline haemodynamically stable. Priority: 12-lead ECG, electrolytes (especially K⁺ and Mg²⁺), rate control (amiodarone, beta-blocker), notify physician. Do not cardiovert unless haemodynamically unstable (systolic < 90 mmHg with symptoms).

Q2. A post-CABG patient's mediastinal drain output drops from 80 mL/hr to 5 mL over the last 30 minutes. Simultaneously, the CVP rises from 10 to 18 mmHg and MAP falls from 72 to 58 mmHg. Which condition MUST be excluded first?

A) Deep sternal wound infection

B) Cardiac tamponade

C) Pulmonary embolism

D) Hypovolaemia

Correct Answer: B — Cardiac tamponade. Sudden cessation of drain output with rising CVP and falling MAP is the classic tamponade picture post-cardiac surgery. The combination of hypotension + raised venous pressure + cessation of drainage must be treated as tamponade until proven otherwise. Escalate to surgical team STAT. Prepare for echo or emergency re-sternotomy.

Q3. A patient on IABP therapy shows the following waveform pattern: the balloon inflates BEFORE the dicrotic notch on the arterial waveform. What does this represent and what is the risk?

A) Late inflation — reduces diastolic augmentation, less effective support

B) Early inflation — increases ventricular afterload and may worsen aortic regurgitation

C) Late deflation — impedes LV ejection during systole

D) Early deflation — causes premature return of afterload

Correct Answer: B — Early inflation (balloon inflating before dicrotic notch / aortic valve closure) increases afterload because it impedes LV ejection while the valve is still open. It may also worsen aortic regurgitation. The nurse must notify the perfusionist or IABP-trained practitioner to delay the inflation trigger.

Q4. A patient with a newly implanted mechanical mitral valve is on heparin infusion with APTT 68 s. Warfarin was started 2 days ago; today's INR is 1.8. Which action is MOST appropriate?

A) Discontinue heparin — INR is now therapeutic for a mechanical mitral valve

B) Continue heparin — INR target for mechanical mitral valve is 2.5–3.5; 1.8 is sub-therapeutic

C) Switch to enoxaparin — equivalent to UFH for mechanical valves

D) Start rivaroxaban — DOAC is preferred for mechanical valves

Correct Answer: B — The INR target for a mechanical mitral valve is 2.5–3.5. An INR of 1.8 is sub-therapeutic. Heparin bridging must continue until INR is therapeutic for 2 consecutive readings. DOACs (rivaroxaban, apixaban, etc.) are CONTRAINDICATED in mechanical valves — increased valve thrombosis risk demonstrated in RE-ALIGN trial. LMWH (enoxaparin) is also generally not recommended for mechanical valves.

Q5. During administration of protamine to reverse heparin after CABG, the patient suddenly develops hypotension (MAP 48 mmHg), bradycardia (HR 44 bpm), and bronchospasm. What is the MOST likely cause and PRIORITY intervention?

A) Heparin rebound — give additional protamine bolus

B) Anaphylactic reaction to protamine — stop infusion; adrenaline IM/IV; fluid resuscitation

C) Cardiac tamponade — prepare for pericardiocentesis

D) Low cardiac output syndrome — start dobutamine

Correct Answer: B — This is an anaphylactic/severe adverse reaction to protamine. Risk factors include fish allergy and prior exposure to NPH (protamine-containing) insulin. The triad of hypotension + bradycardia + bronchospasm after protamine administration is classical. Priority: STOP protamine immediately, call for help, adrenaline (epinephrine) 0.5 mg IM (or IV 0.1 mg aliquots if arrest imminent), IV fluid bolus, antihistamine, hydrocortisone. Notify surgical/anaesthetic team immediately.