Cardiac surgery

The left hemidiaphragm is often elevated after cardiac surgery. In one study it was found that, if ice slush was used for topical cooling of the heart, the hemidiaphragm was elevated in 26 per cent of patients. If an internal mammary artery graft was used, the incidence increased to 39 per cent. In addition to the risk factors mentioned above, the phrenic nerve may be injured directly by topical cooling. Phrenic nerve injury can also occur during mobilization of the internal mammary artery because of its anatomic proximity. Bilateral phrenic nerve injury can result in the need for prolonged ventilatory assistance and tracheostomy. Another potential mechanism of atelectasis unique to cardiac surgery arises if the cardioplegia solution enters the pulmonary circulation. It is postulated that the high potassium chloride concentration may damage pulmonary endothelial cells.

Recommendations to prevent or minimize atelectasis after cardiac surgery include the use of careful technique in mobilization of the internal mammary artery, use of a pericardial insulating pad, avoidance of entry into the pleural space, and recovery of as much of the cardioplegia solution as possible before it enters the pulmonary circulation.

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