dr.

Nanik Trimulyani, SpKFR

PERKI / PERDOSRI
SEMARANG
CABG : Coronary Artery Bypass Grafting
GOALS :
1) ↑ Revascularization→ ↓Symptoms→↑Survival
2) ↓ Morbidity & Mortality
3) ↑ Quality & Length of Life

CABG

+ CPB (Cardio
Pulmonary - CPB
Bypass →Heart
Lung Machine)
Effects Of CPB During & After Operation:
 Lung Vascular Resistance ↑
 Platelet & Leucocyte Aggregation in the Lung
Vasculature
 Release of Vasoactive Subtances of Leucocyte & Lung
endothels during CPB → Inflamatory Reaction
→ Respiratory Complication → Post Op:
- Vital Capacity↓
- Spontaneous Respiratory Work ↑
- Inspiratory Cap ↓ Ended up
- Functional Residual Cap↓ ±2 weeks
- Surfactant Production↓ post op
 Effect On Renalfuction etc
1. Narcotics & Sedatives Block Respiratory Drive
Activation:
- ↓ Response to Hypoxia
- ↓ Response to Hypercapnia
- ↑ Dead space of the Lung
2. Neuro muscular blocking drugs → Total Minute
Ventilation ↓
Post Op : - Dizziness, Light Headedness
- Muscle weakness
- Prolong time for weaning
- > Ventilator dependency
1. Low Output Syndrome
2. Cardiac Tamponade
3. Perioperative myocardial
infarction
4. Arrhythmia
5. Thromboemboli
6. Haemorrhage post op
7. Post perfusion Syndrom
(Effect of CPB)
8. Acute Renal Failure(CPB)
9. Icteric – Hepatic disorders
(Alb, Glob, etc?)
10. Stress Ulcer
11. Neurologic Abnormalities
ec Hypoxia, Emboli,
Bleeding, metabolic
disorders, anesthetic drugs
12. Infection on the surgical
sites →mediastinum, lung,
systemic
13. Death
Definition : Interdisciplinary approach to restore
maximally physical, mental emotional, socioeconomic,
sexual & vocational function of patients undergone
CABG.

GOALS:
 Return to work → as soon as possible → productive
+/↑
 ↑ CV Functional cap: optimal → maximal
 No return to previous work:
1. maintain active living
→↑Q of L
2. change other job
I. In ICU
1. General Condition
 Consciousness, speech, language, perception,
dysarthry, dysphagia, memory GCS
 Movement : N/ Paresis/ Chorea/ Dyskinesis

 Haemodynamic state: HR, BP, RR, Diuresis,

Turgor, Temp
 Nutrition State: <</ </N/ >/ >>

 Renal & Liver fungtion (Clinical & Laboratory

Findings)
 Comorbidity pre op?
2. Lung Function : (Pre Op Problems : Smoker, Bronchial
Hypersecretion, Infection ect)

Thoracal Cavity Opened →Vital Cap ↓  Hypoxemia ±18 Hours

post op
 Breathing Pattern (N/ Cheynestoke/ Kussmaul/ Apneu)
 Ronkhie after hypothermia effect: Overfluid, lungedema,
microatelectase, pneumonic aspiration, negative pressure
pulmonary edema (→ non cardiogenic)
 Respiratory impairment:
 Bronchial Hyperresponsiveness →airway obstruction
 Low lung volume →gas diffusion ↓ → atelectase
 Respiratory muscles weakness →Inadequate coughing
 Neuromuscular disorders (chest wall & Spinal
deformity)→thoracic & lung expansion↓
 Residual of neuromuscular blocking drugs → prolonged
weaning time
 Edema glottis / subglotis →resp. failure

Rehab : Chest physiotherapy & secret elimination, ROM & General

ex, early mobilization
 CABG stress CV system →haemodynamic ↑↓abruptly

-Hypovolemic →Preload ↓
Cardiac output + SVR ↓
-Ischemic/ myoc. Infarction
↓
→LV Function ↓→RVHF
Hypotension
& Dysfunction →
↓
cardiac tamponade
Cardiogenic shock
-Electrolyte
↓
imbalance→acidosis
Fatal
-Dys/ Arrhythmia→Fatal

Hypertension: -Inadequate analgesic

-Vasoconstriction ec. Residual hypothermia
-Previous HT

Rehab: !!Monitor Haemodynamic during physiotherapy!!

 ● Haemostatic impairment on
CPB
● Hypothermia
● Inadequate heparine Liver Function !
● Platelet dysfunction
● Prolonged fibrinolysis
● Coagulation factors ↓

Haemorhage → haemodynamic instability

→tamponade→ Re Exploration

Rehab: !!! Surgical Sites !!!

A. Cerebral emboli : Light → severe symptoms
(cerebrovasc collaps) → - Coma
- Sudden death
 A. Cerebri Media : Hemiparesis,
Hemisensoric deficits, Dysphasia,
Dysphagia, Hemianopsia, ect.
 A. Vertebrobasillaris : Diplopia, Vertigo,
Ataxia, Cross/ Billateral impairment of
sensoric/ motoric →coma → Fatal
B. Encephalopathy (Hypotension →Ischaemic area >):
Confusion, delirium, stupor, coma.
Convulsion, myoclonus movement on deep
tendon reflexes, tetraparesis/ plegia, paratonic
rigidity, focal neurologic sign (mono/hemiparesis)

C. Peripheral nerve system : lesions of plx brachialis,

n. peroneus communis, n. saphenus, n. ulnaris, n.
phrenicus (persistent singultus), n. laryngeus
(paralysis of plica vocalis), neuropathy facialis,
partial horners syndrome.

Rehab: Physiotherapy, speech therapy,

occupational therapy, orthotics / walking aids,
social worker.
Cardiac output ↓→Renal blood flow ↓→Decompensated kidney

Rehab: Chest Physiotherapy

Rom & General
Strengthening Ex
ARF → Oliguria
↓
Active Passive Electrolyteimbalance
↓
Na ↓,K ↓
↓


Hemodynamic
Surgical Sites !! Arrhythmia
↓
Fatal
7. Psychosocial problems : Anxiety, Depression,
Neurosis → Psychologist / Psychiatrist

8. Vocational problems:
- Occupational Therapist
- Social worker
 Breathing Ex, Huffing, Effective coughing
 Postural drainage, chest physiotherapy
 Respiratory muscles & diaphragm strengthening Ex
 General ROM Ex: !! Shoulder!!, Ankle pumping
 Static Contraction !! Upper back & shoulder Arm!!
 General Ex. →Extremities, neck & Trunk
 Mobilization (Gradually) → Up to Sitting on The Bed
 Psychosocial Management

Surgical Sites
Haemodynamic !!
II.In High Care Unit
 No Complication → Continue Above
Management
 Mobilize Patient → Bedside Sitting with
dangling feet → standing
 Incentive Spirometry to expand the
thoracic volume & ↑ Lung capacity
 Any Complication : Rehab Adapted
specifically (Stroke)

!! Surgical Sites & C.V Problems !!

III. Average Rehab Management before discharge:
 Rom & General Ex

 Mobilization →Walking → Distance & Speed ↑

Gradually
 6 M Walk test before discharge  repeat every
month
 Incentive Spirometry →Target ≥ Pre Op

 Home Training program before discharge ( !!

General condition, comorbidity, physical
adaptation, complication exist during hospital
stay, ect !! ), Education
 Endurance Ex: Low level with interval(Brisk
walking, stair climbing):Discharge → 2-3
months afterwards
IV. Rehab management post CABG in the long
run (› 3 mo)
!! General condition, haemodynamic, nutritional states, comorbidities !!
 ↑ Lung functional capacity
 ↑ C.P Functional cap.
 ↑ Musculoskeletal strength
 ↑ ADL →sense of well being in doing ADL ↑
 ↓ Psychosocial problem
 ↓ Sexual problem
 ↑ Return to work
 ↑ Quality & length of life
 Secondary / Tertiary prevention:
- Education
- Lifestyle modification
- Ex programs:
•Endurance Ex (F, I, T, T)
•Resistance Ex: *needed for ADL↑
*Return to work

Strength, flexibility, balance, speed, weight bearing → ↑Endurance →

functional cap ↑ → Q of L ↑
 Elderly
 LVEF↓↓
 DM
 Multivascular Involved
 Female

Predictors:-Class of angina
-Hypertension
-Perioperative myocardial infarction
-Renal dysfunction
-Clinical CHF
-Repeated angina
-Obesity/ cachexia
-Less commonly used a. mammaria interna
Thank You