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CLINICAL PATHWAY FOR

ELECTIVE CABG SURGERY

I. PREOPERATIVE PATHWAY

A. CARDIOLOGY SPECIALTY CLINIC

Location SPECIALTY CLINIC


Consults o ISCHMEMIC SERVICE/CATH conference: Coro
angiography results available
o Social Welfare Consult
o PULMONARY CLINIC
o Pulmonary FunctionTests on selected patients
o Arterial Blood Gas
o Nephrology Consult for Renal Patients
o Neurology Consult
o Dental consult for valve pts
o Nutrition care for preoperative assessment
o Pulmo Rehab
o Consider use of autologous blood

CONSULTS COMPLETED PRIOR TO CARDIAC SURGERY


REFERRAL

Tests LABS: CBC, CHEM-7 (Na, K, Mg, Ca)

o , PT,APTT, Alkaline phosphatase, SGOT Bilirubin, Uric


Acid
o Chest X-ray (with in 30 days of surgery)
o 12-L ECG (within one week of surgery)

RESULTS AVAILABLE FOR PREOPERATIVE REVIEW PRIOR


TO CARDIAC SURGERY

Assessment o Nursing- History and Assessment


o Cardiac risk factors with appropriate referrals (smoking
cessation, nutrition)
o Physician- History and Physical Examination

PRE-OP ASSESSMENTS COMPLETED

Treatments o Stress Test, Dobutamine Echocardiography, MPI as


Required
o Dental Clearance for if with concomitant valve lesions
o Vascular Section Evaluation

Medications o Beta-blocker
o Statins
o ASA
o Clopidogrel

Diet/ o As Prescribed
Nutrition
Activity o Activity as tolerated /as ordered pre- operatively

Education o Advance Directive information provided


Discharge o Home care needs assessed: support system, home care
Planning provider home care plan
o Identify Primary Care physician

PATIENT/FAMILY PARTICIPATE IN DISCHARGE PLAN

B. CARDIOVASCULAR SURGERY SPECIALTY CLINIC

Location Surgery OPD Clinic


Consults o Ischemic Service Consult:
st
o 1 year Fellow
 Prepares Powerpoint for Pre-Op presentation
o Senior Fellow
 Determine approval of Social Welfare as
Service Case
 Determine Patient Category
 Schedules Surgery Date
o Referral to Head of Adult CV Surgery
o Referral to Ischemic Section Head
o Referral to Consultant-on-Deck
o Co-Management Refererral: (PRN)
o Adult CT Valve Service
o Adult CT Vascular Service
o Adult CT Congenital
o Adult CT Misc. Service

Tests o Review of:


o 2DED film
o Coronary Angiogram
o Stress Test
o MPI

o Review of Lab results


o Request additional Labs as Required
o Blood Donor Selection
o Type & Cross-match:
o 4units Packed RBCs
o 4 units Fresh Frozen Plasma
o 4 units Platelet concentrate

Assessment o Physician History and PE


o Ankle Brachial Index, (Need for Venous Mapping)
o Arterial Duplex Scan, Carotid Duplex Scan
o Cardiac Risk Factors Assessment
o Euroscore
nd
o Surgical consent signed/ witnessed – 2 year Surgery Fellow
o Anesthesiologist pre-anesthetic evaluation
o Pre-surgical multi-disciplinary patient education

PRE-OPERATIVE ASSESSMENTS COMPLETED


PATIENT/FAMILY VERBALIZE MANAGEABLE ANXIETY
CARDIAC SURGERY PRE OP CHECKLIST COMPLETED
AND REVIEWED
Treatments
o
Medications o Continue patient’s normal medications
o Discontinue NSAIDS, ASA, warfarin per order
o Pre-operative medications per anesthesia orders

PATIENT VERBALIZES UNDERSTANDING OF MEDICATION


INSTRUCTIONS
Diet/ o Continue normal diet
Nutrition PATIENT VERBALIZES UNDERSTANDING OF DIET
ORDERS
Activity Activity as tolerated /as ordered

PRE-OP ACTIVITY LEVEL DOCUMENTED


Education o Pre-op teaching completed (Surgeon, nursing, Anesthesia,
SSC)
o Cardiac risk factors discussed
o Explain patient calendar/ care pathway
PATIENT/ FAMILYPARTICIPATE IN IDENTIFYING LEARNING
NEEDS
Discharge o Home care needs assessed: support system, home care
Planning provider home care plan
o Identify Primary Care physician/ Referring Cardiologist
PATIENT/FAMILY PARTICIPATE IN DISCHARGE PLAN

C . HOSPITAL ADMISSION

Location Admission
Consults o Surgery Pre-Op Conference
Tests o Additional/ Repeat Diagnostics as required
Assessment o Mediastinitis Risk
o Mortality Risk
o CVS risk
o Suitability for Bypass/ Maximal Medical Management
o Number of Bypassable Vessels
o Pre-Op IABP
o Concomitant Valve Surgery/CEA
o Urgency of Surgery

Treatments o Dobutamine Stress Echo


o MPI
o
Medications Confirm Discontinuation of Oral Anti-Coagulant Medications
Diet/ Pre- Nutritional Rehabilitaion
Nutrition
NPO AFTER MIDNIGHT

Activity Activity as tolerated /as ordered


PRE-OP ACTIVITY LEVEL DOCUMENTED

Education
Discharge o Discharge Plans if Inoperable
Planning

D . PRE-OPERATIVE TO OPERATING ROOM

Level of Care Pre-Op  O.R


Location WARD/ROOM
Consults o Set Final Date of Surgery
o If with Valve procedure, IntraoperativeTEE
Tests o Labs per Surgical OR protocol
Assessment o Physical assessment per intra-operative protocol
o Pre-Operative Checklist
o Time-Out
o
Treatments o Hibiclens shower :
o night prior to surgery
o morning of surgery
o Weight recorded: ICU and WARD
o I & O documented:
o Cardiopulmonary Bypass fluids
o Anesthesia totals
o PHC Insulin Protocol
o
Medications o Vancomycin 1 GM IVPB) 1 Hr PTOR
o Gentamycin 240mgIV 1 Hr PTOR
o Pre-op meds per anesthesia orders
o Anesthesia per Rapid Extubation protocol

Diet/ o NPO
Nutrition
Activity o Ambulatory  bedrest
Education o Surgical consent signed and witnessed
o Reinforce pre-operative teaching
o Initiate Patient Plan
o Family Operative updates prn by surgeon/ attending
cardiologist
PATIENT/HOME CARE PROVIDER VERBALIZE
UNDERSTANDING OF POST PROCEDURE CARE PLAN
Discharge o ICU and Respiratory Therapist notified of pending patient
Planning transfer from OR
ADDITIONAL DISCHARGE PLANNING NEEDS IDENTIFIED

II. OPERATIVE DAY/ RECOVERY ROOM PATHWAY

Level of Care OPERATION TO EXBUTATION


Location OR to RR
Consults o Critical Care Service
o CV Surgery
o CV Anesthesia
o Cardiology
o Co-Management:
o Pulmonology
o Nephrology
o Neurology
o IDS
o Vascular Medicine

Tests o STAT labs per protocol


o STAT Chest X-ray, ECG
o Hematocrit q. 6 hrs and after PRBC transfusion
o K+ q. 4 hrs X 3 and after PRBC transfusion
o STAT serum K+ at least q. 1 hr if urine output >400cc / hr
o ABG as needed
o Diabetics: STAT Blood Glucose repeat q. 4 & 8 hrs then q. 8
hrs
LABS , ECG, XRAYS WITHIN EXPECTED LIMITS
DIABETICS : Glucose controlled

Assessment o Hemodynamic monitoring:


o Swan Ganz, EKG, A-line
o Temporary pacemaker available
o VS q 15 min X 8, then q 1 hr
o Cardiac output: q ½ hr X 4, then q 1 hr X 6, then q 2 hr X 6,
then PRN until SGC dc’d
o Pulse oximetry continuous
o Systems assessment q shift and PRN
o Wound assessment
NORMOTHERMIC
NO EVIDENCE EXCESSIVE BLEEDING
HEMODYNAMICALLY STABLE
ADEQUATE RESPIRATORY WEANING PARAMETERS

Treatments o Foley cath


o Oral/gastric tube to low cont suction
o Chest tube to 20 cm suction and care per protocol
o I & O q. 1 hr- include urine, chest tubes
o Initiate early extubation protocol
o Endotracheal suction PRN
o O2
o Soft wrist restraints while pt is intubated per protocol
o Dressing changes per protocol
o Pacer wire care per protocol
o Pacemaker standby
o Observe for bleeding: CT output, wounds, lab values
o Heat lamp/Bear Hugger to core temp 370C
MINIMAL CHEST TUBE OUTPUT
SUCESSFULLY WEANED FROM VENTILATOR

Medications o D5NS @ 20cc/hr via cordis


o Levophed 4mg/ 250cc D5W o/c
o Nitroglycerin 50mg/ 250cc D5W o/c
o Sodium Nitroprusside 50mg/250cc D5W o/c
o Antibiotic IV per orders
o Analgesia IV per orders
o Omeprazole 20mg IVPB q. 12 hrs
o KCL replacement per orders
o MgSO4 replacement per orders
o Paracetamol 300mg IVTT for T>38.4C
o Plasmanate / Albumin/ Hespan for volume replacement
and notify House Officer
o Sedation per protocol
o Auto transfusion per protocol
MAINTAIN HEMODYNAMIC STABILITY WITH MEDS AS
NEEDED

Diet/ o NPO
Nutrition o Oral/gastric tube to low suction

Activity o Cardiac position until weaned for extubation

MEETS WEANING PROTOCOL:


o Hold head up x 5 seconds
o Follow simple commands
o Move extremities x 4

Education o Reinforce teaching


o Review patient progress using Patient Plan

Discharge o Social Welfare Services Discharge Planning screening


Planning

III. POSTOPERATIVE PATHWAY

A. EXTUBATION

Level of EXTUBATION
Care
Location ICU  Ward
Consults Remove from VSI list

Tests o CBC, Chem 10, a.m. after surgery


o PT, PTT if bleeding
o Chest X-ray, ECG in a.m. and PRN
o Diabetics: STAT Blood glucose check q. 6 hrs until on diet

LABS, EKG, XRAYS WITHIN EXPECTED LIMITS


DIABETICS :Glucose controlled

Assessment o Discontinue all central lines


o VS q. 1 hour
o Cardiac monitoring
o Pulse oximetry continuous
o Systems assessment q. shift and PRN
o Pacer wire removal per protocol
o Wound assessment

Treatments o Foley catheter until 2200 evening of transfer


o Daily weight by 0500
o I & O q. 1 hour
o Chest tube removal – as per MD orders
o Dressing changes per protocol
o Pacer wire removal / care per protocol
o Incentive spirometry supervised q. 1 hr while awake
o C & DB
o O2 @ 4L/NC. Wean as tolerated to maintain SAO2 > 90%
o Wound care per protocol

MAINTAINS SAO2 >90% ON NASAL CANNULA


NO EVIDENCE OF BLEEDING S/P PACER WIRE AND CHEST
TUBE REMOVAL

Medications o Hep lock IV for transfer to Ward


o No IV drips
o Analgesia P.O. per orders
o BP and Atrial fibrillation management per orders
o Antibiotics per orders
o CT removal per MD order
o Ketorolac 30mg q 8 hrs for analgesia per orders
o Enteric Coated ASA 325 mg P.O. q. day
o Oral Beta-Blockers
o LMWH (DVT Prophylaxis)
NO VASOACTIVE DRIPS
Diet/Nutrition o NPO  advance to ice chips, to Clear Liquids, to Post
CABG diet as tolerated
CLEAR LIQUID DIET TOLERATED

Activity o Out of Bed (OOB) to chair


o Ambulate PRN
o HOB up 300 - advance as tolerated
MAINTAINS STERNAL PRECAUTIONS
TOLERATES ACTIVITY WITH STABLE VITAL SIGNS

Education o Reinforce pulmonary toilet, activity, pain management plans

Discharge o Ongoing SWS assessment as needed


Planning

B. POSTOPERATIVE DAY 1

Level of 1 POST- OPERATIVE DAY


Care
Location Ward

Consults
Tests o Chest X-ray , ECG in a.m. X 1
o Diabetics: Blood glucose check 30 min before meals and
H.S.
o Warfarin patients: Prothrombin Time q. a.m.

LABS, ECG, XRAYS WITHIN EXPECTED LIMITS


DIABETICS : Glucose controlled

Assessment o Cardiac/telemetry monitoring


o VS + pulse oximetry q. 4 hrs
o Systems assessment q. shift and PRN
o Wound assessment

Treatments o Daily weight by 0500


o Dressing changes per protocol
o Foley catheter removed at 2200 hrs
o Incentive spirometer q. 1 hr while awake
o C & DB
o O2 @ 4L/NP. Wean as tolerated to maintain SAO2 >90%
o Wound care per protoco

Medications o Enteric coated ASA 325mg P.O. q. day for patients not
receiving Coumadin
o Mefenamic Acid q 6 hrs P.O. q. 6 hrs PRN (with food)
o Colace 250mg P.O. BID
o MOM 30cc P.O. PRN constipation
o Restoril 15mg P.O. PRN sleep -may
o repeat X 1
o Beta Blocker:
o Kdur:
o Lasix

Diet/Nutrition o Post CABG diet as tolerated


o Attend dietary class on ward

POST CABG DIET TOLERATED


Activity o Stand to weigh
o OOB to chair BID
o Ambulate with assistance
Education 
Discharge o Ongoing SWS assessment as needed
Planning o Physical Therapy/OT per protocol

C. POSTOPERATIVE DAY2

Level of 2 POST- OPERATIVE DAY


Care
Location Ward
Consults
Tests o Chem 7 in am
o Chest Xray, EKG in a.m. and PRN
o Diabetics: Accucheck 30 min before meals and h.s.
o Coumadin patients: PT q. a.m.

LABS, EKG, XRAYS WITHIN EXPECTED LIMITS


DIABETICS : Glucose controlled

Assessment o Telemetry monitoring


o VS + pulse oximetry q. 4hrs
o Systems assessment q.shift and PRN
o Wound assessment

Treatments o Daily weight by 0500


o Shower daily after CT removed (cover pacer wires)
o D/C chest and leg dressing
o Paint incisions with Betadine q. day
o If wound is draining, continue dressing changes using
sterile technique q shift and prn
o Replace Foley catheter if no void by 0600 hr
o Incentive spirometer q. 1hr while awake
o C & DB
o O2 @ 4L/NP. Wean as tolerated to maintain SAO2 > 90%
o Wound care per protocol

Medications 
Diet/Nutrition 
Activity

Education 
Discharge o
Planning

D. POSTOPERATIVE DAY 3 to DISCHARGE

Level of 3 POST- OPERATIVE DAY  DISCHARGE


Care
Location Ward
Consults
Tests o CBC, Chem 7 third day after transfer to 2ward
o Diabetics: Blood Sugar check 30 mins before meals and
H.S.
o Warfarin patients—PT q. a.m.

LABS, ECG, XRAYS, WITHIN EXPECTED LIMITS


DIABETICS : Glucose controlled

Assessment o Telemetry monitoring


o VS + pulse oximetry q. 4 hrs
o Systems assessment q. shift and PRN
o Wound assessment

HEMODYNAMICALLY STABLE
NO DYSRRYTHMIAS
AFEBRILE
+ BOWEL MOVEMENT
ADEQUATE COMFORT LEVEL WITH ORAL ANALGESIA
ADEQUATE ANTICOAGULATION FOR VALVE PATIENTS
WOUND CLEAN, DRY , INTACT

Treatments o Daily weight by 0500


o Shower daily (cover pacer wires)
o Paint chest and leg incisions with Betadine q. day
o If wound is draining, continue dressing changes using
sterile technique q. shift and PRN
o Incentive spirometer q. 1 hr while awake
o C & DB
o O2 @ 4L/NP. Wean as tolerated to maintain SAO2
o Wound care per protocol

WEIGHT = PREOPERATIVE LEVEL


PATIENT/HOME CARE PROVIDER DEMONSTRATE
APPROPRIATE WOUND CARE

Medications o Enteric coated ASA 325mg P.O. q. day for patients not
receiving Warfarin
o Analgesics P.O. q. 4hr PRN pain (with food)
o Colace 250mg P.O. BID
o MOM 30cc P.O. prn constipation
o Restoril 15mg P.O. PRN sleep
o Beta Blocker:
o K dur:
o Lasix:
o NO MEDICATION ADJUSTMENTS REQUIRED
o TAKING MEDICATIONS
o APPROPRIATE FOR OUTPATIENT SETTING

Diet/Nutrition o Post CABG diet as tolerated


POST CABG DIET TOLERATED

Activity o Supervised ambulation in hallway at least QID


INDEPENDENT /MINIMAL ASSIST FOR ADLs AMBULATING IN
HALLWAYS

Education o Medications reviewed


o Follow-up appointments reviewed
o Printed Open Heart discharge instructions reviewed with
patient home care provider per CV Nurse Specialist
o Wound care instructions reviewed
o Multidisciplinary Patient Education Form reviewed
PATIENT/HOME CARE PROVIDER VERBALIZE
UNDERSTANDING OF DISCHARGE INSTRUCTIONS

Discharge o Ongoing SWS assessment as needed


Planning
PATIENT/CARE PROVIDER VERBALIZE/DEMONSTRATE
ABILITY TO PROVIDE CARE AT HOME

PATIENT VERBALIZES UNDERSTANDING OF POST OP


CLINIC APPOINTMENTS:
o 5-10 days to CV Surgeon (scheduled by C/T clinic)
o 2-4 weeks to Cardiology-(scheduled by TRAC)
o PCM appointment for ongoing health promotion

o Specialty clinic appointments as ordered on


Multidisciplinary discharge form

E. POSTOPERATIVE OUTPATIENT FOLLOW-UP

Level of Care Post Op Follow Up Post Op Follow Up


(5-10 days) (2-4 weeks)

Location CV Surgery Clinic Cardiology Clinic

Consults o Consider consult to o Seen by MD who


Nutrition Clinic scheduled surgery
o Make referral to
outpatient Cardiac
Rehab Program
when appropriate

Tests o Labs as indicated o Echocardiogram-for


o Chest x-ray valve patients
o Treadmill
scheduled
Assessments o Follow up phone
consult by Cardio
Thoracic Nurse
Specialist 2-5 days
post discharge
o Evaluate
understanding of D/C
instructions and
medications
o Assess activity level
o Assess wound status
and wound care

Treatments o Suture/staple
removal if required

Medications o review medications


o Aspirin, 75 to 325 mg
per day
o Clopidogrel (Plavix),
75 mg per day, in
patients who cannot
tolerate aspirin or in
addition to aspirin,
with treatment given
for up to nine months
o Beta blocker in
patients without
contraindications
o Statins: Lipid-
lowering agent
(statin) and diet
therapy in patients
with an LDL
cholesterol level
above 130 mg per dL
(3.40 mmol per L), or
in patients with an
LDL cholesterol level
higher than 100 mg
per dL (2.60 mmol
per L) after diet
therapy*

Angiotensin-
converting enzyme
inhibitor in patients
with congestive heart
failure, left
ventricular
dysfunction (ejection
fraction below 40%),
hypertension, or
diabetes mellitus

Diet/Nutrition o Evaluate activity


Activity tolerance
o Reinforce no driving
X 6 wks post op

Education o Reinforce sternal


precautions
o Review wound care
o Review medication
instructions
o Control Risk Factors
for Atheroscelrosis:
o Stop
smoking
o Appropriate
body weight
should be
manitained
o Diet
o Control HPN
o Avoid
saturated
fats
o Serum lipids
must be
normal
Discharge o Referred back to o Referred back to
Planning Cardiology PCM for ongoing
o Clinic health promotion
and follow up