WELCOME

Care of patients undergoing cardiac surgery

VIJAYAKRISHNAN.R MSc. RN STAFF NURSE-A CSWRD SCTIMST

INTRODUCTION
Mankind has long recognized the heart as vital to sustaining life-often romanticizing it as the repository of the soul and the seat of the emotionsbut we did not have the ability to repair it surgically until a relatively short time ago.

Nurses care for patients through out all phases of cardiac surgical experience nd have an important role in enhancing psychological, physiological, and functional status and self care outcomes.

CABG
Coronary artery bypass graft (CABG) surgery is indicated for patients with coronary artery disease to relieve symptoms, improve quality of life, and/or prolong life. Proper preparation of the patient and significant others, expertise during the intra operative phase, and a thorough knowledge base combined with skill and compassion of the nursing staff during the postoperative phase increase the likelihood of a positive outcome for the patient

As operative techniques continue to improve and perioperative care is enhanced, patients who were once denied surgery may now be surgical candidates. With this increase in the complexity of surgical cases, it becomes even more crucial that there be an effective collaboration among the surgeon, the anesthesiologist, the perfusionist, and the perioperative nursing staff.

Heart bypass surgery creates a conduit or"bypass" around the blocked part of acoronary artery to restore the bloodsupply to the heart muscle.The surgery is commonly called CoronaryArtery Bypass Graft, or CABG

PREOPERATIVE ASSESSMENT AND

PREPARATION

Assessment

History History of DiabetesPromotes arterial atherosclerosis, retards healing and predispose infection.

Investigations Chest X-Ray Echocardiography-assess ventricular function ECG Cardiac Catheterization

Hematological Tests
Detailed coagulation profile Blood typing and cross match Blood virology

Education of the patient prior to surgery

assists with recovery, increases patient contentment, and decreases postoperative complications

Important Preoperative Teaching Points

Focus Points for Preoperative Patient Education

1. Sights and sounds in the perioperative environment

2. Insertion of monitoring lines

3. Preoperative medications and anticipated sensations

4. Use of incentive spirometer.- Deep breathing and coughing exercises 5. Length of the operation

6. Expectations related to postoperative environment 7. Availability of postoperative pain medication and nursing staff 8. Effectiveness of splinting incision for pain control 9. Postoperative presence of an endotracheal tube 10. Anticipated time of intubation 11. Communication issues 12. Postoperative activity 13. Preparation of the significant other

INTRAOPERATIVE CARE

POSITIONING

Commonly supine position -Allows best exposure to heart and great vessels -access for cardiopulmonary bypass -less respiratory impairment and postoperative discomfort. o Dependent areas and bony prominences are padded with soft material to prevent skin breakdown, neurological damage, and pressure necrosis resulting from immobility o Padding prevents venous stasis ulcers.
Factors associated with development of pressure ulcers
1. Diabetes mellitus 2. Lower preoperative Hb, hematocrit and serum albumin 3. Presence of Intra Aortic Balloon pump

Arms are positioned anatomically along the side of the body. The legs may be slightly everted to provide access to the femoral arteries for insertion of pressure lines or intra aortic balloon pumps. Or to excise the saphenous vein.

ANESTHESIA
After the insertion of the invasive lines, anesthesia will be administered. It is important to provide anesthesia, analgesia, and amnesia with agents utilized during the operation. Inhalation agents and intravenous narcotics are given to induce anesthesia. Examples of inhalation agents are desflurane and sevoflurane. After anesthesia is induced the patient will be given a neuromuscular blocking agent, such as pancuronium or rocuronium, to facilitate endotracheal intubation and relax the skeletal muscles.

Narcotic agents such as fentanyl will assist with anesthesia and will also promote analgesia.5 Amnesia can be accomplished with the inhalation agents as well as with a benzodiazepine such as midazolam. After the patient is anesthetized, there will be a head-to-toe surgical preparation and insertion of a urinary catheter.

INCISIONS

The standard surgical approach is via a median sternotomy. Sources of grafts can be the internal mammary artery, the radial artery, the gastroepiploic artery, and/or the saphenous vein. The internal mammary and the saphenous vein continue to be most commonly used for grafts. At 5 years postoperatively, 70% to 80% of saphenous vein grafts are patent compared with a 40% to 60% patency rate at 10 years. In comparison, there is a 90% patency rate of internal mammary artery grafts at 10 years

CARDIOPULMONARY BYPASS (CPB)

CPB comprises an extra corporeal circuit that circulates systemic throughout the body during the periods of time the heart and lungs are not functioning during cardiac surgery.

Components

Venous and arterial cannulae Oxygenator Heat Exchanger Pump Filters

HEPARIN DURING CPB

Heparin used for anticoagulation to prevent clotting in CPB circuit Before initiation of CPB heparin 3mg/kg is administered through central line. Monitor ACT Heparin reversed when CPB is off using protamine sulphate

Administer protamine slowly Watch for possible protamine reaction Vary from mild hypotension to full blown anaphylaxis

COMPLICATIONS OF CPB
Triggers a series of cascades mediated by proteolytic enzymes as a result of bloods contact with non endothelielal surfaces in CPB. Produce a systemic inflammatory response that releases biologically active substances that impair coagulation and immune response. Oxygen free radicals are released in response reperfusion injury-transient ventricular dysfunction postoperatively. Systemic warming is started approximately 30 mts before the anticipated time of discontinuing CPB

If

left atrium , left ventricle, or aorta has been entered, air must be evacuated before aortic cross clamp removal to prevent air embolism. CPB Weaning Begins by ventilation of lungs. Gradually weaned by decreasing the amount of blood diverted through CPB circuit. When heart is functioning normally with adequate pressure and adequate cardiac index CPB discontinued, heparin reversed and cannulae removed.

MYOCARDIAL PROTECTION
Defines as the specific intraoperative strategies designed to protect the myocardium from tissue damage resulting from the ischemic state the occurs with extra corporeal circulation. Hypothermia Deliberate reduction of body temperature for therapeutic purposes. Moderate hypothermia (28oC [82.4o F] significantly reduces oxygen consumption. Surface cooling of heart with topical application of cold saline.

CARDIOPLEGIC ARREST
Cardioplegic arrest is accomplished by infusing the coronary arteries with a 4o C to 10o C solution containing (2 to 50 mEq/lr), blood to replenish oxygen and buffering agents to counteract ischemic acidosis. Potassium acts by depolarizing the myocardial cell membrane and arresting the heart in diastole. Delivery of cardioplegia solution can be anterograde or retrograde.