8/13/2019 cabg-130102113345-phpapp01

1/29

Critical Care Nursing - Clinical

Seminar Title :

CABG ( Coronary Artery Bypass Graft )

OR

ACB ( AortoCoronary Bypass )

Served To :Dr. Lourance Al Hadid

MsN. Hadeel Taleb

Prepared by :

Khaled Mahajna

8/13/2019 cabg-130102113345-phpapp01

2/29

Outlines

Definition of CABG

Review of Coronary Arteries

Purposes

Indications for CABG

Contraindications for CABG

Procedure

Nursing Management

Pre operative Phase Intra operative Phase

Post operative phase

Complications

References

8/13/2019 cabg-130102113345-phpapp01

3/29

Objectives

At the end of this presentation the students will be able to :

1. Define CABG

2. Describe the review of coronary arteries

3. Describe the process of the procedure

4. Use the nursing management

5. Define the indications , contraindications , complications

8/13/2019 cabg-130102113345-phpapp01

4/29

Definition

Is a surgical procedureperformed to relieveanginaand reduce the risk of death fromcoronary artery disease. Arteriesor veinsfromelsewhere in the patient's body are grafted(internal thoracic arteries, radial arteries andsaphenous) to the coronary arteriesto bypassatheroscleroticnarrowingsand improve thebloodsupply to the coronary circulationsupplying the myocardium(heart muscle).This surgery is usually performed with theheart stopped .

http://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Angina_pectorishttp://en.wikipedia.org/wiki/Coronary_heart_diseasehttp://en.wikipedia.org/wiki/Arteryhttp://en.wikipedia.org/wiki/Veinhttp://en.wikipedia.org/wiki/Medical_graftinghttp://en.wikipedia.org/wiki/Coronary_arteryhttp://en.wikipedia.org/wiki/Atherosclerosishttp://en.wikipedia.org/wiki/Stenosishttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Coronary_circulationhttp://en.wikipedia.org/wiki/Myocardiumhttp://en.wikipedia.org/wiki/Myocardiumhttp://en.wikipedia.org/wiki/Coronary_circulationhttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Stenosishttp://en.wikipedia.org/wiki/Atherosclerosishttp://en.wikipedia.org/wiki/Coronary_arteryhttp://en.wikipedia.org/wiki/Medical_graftinghttp://en.wikipedia.org/wiki/Veinhttp://en.wikipedia.org/wiki/Arteryhttp://en.wikipedia.org/wiki/Coronary_heart_diseasehttp://en.wikipedia.org/wiki/Angina_pectorishttp://en.wikipedia.org/wiki/Surgery

8/13/2019 cabg-130102113345-phpapp01

5/29

Number Of Bypass

The terms single bypass, double bypass, triple bypass,quadruple bypassand quintuple bypassrefer to thenumber of coronary arteries bypassed in the procedure.In other words :

double bypass means two coronary arteries are

bypassed (e.g. the left anterior descending (LAD)coronary artery and right coronary artery (RCA)

triple bypass means three arteries are bypassed (e.g.LAD, RCA, left circumflex artery (LCX)

quadruple bypass means four vessels are bypassed (e.g.LAD, RCA, LCX, first diagonal artery of the LAD)

Bypass of more than four coronary arteries isuncommon.

8/13/2019 cabg-130102113345-phpapp01

6/29

Review Of Coronary Arteries

8/13/2019 cabg-130102113345-phpapp01

7/29

Purposes

Restore blood flow to the heart

Relieves chest pain and ischemia

Improves the patient's quality of life

Enable the patient to resume a normal lifestyle

Lower the risk of a heart attack

8/13/2019 cabg-130102113345-phpapp01

8/29

Indications For CABG

Patients with blockages in coronary arteries

Patients with angina

Patients who cannot tolerate PTCA (Percutaneous

transluminal coronary angioplasty ) and do not respond

well to drug therapy

8/13/2019 cabg-130102113345-phpapp01

9/29

Contraindications For CABG

Aneurysms

Valvular diseases

Congenital diseases

diseases of blood

8/13/2019 cabg-130102113345-phpapp01

10/29

Procedure

An endotracheal tubeis inserted and secured by the anaesthetist andmechanical ventilationis started. General anaesthesia is maintained by

a continuous very slow injection of Propofol.

The chest is opened via a median sternotomyand the heart is

examined by the surgeon involves creating a 6 to 8 inch incision in the

chest (a thoractomy) . The bypass grafts are harvestedfrequent conduits are the internal

thoracic arteries, radial arteriesand saphenous veins. When harvesting

is done, the patient is given heparinto prevent the blood from clotting.

"on-pump", the surgeon sutures cannulaeinto the heart and instructs

theperfusionistto start cardiopulmonary bypass(CPB). Once CPB isestablished, the surgeon places the aortic cross-clampacross the aorta

and instructs the perfusionist to deliver cardioplegia to stop the heart

and slow its metabolism

http://en.wikipedia.org/wiki/Endotracheal_tubehttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Propofolhttp://en.wikipedia.org/wiki/Median_sternotomyhttp://en.wikipedia.org/wiki/Internal_thoracic_arteryhttp://en.wikipedia.org/wiki/Internal_thoracic_arteryhttp://en.wikipedia.org/wiki/Radial_arteryhttp://en.wikipedia.org/wiki/Saphenous_veinhttp://en.wikipedia.org/wiki/Heparinhttp://en.wikipedia.org/wiki/Cardiopulmonary_bypasshttp://en.wikipedia.org/wiki/Perfusionisthttp://en.wikipedia.org/wiki/Cardiopulmonary_bypasshttp://en.wikipedia.org/wiki/Aortic_cross-clamphttp://en.wikipedia.org/wiki/Cardioplegiahttp://en.wikipedia.org/wiki/Cardioplegiahttp://en.wikipedia.org/wiki/Aortic_cross-clamphttp://en.wikipedia.org/wiki/Aortic_cross-clamphttp://en.wikipedia.org/wiki/Aortic_cross-clamphttp://en.wikipedia.org/wiki/Cardiopulmonary_bypasshttp://en.wikipedia.org/wiki/Perfusionisthttp://en.wikipedia.org/wiki/Cardiopulmonary_bypasshttp://en.wikipedia.org/wiki/Heparinhttp://en.wikipedia.org/wiki/Saphenous_veinhttp://en.wikipedia.org/wiki/Radial_arteryhttp://en.wikipedia.org/wiki/Internal_thoracic_arteryhttp://en.wikipedia.org/wiki/Internal_thoracic_arteryhttp://en.wikipedia.org/wiki/Median_sternotomyhttp://en.wikipedia.org/wiki/Propofolhttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Endotracheal_tube

8/13/2019 cabg-130102113345-phpapp01

11/29

Procedure

One end of each graft is sewn on to the coronary arteriesbeyond theblockagesand the other end is attached to the aorta.

Chest tubesare placed in the mediastinal and pleural space to drain

blood from around the heart and lungs.

The sternumis wired together and the incisions are suturedclosed.

The patient is moved to the intensive care unit(ICU) to recover.

Nurses in the ICUfocus on recovering the patient by monitoring

blood pressure, urine output and respiratory status as the patient is

monitored for bleeding through the chest tubes. If there is chest tube

clogging, Thus nurses closely monitor the chest tubes and under take

methods to prevent clogging so bleeding can be monitored and

complications can be prevented.

After awakening and stabilizing in the ICU (approximately one day),

the person is transferred to the cardiac surgery warduntil ready to go

home (approximately four days).

http://en.wikipedia.org/wiki/Coronary_arteryhttp://en.wikipedia.org/wiki/Coronary_artery_diseasehttp://en.wikipedia.org/wiki/Aortahttp://en.wikipedia.org/wiki/Chest_tubehttp://en.wikipedia.org/wiki/Human_sternumhttp://en.wikipedia.org/wiki/Surgical_suturehttp://en.wikipedia.org/wiki/Intensive_care_unithttp://en.wikipedia.org/wiki/ICUhttp://en.wikipedia.org/wiki/Chest_tubehttp://en.wiktionary.org/wiki/wardhttp://en.wiktionary.org/wiki/wardhttp://en.wikipedia.org/wiki/Chest_tubehttp://en.wikipedia.org/wiki/ICUhttp://en.wikipedia.org/wiki/Intensive_care_unithttp://en.wikipedia.org/wiki/Surgical_suturehttp://en.wikipedia.org/wiki/Human_sternumhttp://en.wikipedia.org/wiki/Chest_tubehttp://en.wikipedia.org/wiki/Aortahttp://en.wikipedia.org/wiki/Coronary_artery_diseasehttp://en.wikipedia.org/wiki/Coronary_artery

8/13/2019 cabg-130102113345-phpapp01

12/29

Explanation

8/13/2019 cabg-130102113345-phpapp01

13/29

Heart Lung Machine

8/13/2019 cabg-130102113345-phpapp01

14/29

Nursing Management

Pre operative Phase

Intra operative Phase

Post operative Phase

8/13/2019 cabg-130102113345-phpapp01

15/29

Pre operative Phase

Assessment

Patient history

Physical Examination (head to toe ) Diagnostic procedure

8/13/2019 cabg-130102113345-phpapp01

16/29

Patient History

Patient history of major illness, previous surgery,medications, and usage of drugs and smoking and

drug history

A systematic assessment of all systems performed

,with emphasis on cardiovascular functioning

8/13/2019 cabg-130102113345-phpapp01

17/29

Physical Examination

Functional status of the cardiovascular systemdetermined by reviewing the patient symptoms ,

including past and present experience with chest

pain ,hypertension, palpation ,cyanosis, breathing

difficulty ,leg pain that occur with walking

,Orthopnea, peripheral edema.because alteration

in cardiac function (cardiac out put can affect

renal, respiratory, gastrointestinal ,integumentary, hematological, and neurological

functioning )

8/13/2019 cabg-130102113345-phpapp01

18/29

Physical Examination

General appearance and behavior.

Vital signs

Nutritional and fluid status ,weight, height

Inspection and palpation of the heart ,noting the point of

maximal impulses ,abnormal pulsation ,and thrills

Auscultation of the heart ,noting pulse rate ,rhythm, and

quality; S4 and S3 , murmur, and friction rib

Jugular venous pressure

Peripheral pulses

Peripheral edema

8/13/2019 cabg-130102113345-phpapp01

19/29

Psychosocial Assessment

Meaning of the surgery to the patient and family

Coping mechanisms that are being used

Measures used in the past to deal with stress

Anticipated changes in life style

Support system in effect

Fears regarding the present and future

Knowledge and understanding of the surgical procedure,

postoperative course and long term rehabilitation

8/13/2019 cabg-130102113345-phpapp01

20/29

Nursing Intervention

Explain all treatment and procedure done for the patientanswering any question patient may have .present

information at patient understanding level to reduce

patient anxiety

Orient patient to surrounding Assign the same nurse to care for patient when ever

possible to provide consistency of care, enhance trust and

reduce threat often associated with multiple care givers.

Spend time with patient each shift to allow time forexpression of feelings, provide emotional outlet and

promote feeling of acceptance.

8/13/2019 cabg-130102113345-phpapp01

21/29

Intra operative Phase

Patient will receive general anesthesia ,be intubated , and placed on

mechanical ventilator, the preoperative nurse are responsible for the

patient safety and comfort. Someof the areas of intervention

include positioning, the skin preparation wound care, and

emotional support to the patient and family. Before chest incision is closed, chest tubes are positioned to evacuate

air and drainage from the media sternum and the thoracic cavity .

8/13/2019 cabg-130102113345-phpapp01

22/29

Intra operative complication

Possible Intraoperative complication

includes Dysrthmyais,Hemorrhage ,

Emobilization , Organ failure from shock ,or adverse drug reaction.

8/13/2019 cabg-130102113345-phpapp01

23/29

Post Operative

GOAL: achieving or maintaining homodynamicstability and recovery form general anesthesia

Assessment

Neurological system Cardiac status

Respiratory status

Peripheral vascular status

Monitor complication

Renal function

Pain

Fluid and electrolyte

8/13/2019 cabg-130102113345-phpapp01

24/29

Complications

Decrease C/O Fluid overload

Hypothermia HTN

Tachydysrythmias Bradycardia

Cardiac failure Acute renal failure

Electrolyte imbalance Hepatic failure

Infection

8/13/2019 cabg-130102113345-phpapp01

25/29

Nursing Diagnosis Related To CABG

Decrease cardiac output

Impaired gas exchange

Risk for imbalance fluid volume

Acute pain

Deficient knowledge

8/13/2019 cabg-130102113345-phpapp01

26/29

ANY QUESIONS

8/13/2019 cabg-130102113345-phpapp01

27/29

References Medscape http://emedicine.medscape.com/article/1893992-overview

AHA http://my.americanheart.org/professional/General/2011-ACCFAHA-

Guideline-for-Coronary-Artery-Bypass-Graft-Surgery

TextbookBrunner and Siddhartha's Textbook of Medical-Surgical Nursing, 12th edition,Brunner and Siddhartha's Textbook of Medical-Surgical

Nursing 2012

http://emedicine.medscape.com/article/1893992-overviewhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://my.americanheart.org/professional/General/2011-ACCFAHA-Guideline-for-Coronary-Artery-Bypass-Graft-Surgeryhttp://emedicine.medscape.com/article/1893992-overviewhttp://emedicine.medscape.com/article/1893992-overviewhttp://emedicine.medscape.com/article/1893992-overviewhttp://emedicine.medscape.com/article/1893992-overviewhttp://emedicine.medscape.com/article/1893992-overview

8/13/2019 cabg-130102113345-phpapp01

28/29

THANK YOUFOR

GOOD LISTENING

8/13/2019 cabg-130102113345-phpapp01

29/29

KHALED MAHAJNA .RN

FACULTY OF NURSING

AL ISRA UNIVERSITY

Mobile(+962)-78-6627008

E-mail

Mahajna_kh@hotmail.com

Facebook

Khaled Mahajna