Critical Care Nursing - Clinical

Perioperative CABG ( Coronary Artery Bypass Graft )

Definition

• Is a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease. Arteries or veins from elsewhere in the patient's body are grafted (internal thoracic arteries, radial arteries and saphenous) to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped .

Number Of Bypass

• The terms single bypass, double bypass, triple bypass, quadruple bypass and quintuple bypass refer to the number 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 is uncommon.

Review Of Coronary Arteries

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

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

Contraindications For CABG

• Aneurysms

• Valvular diseases

• Congenital diseases

• diseases of blood

Procedure

• An endotracheal tube is inserted and secured by the anaesthetist and

mechanical ventilation is started. General anaesthesia is maintained by

a continuous very slow injection of Propofol.

• The chest is opened via a median sternotomy and the heart is

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

chest (a thoractomy) .

• The bypass grafts are harvested – frequent conduits are the internal

thoracic arteries, radial arteries and saphenous veins. When harvesting

is done, the patient is given heparin to prevent the blood from clotting.

• "on-pump", the surgeon sutures cannulae into the heart and instructs

the perfusionist to start cardiopulmonary bypass (CPB). Once CPB is

established, the surgeon places the aortic cross-clamp across the aorta

and instructs the perfusionist to deliver cardioplegia to stop the heart

and slow its metabolism

Procedure

• One end of each graft is sewn on to the coronary arteries beyond the

blockages and the other end is attached to the aorta.

• Chest tubes are placed in the mediastinal and pleural space to drain

blood from around the heart and lungs.

• The sternum is wired together and the incisions are sutured closed.

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

• Nurses in the ICU focus 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 ward until ready to go

home (approximately four days).

Explanation

Heart Lung Machine

Nursing Management

Perioperative CABG

Introduction to Perioperative Nursing

Phases of Perioperative Care

• Pre Operative - begins with the patient’s decision to have

surgery, ends with entry into the operating room

• Intra Operative - begins with entry into the operating room and

ends with admission to the recovery room

• Post Operative - begins with admission to recovery room, and

ends with discharge from care (varies but usually 6 weeks post

op) by physician

PERIOPERATIVE NURSING

Pre operative Phase

Assessment

• Patient history

• Physical Examination (head to toe )

• Pshycosocial Assesment

• Diagnostic procedure

Access health care team availability • Surgeon

• Anesthesia personnel

• Circulating nurse

• Scrub person

• Other personnel

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

Physical Examination

• Functional status of the cardiovascular system

determined 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 )

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

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

Nursing Intervention

• Informed consent

• Explain all treatment and procedure done for the patient

answering 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 whenever

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 for

expression of feelings, provide emotional outlet and

promote feeling of acceptance.

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. Some of 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 .

Intra operative complication

• Possible Intraoperative complication

includes Dysrthmyais,Hemorrhage ,

Emobilization, Organ failure from shock, or

adverse drug reaction.

Post Operative

• GOAL: achieving or maintaining homodynamic

stability and recovery form general anesthesia

• Assessment

• Neurological system

• Cardiac status

• Respiratory status

• Peripheral vascular status

• Monitor complication

• Renal function

• Pain

• Fluid and electrolyte

Complications

• Decrease C/O

• Fluid overload

• Hypothermia

• Bradycardia

• Tachydysrythmias

• Acute renal failure

• Cardiac failure

• Hepatic failure

• Electrolyte imbalance

• Infection

Nursing Diagnosis Related To CABG

• Decrease cardiac output

• Impaired gas exchange

• Risk for imbalance fluid volume

• Acute pain

• Deficient knowledge

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