Kim Uddo RN MSN CCRN

Cardiovascular Surgery

Coronary Artery Bypass Graft Surgery Valvular Surgery Aortic Aneurysms

CABG Indications

PTCA Failed Unstable Angina unresponsive to meds 3 vessels LAD > 75% stenosis Failed thrombolysis Ej fx < 35% Valve disease / vent. aneurysm

Diagnostic Studies

Cardiac Catheterization Echocardiogram Stress test CXR 12-lead ECG Blood: coags, CBC, CMP, Enzymes

Conduits

Saphenous Vein Graft (SVG) Internal Mammary Artery (IMA)

LIMA RIMA

Right Gastroepiploic Radial

Saphenous Vein Grafts

Easy to harvest from legs - lots of vessel Laproscopically vs surgically

Turn valve direction 10% occlusion in first weeks Lasts 5 – 10 years Must take ASA Leg swelling

LIMA or RIMA

85 – 95 % Patency at 10 years Remains attached at origin Artery can vasodilate Difficult and timely to mobilize for

anastamosis More post op pain

Right Gastroepiploic Artery

Branch of gastroduodenal artery Laporotomy Abdominal wound Timely and most difficult to harvest Pulled up to the pericardial cavity Origin intact and connected past blockage

RCA and Post. descending

Radial Artery

Artery dilates MUST have good ulnar flow Vasospasms (control with meds) Forearm swelling

Stabilize Pre-op Condition

Control dysrhythmias Treat CHF Relieve Angina Maintain cardiac output

CO=HR X SV (preload, afterload, contractility) Drugs Intra Aortic Balloon Pump (IABP)

Intra-Aortic Balloon Pump

Provides Counterpulsation Balloon inserted in aorta via fem. Art. Inflates during diastole (AV valves open)

Timed at dicrotic notch (aortic valve closes) Increase perfusion forward to brain and ca’s and

backward to kidney Deflates during systole (SL valves open)

Decreases afterload when heart ejects blood thus decreases workload

IABP Indications Pre and Post Op

Recurrent / Unstable Angina Cardiogenic Shock from AMI High risk patient

Elderly, low Ej Fx, diabetic, MI LV Failure after surgery Unable to ween from heart lung bypass

machine after surgery

IABP Complications

Peripheral Ischemia Aortic Dissection Pseudoaneurysm at insertion site Balloon Perforation Bleeding and Infection

Peripheral Ischemia

From emboli formation or the balloon Hourly assessment of distal pulses,

extrimity color, temp, and capillary refill Hourly documentation of assessment May need doppler Keep leg straight and log roll HOB < 30 degrees

Balloon Perforation

Gas leak alarm on pump console Blood visible in IABP tubing Turn off pump and call MD stat Clots will form on nonmoving balloon

IABP Caused Bleeding

Thrombocytopenia from constant pumping (platelets are destroyed) Monitor platelets and CBC

Movement at insertion site (fem art) Monitor site at least hourly & document Log roll

Pre op CABG Interventions

Phisohex shower Shave Medications IV antibiotics Centeral Line / Pulmonary Artery Catheter

CABG: The Operation Sequence

Patient to OR holding area Central line or PA Catheter (Swan)

insertion Harvest saph vein Median sternotomy Dissect vessels off of LIMA to mobilize Heparinize - bolus

CABG continued

Establish Cardioplegia Cold potassium aortic root injection regime Heart is motionless and bloodless

Cross clamp the aorta Insert Cardiopulmonary Bypass (CPB) Catheter

into Sup & Inf Vena Cava (directs venous return to pump oxygenator) and an aortic catheter (blood is returned to the body)

Establish extracorporeal circulation Diverts blood flow from heart and lungs

ABIOMEDS

BVS System 5000

Decreased Cardiac Output related to alterations in preload Decreased Cardiac Output related to alterations in afterload Decreased Cardiac Output related to alterations in

contractility Decreased Cardiac Output related to alterations in heart

rate or rhythm Activity Intolerance related to cardiopulmonary dysfunction Ineffective Cardiopulmonary Tissue Perfusion related to

acute myocardial ischemia Risk for Infection: invasive procedures Disturbed Sleep Pattern related to circadian

desynchronization Disturbed Body Image related to functional dependence on

life-sustaining technology

CABG : Hypothermia

Establish hypothermia: irrigate topical iced saline slush across pericardial sac This decreases ischemia to heart and organs (28 – 36

degrees C) by reducing tissue requirements 50% OR is cold and chest is open to cold air Hypothermia induced Vasoconstriction Will warm blood prior to ending CPB but pt temp

drops once off the pump & can show HTN and shivering for first two hours post op

May need Nipride until warm

Induced Hypothermia

Shivering leads to increased heart workload

This increased CO2 and L. acid prod. Chemoreceptors respond Vasoconstriction occurs Use warm blankets to reduce shivering .

Take care not to overwarm – vasodilation- Keep MAP > 60

CABG: Hemodilution

Blood diluted with isotonic crystalloid solution that is used to prime the bypass machine.

Lowers the colloidal oncotic pressure Stress promotes ADH production Come to ICU post op with facial and hand

swelling. Can be ahead by liters of fluid.Check OR I&O.

CABG: Anticoagulation

Establish anticoagulation Heparin bolus Prevents coagulation in the bypass

machine once blood comes in contact with the machine’s surface

Stress promotes clotting

CABG continued

Perform graft anastamosis from aorta to past the obstructed coronary artery.

Place chest tubes in mediastinal cavity above and below the heart. Can place in the pericardial sac.

Place CT in intrapleural space if violated Loosely stitch on epicardial pacing

electrodes to atrial and ventricular wall.

CABG: continued

Jump start the heart: shock Disconnect from CPB Use IABP if difficulty coming off CPB Pull out pacing electrode wires through the

chest before closing sternum with wires. Skin stapled or sutured

Transport to ICU

CPB: Results / Complications

Hemodilution (interstitial / pulm edema) third spacing edema and wt gain due to plasma protein conc & capillary permeability.

Platelets damages & vasoactives subs released in blood (capillary permeability).

Alteration in fluid & electrolyte balance Alteration in cardiac function (dysrhythmias and

cardioplegia causes ischemia, acidosis, necrosis, and decreased cardiac output)

CPB cont

Coagulopathies (bleeding) damaged plts, heparin, hypothermia induced clotting factors in liver.

Catecholamine / renin release (HTN – watch out for bleeds at suture sites)

Supressed insulin release & epi stimulated glycogenolysis (hyperglycemia)

Alteration in central nervous system (cerebral ischemia, plaque, or embolic events)

CPB cont

Blood sitting in pulmonary capillaries and mesentary for length of time on CPB so capillary walls break down ( pulmonary edema, atelectasis, bowel ischemia, microemboli).

Impaired gas exchange from surfactant prod. Increased renin, angiotensin, aldosterone, and

ADH ( sodium & water retention, potassium excretion)

Serum dilution (Low K, Na, Cl, Mag) Hemolysis ( RBC’s damaged in CPB )

CPB cont

Hypothermia (increased SVR, decrease in contractility & HR & CO thus decreased perfusion pressure thus decreased urine output)

Hypothermia causes impaired release of insulin and low perfusion pressure, lytes are diluted so altered glucose transport (hyperglycemia)

Off Pump Normothermic Trend

Minimally invasive approach/ thoracotomy Less complications (no CPB) Higher technician difficulty suturing on

beating heart Poor visualization Some aspects of heart unreachable

ICU : Equipment

Turn on ECG, vent settings, 12 lead, CXR 2 wall suctions (NG, ET) Brackets on IV poles, thermometer, doppler Multiple infusion pumps Autotransfusion set up with CPD External pacmaker generator with battery 60cc cath tip syringe

Admit into ICU

Hook to vent Hook to ECG, NIBP, Pulse Ox,

transducers Assess ET for placement (may dislodge) Connect pacer wires to generator Zero and calibrate pressure lines (Radial,

CVP, Pulmonary Artery)

Admit continued

Connect CT to autotransfusion Tape CT connections and check for clots Empty urometer every hour Record admit vitals and hemodynamics HOB 30 degrees Stat labs and ABG’s CMP, CBC, Plts,

PT/PTT, Enzymes, Troponin

Admit continued

12 lead ECG and CXR Hang necessary hemodynamic drugs and

do calculations Connect NG to suction Suction ETT Soft wrist restraints

Monitor and Record

Vital signs every 15 min for first 4 hours Then every 30 min for 4 hours Then hourly Monitor CT drainage every 15 min for first

few hours then every hour Breath sounds, peripheral pulses,

hemodynamics and neuro checks every hour X 4, then every 4 hrs.

Hemodynamics

Intraarterial Line -usually radial (BP /MAP) Central Venous Pressure (CVP) Pulmonary Artery Catheter with balloon

forward flow (Swan-Ganz Catheter) All have waveforms and pressure readings

(numerical values). Need pressure tubing, transducer, flush system, & monitor

Arterial Pressure

Keep patient normotensive! Low BP / MAP

Can cause graft closure. Keep MAP > 60. HR will increase to maintain CO, this increases

oxygen demands on the heart . High BP / MAP

Can cause bleeding at graft sites due to increased pressure.

Increases afterload so L heart works harder.

CVP

Preload to the Right side of the Heart Pressure created by volume in the RIGHT side

of the heart. When the tricuspid valve is open, the CVP reflects RVEDP – right ventricular end diastolic pressure. Guides fluid volume replacmt.

Not good indicator of L side of heart since the pressure must go through the lungs (by the time CVP gets high readings the L side : full failure).

Normal value: 2 – 6 mm Hg

Low CVP

Hypovolemia / insufficient blood volume HR will increase to maintain CO.

Increases myocardial oxygen demand CVP falls before MAP

Peripheral vasoconstriction keeps MAP up CVP excellent warning for bleeding,

vasodilation, diuretics, & rewarming after cardiac surgery

CVP High

Fluid Overload Heart must increase contractility to move the

larger volume of blood This increases cardiac workload Also increases cardiac oxygen consumption

Follow CVP TRENDS to manage volume replacement or diuretic use

Pulmonary Artery Catheter

Similar to TLC but longer / has a balloon. Flow directional catheter/ 4-5 ports.

Advance to R Atrium (RAP : 4-6) Inflate Balloon 1 1/2 cc air into balloon port.

Advance to RV (20-30S) Advance to PA ( PAS: 20-30/ PAD: 8-15) Advance to wedge position into a small

pulmonary vessel (PCWP: 6-12). Deflate within 10 seconds. Floats back to PA.

PCWP: Preload to the L Heart

While balloon is inflated, only pressures on the Left side of the heart are seen.

Diastole: Mitral valve is open No valves obstructing between cath tip and

left ventricle. Pressure exerted by the volume in the LV is

reflected back to the pulmonary capillaries. “Preload” (L heart) = LVEDP = PCWP

PCWP Low

Volume Loss (bleeding or third spacing) Tachydysrhythmias (afib) Increased intrathoracic pressure (vent) Increased intracardiac pressures (cardiac

tamponade) Give volume replacement (autotransfusion

best) or control dysrhythmias or tx problem.

PCWP High

Volume Overload. Excessive fluid administration.

Venous Constriction. Hypothermia.

Left Ventricular Failure (The Pump). Acute Myocaridal Infarction.

Give: Tridil drip (this decreases preload and afterload due to dilation and v. pooling).Or can try Nipride drip or diuretics.

Afterload

Pressure the ventricle has to generate to overcome the resistance to ejection by the arteries. Systemic Vascular Resistance.

SVR = 900 – 1200 dynes ( L heart ) PVR = pulmonary vascular resistance (R) Low= hyperthermia or shock High= hypothermia or shock/constriction

Afterload Drugs

Elevated afterload give: Dilators: Nipride (Nitroprusside), Tridil

(Nitroglycerine), Calcium Blockers, IAPB Lowered afterload give:

Pressors: Dopamine, Epinepherine, Norepi, Neo-Synephrine

Decreased Contractility

Excessive preload or afterload. Drugs (negative inotropes). Myocardial Damage. Ionic Environment Changes (acidosis ,

electrolyte disturbance, hypoxia). Give Positive Inotropes:

Dobutamine, Dopamine, Digoxin

Elevated Contractility

Drugs (positive inotropes) Hyperthyroidism Give:

Beta Blockers Calcium Channel Blockers Reduce inotrope therapy

Thermodilution Cardiac Output

10cc saline injected in RA port at end of expiration

Fluid passes temperature sensor (thermistor) to catheter tip.

Thermistor is already connected to monitor. Measures core temp change.

Obtain 3 readings and average Normal CO = 4 – 7 liters/ minute

Cardiac Index

Individualized Cardiac Output. CO divided by Body Surface Area Normal Cardiac Index: 2.5 – 4 liters/ min. Cardiogenic Shock: < 1.5 liters/min

PA Catheter Risks

Air Emboli. Pneumothorax. Hemothorax. Arterial Puncture. PA Art Rupture. Balloon Rupture. Pulmonary Infarction. Clots. Emboli. Thrombosis. Exsanguination. Bleeding. Infection. Hypothermia

CABG Post Op Problems

Low CO Syndrome Cardiac Tamponade Dysrhythmias (lethal) Pulmonary Emboli (3rd Day Post Op)

Esp if saphenous vein used MI Bleeding / Coagulopathies HTN

Post op problems continued

Fever Endocarditis Organ/ peripheral emboli Organ Failure (lungs, neuro, renal) Paralytic Ilieus Pain/ Pychosis Electrolyte Disturbance

Low Cardiac Output Syndrome

Blood Loss Vascular Dilation LV impaired Low Contractility High Afterload Hypothermia induced

hypertension

Active Bleeding at anastamosis

Intraoperative MI Increased preload Decreased preload Hypovolemia

Decreased CO Secondary to:

Decreased contractility from hypothermia and cardioplegia AMI

Increased Afterload (hypothermia) Increased Preload

CHF, volume excess Decreased Preload

Bleed, permeability, hypovolemia Dysrhythmias (afib common: no atrial kick)

Decreased CO: Bradycardia

Connect epicardial pacing wires to external generator if not already connected.

Turn on generator or increase rate of pacemaker.

Atropine only used if no pacer wires or pacer malfunction

Usually need HR of 80 beats/ minute

Cardiac Tamponade

Clots forming in mediastinal tubes

Decreased SBP,narrow pulse pressure

Sudden decrease in CT drainage

Quiet heart sounds Low amplitude ECG Pulsus paradox >10 Wide mediastinum

Call MD stat Break up clot in CT or

aspirate clot MD insert new CT Pericardiocentesis at

bedside Rush back to OR to

reopen the chest

Other Diagnoses

Altered Safety: High risk for Bleeding

Safety: Risk for Dysrhythmias/MI

Intravascular fluid deficit due to third spacing from CPB, post op diuresis or bleeding, rewarming dilation.

Decreased gas exchange sec to low CO, hypothermia, altered breathing, decreased surfactant production from CPB.

Potential for altered LOC (emboli)

Stress from Surgery

Activates ADH Hold onto water to

keep from going into shock

Cells swell and third spacing occurs from CPB

Edema noted

IV Fluid Post Op: D5 ½ Normal Saline Hypertonic Pulls water from

swollen cells into the intravascular space

Increases iv volume Increases urine

output

Progression

Extubated by next morning, hopefully sooner and up in chair. Lung exercises.

1 –2 nights in ICU if no complications. D/C PA and art lines, CT’s, pacer wires. Transfer to telemetry. Cardiac Rehab inpatient. Cardiac Rehab outpaitent.

Pre-Op Teaching

No Smoking Lung exercises : IS CTDB ICU Visit Sensory Preparation ETT and restraints Ankle Rotation Cardiac Rehab

ICU Routines Visiting Schedules Assure Pain

Measures Done Pain Scale Used Post op expectations Explain surgery TED Hose (2 pair)

Post Op Teaching

Low Na, Low cholesterol diet

Medications Gradual increase in

activities Stair climb / walk: get

up to 60 min a day, climb 2 flts before sex

Shower is ok

No tub baths No heavy lifting>10lbs No driving X 6wks:

may be a passenger No smoking No fatty diet Support groups

available & rehab

Valvular Surgery

Diagnosis

Echocardiogram. Cardiac

catheterization detects pressure changes across a faulty valve.

ECG show hypertrophy.

CXR show calcification on valves and increased heart size

Transesophageal Echocardiogram (TEE) and Doppler Study show color flow imaging of faulty valve

Three Methods of Valve REPAIR

Mitral commisurotomy Valvuloplasty Annuloplasty

Mitral Commisurotomy

To correct mitral stenosis Incise fused leaflets, debride calcium

deposits, suture torn leaflets to increase mobility of valve.

Open Method Used in USA on CPB

Closed Method Used in Third World Countries off pump

Valvuloplasty

Percutaneous Transleuminal Balloon Valvuloplasty (PTBV) (valvotomy) Developed after PTCA, balloon inserted in valve and

inflated, works well on MV, only short tem effect on AV – stabelize for surgery.

Inflations separate fused commisures, cracked calcified leaflets, stretches valve structures.

Open Surgical Repair Suture torn leaflets, papillary muscle, cordae

tendenae

Annuloplasty

Annulus Anatomical ring in which the valve sits.

Surgical Repair Good for Mitral Regurgitation Suture a prostetic ring to the dilated annulus

to increase leaflet coaption or reconstruct annulus without a ring

Valve Replacement

Most Common AVR for stenosis or regurgitation MVR for stenosis or regurgitation

Article: When to go to Surgery? Before LV dysfunctions or Ej Fx < 55% or Symptomatic even with good Ej Fx

True open heart surgery

Pre Op Care

Try to give 48 hours of antibiotics Begin on Nipride drip to decrease preload

and afterload Emergency AVR due to acute endocarditis

Body hasn’t compensated yet = emergency Give antibiotics on call to OR

Valves Used for Replacement

Biological: Tissue Valves Porcine (pig) Bovine (calf) Homograft (human cadaver)

Mechanical: Metal and Dacron Caged ball Tilting disc Bi-Leaflet: mechanical central flow disc/ most

Young Recipients

If a patient is young, they will probably receive a mechanical valve since they last much longer.

If conditions exist that prevent taking coumadin such as pregnancy, they will receive a biological valve.

Biological Valves

Chance of Rejection Virchow’s Triad activated Less Durable (lasts 7 years) Tendency to calcify Endocarditis: early and late (p 60 days) Low thrombogenicity (less emboli) Only 12 wks of anticoagulants if no a fib

Mechanical Valves

High chance of clot formation Long term anticoagulation therapy Mechanical malfunction Hemolytic anemia Early and late endocarditis Virchow’s triad Last longer (20 years)

Virchow’s Triad

1. Stasis of Blood Flow (pooling) 2. Tissue Damage 3. Hypercoagulability Valves are foreign. Susceptable to fibrin

and platlet aggregation. Suture material and endothelial damage agrivate this.

Give Heparin post op

Post Op Anticoagulation

Heparin 80u/ kg bolus 18u/kg/hour gtt Follow PTT or aPTT every 6 hours

Activated partial thromboplastin time Therapeutic range : 46- 70 seconds Get blood thin quickly and keep thin,

subtherapeutic PTT allow clots to form and are dislodged when thin again.

Discharge Teaching

Anticoagulation tx (INR 2.5 – 3.5)

Prophylactic antibiotics

Incision care Exercise Avoid fatigue endocarditis

Call MD: S&S of infection, CHF, bleeding, planned invasive or dental procedures.

Monitor I&O, weight, and temp.

Diet Meds

Aneurysms

Definition

An outpouching or sac (dilitation) of the arterial wall commonly occuring in the aorta at the weak spot.

½ of all aneurysms >6cm rupture in 1 yr Dangerous Thrombi like to deposit here

3 layers of Arterial Wall

Adventitia : outer layer Media : middle layer Intima : inner layer

Segments of the Aorta

Ascending thoracic aorta Aortic arch which includes the decending

thoracic aorta Abdominal aorta Terminal aorta

Four types of Aneurysms

Fusiform (true) Sacculated (true) Dissecting Pseudoaneurysm (false) True aneurysm

Has at least one vessel layer intact

Fusiform

Circumferencial and uniform in shape

Saccular

Pouch like buldge connecting to one side of the aneurysm. Narrow neck.

Pseudoaneurysm

Disruption of all 3 layers of arterial wall resulting in a leak of blood that is contained in surrounding sutures.

Examples: Post PTCA femoral insertion site D/C of the IABP

Causes

Athlerosclerosis : plaques and fibrin deposits weaken wall, loose elasticity

Infection Congenital disorders Trauma HTN, men Smoking

How Discovered

By Accident :ruling out something else Routine physical CXR US ECG Aortagraph done when surgery

contemplated

Diagnostic Tests

Ultra sound gen location & size

CT scan accuratley detects cross section size

Abdominal aortography exact position

ECG MRI

Thoracic Aneurysms

Asymptomatic usually Deep difuse chest pain Hoarseness (laryngeal nerve pressure) Dysphasia (esophageal pressure) Distended neck veins (SVC pressure) Dyspnea, cough, airway obstruction

Abdominal Aneurysms

Pulsitile mass : periumbilical Audible bruits over aneurysm Asymptomatic or Back, flank, abd pain (lumbar pressure) Epigastric discomfort (bowel compression) Bloody stools, post prandial pain Blue toe syndrome: plaque breaks off

Repair criterion

Aneurysm > 6.0 cm (text says 6.5). If it is 2 times > normal artery diameter. Not repaired if small or poor surgical risk. Traditional Surgery vs. Endovascular Graft Surgery

Traditional Surgery: Aneurysmectomy

Midline incision xyphoid to pubis Cross clamp aorta above and below site.

Heparinize first. If clamp above renals, check for acute tubular necrosis :ATN.

Incize diseased aorta. Insert synthetic graft Suture native aortic wall around graft.

Endovascular graft surgery

Percutaneous approach Femoral arteries in each leg Synthetic graft deployed anchored c hooks Graft inside vessel prevents bowel erosion Less pain & blood loss (500cc vs 1-3

liters), no scar, fast to heal Extubated in OR, to PACU, then to floor

on telemetry vs ICU overnight.

Pre-op care

Fix carotid or coronary arteries first Get baseline vitals & mark pulses Abdominal girth Assess all systems Teaching Titrate Nipride or Tridil to Keep MAP 60-90

Most serious pre-op complication

Rupture, Bleeding , Shock High HR, Low BP, LOC, urine output, clammy

May have Turner’s Sign Severe back pain, flank eccymosis A clot could dislodge

Post op goals

Normal tissue perfusion Intact neurological / motor function Prevent post op complications

Tissue perfusion

Titrate Nipride or Tridil to keep MAP 60-90 May use lasix Keep systolic 95-160, warm if hypothermic Give fluids, blood, & meds to keep

adequate BP to keep graft open Prevent low BP to keep graft patent. Palpate pulses q 15 X4, q1hr x 4, q4 hrs.

MEDICATION SHEET FOR CONTINUOUS INFUSIONDrug:________________________________________

Actual Drug in Solution: ___________mg in __________cc of ______________Doctor’sOrders: (include parameters) ______________________________________________________________________________________________________________________________________________________________________________________________________

Current Infusion Rate:_________________cc/hourHow is this drug normally infused? Check one. Mcg/kg/min___? Mcg/min___? Mg/min___? cc/hr___? Mcg/hour___? Mg/hr___? Units/min___? Units/hr___?

Patient Weight:__________________________kgCalculate the current infusion dose being delivered at the current rate. Show calc.Setting the pump: cc’s per hour = ( mcg/kg/min ordered ) x (kg) x (60 minutes)

(concentration of solution in mcg per cc) Calculating the dose being infused based on set rate on the infusion pump:

Mcg/kg/min = (set pump rate cc/hr)x (concentration mcg/cc) (kg body weight) x ( 60 minutes)

Your calculation:

Continuous Medication Sheet

Nipride 50mg in 250cc D5W 50mg:250cc=xmg:1cc 250x=50 X=50/250 x= o.2mg per cc or 200mcg per cc This is the concentration of the solution. Book says begin at 0.3 mcg/kg/min

Computation of Nipride

ml’s per hour= (0.3mcg)(100kg)(60min/hr) __________________________________

(200 mcg/cc concentration)

1800/200= 9cc hour

(Patient Weight is 100kg)

Now the Pump : 300 ml’s/hr

Mcg/kg/min = (300ml/hr)(200mcg/ml concentration) _____________________________ (100kg body weight)(60 min/hr)

= 10mcg/kg/min Text says not to exceed this dose

Tissue Perfusion: Renal

Complications of surgery: hypotension, dehydration, prolonged cross clamped aorta, blood loss.

Nursing: Mointor : BUN,Creat, CBC, Na, Osmolality,I&O, signs of shock, back pain, & pulsating mass in abdomen.

Nursing: Give: Autotransfusion, fluids, heparin to decrease clots.

Tissue Perfusion: Bleeding

Observe for falling trend in CVP (earlier sign then BP)

Monitor labs: coagulation studies, CBC Hourly: CVP, PA Pressures, vitals Every 4 hours: H&H, abdominal girth

Tissue Perfusion: Mesentary

Paralytic ileus common. Intestines become swollen and bruised from manipulation.

Observe for: absent bowel sounds and passing of flatus, distended abdomen, N&V.

Encourage early ambulation. Connect NG to low cont. suction & irrigate for patency.

Tissue Perfusion: Fluids/ Lytes

Monitor: daily weights, I&O, wound & NG drainage, abnormal labs.

Give: autotransfusion, blood transfusion – PRBC’S, colloids, intravascular fluids.

Tissue Perfusion: Cerebral

Neuro checks hourly X 4, then every 4 hours.

Motor checks hourly X 4, then every 4 hours.

Other Post Op Complications

Impaired resp function from vent and abdominal pain. NGT to decr. gastric distention and aspiration

Dysrhythmias from hypothermia, hypoxia, lytes disturbed.

Infection: Wound and invasive lines HTN: graft bleed Hypotension: graft collapse Pain: scale, comfort, possible dissection

Aortic Dissection

Results from a small tear in the intimal lining of the artery, allowing blood to track between the intima and the media – creating a false leumen.

Most Common: thoracic aorta: 90%mort. Ascending aorta or aortic arch Longitudinal splitting of medial layer Each pulse=dissection continues=Emergency

Risks

Cystic medial necrosis Destruction of medial layer of elastic fibers

HTN Marfan’s Syndrome

Connective tissue disease Pregnancy

Symptoms

Sudden pain in back, chest, or abdomen Ripping or Tearing pain Dyspnea possibly Possible murmur

Ascending aortic dissection usually produces aortic valve insufficiency.

Complications of Dissection

Cardiac Tamponade Blood escapes form dissection into the

pericardial sac.

Pre Op Management

BP and contractility to pulsitile force. Vasodilators (Nipride) and beta blockers (olol)

ECG r/o MI, echocardiogram, aortography. CXR may show wide mediastinum. Manage CHF and Pain. Blood replacement. Stat Surgery: ascending aortic dissection. Descending a.: try meds first if possible.

Post op Care: Synthetic Graft Rpr

BP: semifowlers bedrest, quiet, pain control, antihypertensive meds.

Monitor: ECG, A-line BP, LOC (clots) Observe for: widening pulse pressure-

aortic valve insufficiency. Pulse checks . CPB and vent complications.

Discharge Teaching

Same as CABG No lifting of >5lbs for 4-6wks Sex dysfunction possible due to clamping

of aorta. This flow to penis. Observe feet for color, warmth, swelling. Antihypertensives and neg inotropes. Antibiotics prior to invasive procedures.

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