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Nursing Care: Robotic-Assisted Cardiac Surgery
Jane C Whalen RN, MSN, CCRN, CCNS
October 22, 2011October 22, 2011
Objective
Adapt nursing care and patient Adapt nursing care and patient education for patients undergoing education for patients undergoing minimally-invasive / robotic – assisted minimally-invasive / robotic – assisted cardiac surgerycardiac surgery
Are They Different?
What have you heard?What have you heard?What would you expect?What would you expect?What do you think patients want to know?What do you think patients want to know?
Pre-Operative Patient Education
IncisionsIncisionsYes, you will have them!Yes, you will have them!They’re just differentThey’re just different
PainPainYes, you will have painYes, you will have painIt can be more painful than a sternotomyIt can be more painful than a sternotomy
Sternotomy
Robotic / Minimally-Invasive Incisions
Femoral Cannulation
Unilateral Unilateral incisionincisionBilateral incisionsBilateral incisions
Radial Arterial Lines
Pre/Post-Operative Care: Prevent Infection
Same as with sternotomySame as with sternotomy
Intranasal mupirocin (Bactroban®)Intranasal mupirocin (Bactroban®)
Pre-op skin prepPre-op skin prep
Wound care post-opWound care post-op
Insulin infusion / glucose managementInsulin infusion / glucose management
Post-Operative Care: Activity
Same progression as with sternotomySame progression as with sternotomy
No “sternal precautions”, but…No “sternal precautions”, but…
Limit lifting, affected side, for pain controlLimit lifting, affected side, for pain control
Return to work in 2-4 weeksReturn to work in 2-4 weeks
Post-Operative Care: Pain
Pain more severe in 1Pain more severe in 1stst 48 hours 48 hours
Ketorolac (Toradol® ) IVKetorolac (Toradol® ) IV• 15-30 mg q6h x 24 hours15-30 mg q6h x 24 hours• If renal function OKIf renal function OK• Not with CABG Not with CABG (( risk of thrombosis) risk of thrombosis)
IV Acetaminophen (Ofirmev®)IV Acetaminophen (Ofirmev®)• 15 mg/Kg q6h x 24 hours15 mg/Kg q6h x 24 hours• D/C all other forms of acetaminophenD/C all other forms of acetaminophen
Post-Operative Care: Pulmonary
Unilateral pulmonary edema commonUnilateral pulmonary edema common
Crackles, diminished breath soundsCrackles, diminished breath sounds
Pulmonary toilet is criticalPulmonary toilet is critical
Case Study #1 Mr. S68 yo male68 yo maleElective robotic mitral valve repairElective robotic mitral valve repairCrossclamp time 80 minutesCrossclamp time 80 minutesExtubated: 3 hours, 50 minutes post-opExtubated: 3 hours, 50 minutes post-op
Case Study: Mr. S
POD #1POD #1Hemodynamically stableHemodynamically stableSpOSpO2 2 96-98% on 2L nasal O 96-98% on 2L nasal O22
CT 310 CT 310 mlml/8 hrs/8 hrsTo telemetryTo telemetry
Case Study: Mr. S
POD #2POD #2Small PTXSmall PTXSpOSpO22 93% 5L O 93% 5L O22
Case Study: Mr. S
POD #3POD #3Desaturated during night Desaturated during night (POD #2 – POD #3)(POD #2 – POD #3)
0930 ABGs on 12L O0930 ABGs on 12L O22
pHpH 7.537.53PCOPCO22 35.835.8
POPO22 6060
HCOHCO33 3030
SatSat 94%94%
Case Study: Mr. S
POD #3POD #3Pulmonology consultPulmonology consultFurosemide (Lasix®) infusionFurosemide (Lasix®) infusionSputum cultureSputum cultureAntibioticsAntibiotics100% Non-rebreather100% Non-rebreather
Case Study: Mr. S
POD #4POD #4Transfer to ICUTransfer to ICU ABGs on 100% non-rebreather maskABGs on 100% non-rebreather maskpHpH 7.497.49PCOPCO22 4141
POPO22 5858
HCOHCO33 30.530.5
SatSat 92%92%
Bi-PAPBi-PAPSteroidsSteroids
Case Study: Mr. S
POD #5POD #5CXR improvingCXR improving
POD #6POD #6Weaned to 4L OWeaned to 4L O22
Up to chairUp to chairPT/OT for deconditioningPT/OT for deconditioning
POD #8POD #8Transfer to telemetryTransfer to telemetry
Case Study: Mr. S
POD #9-14POD #9-14Weaning OWeaning O22
Continued needing increased OContinued needing increased O22 with activity with activity
Changed furosemide to po dosingChanged furosemide to po dosingCXR improvedCXR improved
POD #15-18POD #15-18ImprovingImprovingHome day 18Home day 18
Case Study #2: Ms. K
30 yo female, non-smoker30 yo female, non-smokerDyspnea, chest painDyspnea, chest painWork-up revealed left Work-up revealed left atrial myxomaatrial myxoma
Case Study: Ms. K
Robotic-assisted resection of LA myxomaRobotic-assisted resection of LA myxoma
Crossclamp time 15 minutes; CPB 1 hourCrossclamp time 15 minutes; CPB 1 hour
Extubated 3 hrs, 5 minutesExtubated 3 hrs, 5 minutes
Case Study: Ms. K
POD #1POD #1Chest tube D/C’dChest tube D/C’dTo telemetryTo telemetry
POD #2POD #2HomeHome
Minimally-Invasive vs Sternotomy
No difference in average extubation timeNo difference in average extubation time
Pain less after first 48 hoursPain less after first 48 hours
Less infection riskLess infection risk
Length of stay 1-2 days shorterLength of stay 1-2 days shorter
Full recovery in half the time Full recovery in half the time (4-6 weeks)(4-6 weeks)
Questions