Case Study Analysis of CABG Surgery

 

Mrs. Andal P.¹* and Dr. Nalini Jeyavanth Santha²

¹Doctoral Student and Associate Professor, Sacred Heart Nursing College, Madurai

²Principal, Sacred Heart Nursing College, Madurai

 

 

PROLOGUE:

Cardiovascular diseases are the number one cause of deaths worldwide. By 2030, 23.6 million people are predicted to die from CVD which places burden on national countries.  The most common type of heart disease is CAD, which is the narrowing or blockage of coronary arteries.  High stress sedentary life style, lack of physical exercise and unhealthy eating habits, diabetes, cigarettes smoking and hypertension have been associated with CVD.  The surgical approach to CAD is coronary artery bypass crafting.  An artery from the chest wall (internal mammary) or vein from be leg (saphanous) is used to supply the distal area of stenosis.

 

Mr X, Y and Z aged 44, 42 and 54 years respectively admitted with the C/o. Chest pain and Angiogram findings confirmed as all three suffered with blocks of TVD, TVD and SVD respectively.  They were underwent CABG and got discharged with uneventful post operative period.  The comparison of all 3 patients and their follow ups were discussed below.

 

 

Age in Years		44	47	54
Diagnosis: Risk Factors: Smoking Alcoholism High fat diet Present of DM Presence of hypertension Stress		Triple vessel disease   No No Yes Since 1 year Since 1 year Due to mother’s death	Triple vessel disease   Known smoker since 8 years Known alcoholic since 8 years Yes Since 2 years Since 2 years No	Single vessel disease LMCA disease Known smoker since 15 years Known alcoholic since 15 years Yes No No Not getting proper salary irregular (35 years)
Occupation Past history Reasons for seeking admission Present surgical history		Driver Poor controlled DM Chest pain, palpitation, sweating LIMA to LAD SVG to D12SVG SVG to Ramus	Hotel master DM and HT controlled with drugs Chest pain, profuse sweating LIMA  - LAD OMI – SVG Double graft done	Bank manager No other complaints Chest pain, dyspnoea on exertion LIMA – LAD Anastamosis done Single graft done
All 3 patients were intubated and weaned from ventilator on 1st POD
Diagnostic Investigations BT CT H6 SGOT SGPT Urea Creat Echo   Angiogram	11 mts 4mts 25 sec 12.7 gms 53.8 69.2 39.9 1.3 Regional wall LV dysfunction Ef 52% CAD – TVD		6mts 19 sec 2mts 20 sec 13.8 gms 46.5 46.7 23 1 Regional wall Dysfunction Ef 45% CAD - TVD	4mts 25 sec 2 mts 12 gms 35 35 40 1.2 LMCA disease Ef 62% LMCA diseased GrIII Thrombus filling the LMCA from osmium (+)
Medications	T. Rantac 150mg bd T. Clopilet 75mg od T. Oflox 200mg bd T. Lasix 40mg od T. Ecosprin 325mg od T. Met.SR 12.5mg od T. Cardice 2.5mg od T. Alorvastin 10mg Hs T. Zincofer 150mg bd T. Alprax 5mg Hs		T. Clopilet 75mg od T. Storvas 40mg Hs T. Nitrocontin 2.6 mg bd T. Cardace 1.25 mg od T. Cardivas 2.125mg bd T. Prolomet 25mg od T. Panto prazole 40mg bd T. Alprax 5mg Hs T. Glyomet 500mg od	C. Cefaloxine 500mg bd T. ASA 150mg od T. clopidogrel 75mg od T. Enalpril 2.5mg 1/2bd T. Metaprolol 25mg bd T. Atorva 10mg Hs T. Rantac 150mg od

 

Guidelines for preparing the patient undergoing cardiac surgery:

1. Describe the Surgical Procedure:

a.       All steps including heart – lung machine

b.      Review of A and P of heart and valves

c.       Brief definition of unfamiliar technical terms

d.      Length of time in surgery and approximate time of first visit by family

e.       Giving the patient pictures of the heart and involved valve for future reference.

 

2. Describe the ICU environment and monitoring equipment

a.       Cardiac monitor and alarm

b.      ET tube and projected length of time with ET tube in place

c.       Mechanical ventilator and alarms

d.      Suctioning procedure

e.       Arterial line and automatic BP cuff

f.       Chest tubes or mediastinal tubes

g.      NG tube and length of NPO status

h.      Urinary catheter

i.        High noise level in ICU

j.        Multiple IV lines and fluids.

 

3. Describe pre operative preparation

a.       Showering with antimicrotial soap

b.      Shaving of chest, abdomen, neck and groin

c.       Special cardiac studies, ECG, Echo, Cardiac centralization

 

4. Describe comfort measures

a.       Pain reduction

b.      Turning range of motion exercises

c.       Out of bed next morning

d.      Medication for sleep if needed.

 

 

CABG Procedure:

The Intra Operative Phase:

·        After the insertion of the invasive lines, anesthesia will be administered.  

·        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. Examples of IV inhalation agents are desflurane and sevoflurane.

·        The standard surgical approach is via a median strernotomy. 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. Heparin is administered to promote anticoagulation.  The activated clotting time is measured during surgery to determine the effectiveness of the anticoagulation and therefore guide the amount of heparin that is administered.

 

·        The cardiopulmonary bypass (CPB) machine can be used during the operation to maintain cardiopulmonary function and tissue perfusion.  Sites of cannulation for CPB are usually the aorta and the right atrium.  After the aorta is cross-clamped, cardioplegia is administered to stop the heart.  Cardioplegia can be a cold solution that is high in potassium.  The surgeon performs the anastomoses while the heart is stopped.  The shorter the time on the bypass machine, the less likely there will be complications related to extracorporeal circulation.

 

·        During extracorporeal circulation, anesthesia may be maintained with propofol, an intravenous medication that provides anesthesia as well as amnesia.  Propofol can cause myocardial depression and hypotension so the hemodynamic status of the patient should be closely monitored.

 

·        Rewarming the body must occur prior to the completion of the operation to begin to offset the surgically induced hypothermia.  Rewarming is initiated with the heat exchanger on the bypass machine while the surgeon finishes the anastomoses.  The cross clamp is then removed from the aorta.  The intrinsic cardiac rhythm is often spontaneously reestablished as blood begins to flow through the heart.  The patient is separated from the CPB machine and protamine sulfate is administered to reverse the effects of the heparin.  Inotropic agents may be required to wean the patient from the bypass machine.

 

·        The OPCAB procedure, adrenergic blocking medication such as esmolol may be used to slow the heart for the anastomoses to be completed.  Surgical stabilizers may be used to decrease the motion of the heart so that the surgeon can complete the anastomoses.  Heparin is administered with the OPCAB to prevent potential clotting.  The patient may receive protamine to reverse the heparin at the end of the operation.  Fluid shifts and hematuria related to long pump times would be minimized and hemodilution from priming the CPB machine is not an issue with the OPCAB.

 

On pump or off?

v  During on pump CABG surgery, a CPB machine circulates oxygenated blood while diverting most of patient’s blood from the heart and lungs.  This provides a bloodless, motionless surgical field while pre tissue perfusion to vital organs.

 

v  The older off pump technique, in which surgery is performed on the beating heart, reduces the adverse reactions associated with CPB and the need for RBC transfusions and positive inotropes.

 

POST OPERATIVE CARE

S.No	I. Decreased cardiac output related to bleeding and fluid loss and surgical manipulation
1. 2. 3. 4. 5. 6. 7. 8. 9.	Monitor vital signs, O2 saturation, hemodynamic parameters every 15 mts Auscultate heart and breath sounds on admission Assess skin colour, temp peripheral pulses, vital signs and level of consciousness Monitor and document cardiac rhythm Measure intake and output hourly Record chest output hourly Monitor Hb, hematocrit and serum electrolytes Administer IV fluids and blood transfusion as ordered Administer medications as ordered
	II. Hypothermia related to cardiac surgery
1. 2. 3. 4.	Monitor core body temperature Continuously monitor ECG Institute rewarming measures (use warm blackest, mattress or warm packs to increase temp slowly) Protect skin against burns providing layer of protection between it’s skin and warming apparatus
	III. Acute pain related surgical incision
1. 2. 3. 4.	Assess the pain including location character, depth and intensity of pain Provide comfortable position Administer analgesics Teach relaxation techniques like PMRT, Biofeedback, music therapy.
	IV. Ineffective airway clearance /impaired gas exchange
1. 2. 3. 4. 5. 6. 7.	Evaluate respiratory rate, depth, effort, symmetry of chest expansion and breath sounds Note ET tube placement Maintain ventilator settings as ordered monitor ABG anlaysis Suction if needed Prepare ventilator weaning and extutation appropriate After extutation teach use of incentive spirometery and encourage use every 2 hrs Encourage deep breathing and coughing. Teach use of a “cough pillow” to splint chest incision and decrease pain.
	V. Risk for Infection
1. 2. 3. 4.	Assess sternal wound every shift document redness, wamth, swelling and drainage from the site. Maintain a sterile dressing for the first 48 hrs Culture wound drainage of indicated Encourage good nutrition and intake
	VI. Disturbed thought process
1. 2. 3. 4. 5. 6. 7. 8. 9.	Reorient during initial recovery period Explain all the procedures before performing them Secure all invasive and IV lines, catheters / tubes Note verbal responses to questions Maintain calendar and clock within the client’s view orient with date, day and time Involve family members in providing reorientation Promote patient participation in decision making Administer sedatives cautiously Re evaluate neurologic status every shift.

 

Discharge Instructions:

v  Mood swings, diminished appetite, and difficulty sleep are common after CABG, but usually resolve in 4 to 6 weeks.

v  Lifestyle changes such as stopping smoking, eating a low-fat diet, controlling BP, and losing weight. Example, patients who continue to smoke have more myocardial infarctions and reoperations.

v  For the first 6 weeks postoperatively, the patient can engage in light activities setting the table, folding clothes, walking, and climbing stairs.  He can return to work part-time after 6 and can gradually increase his activity level to normal by 3 months after surgery.

v  All patients should receive cardiac rehabilitation after patients who participate in cardiac rehabilitation have increased physical mobility, feel in better health generally have a more positive outlook on life.

 

CONCLUSION:

All three patients were got discharged with necessary follow up instructions.  Advised to come for regular follow up after 15 days.

 

REFERENCES:

1.       Nursing critical care, Jan 2009 Vol-4, Issue-1, P.No: 22-27, Carrying for a patient after CABG surgery mullen fortino, Margaret RN, MSN, O’Brien, Noreen RN, MSN

2.       Black, J.M and Jacobs EM, Nursing management of the client after CABG surgery medical surgical nursing (8^th ed), Philadelphia, WB Saunder, P.No: 1421-1425

3.       Suzane C. Smeltzer and Brenda GB, Nursing Care of patient after CABG surgery, Brunner and Suddarth text book of medical surgical nursing 11^th ed, London, Lippincott, P.No: 190-192.

 

 

 

Received on 23.04.2013           Modified on 24.05.2013

Accepted on 28.05.2013           © A&V Publication all right reserved