Cardiac Surgery (Post-ICU Care)

Definition/Etiology:

• CABG
  • Addresses Perfusion (Hose) Problem that cannot be fixed with a stent = CABG
    • No water = No garden
    • Reroutes hose around the blockage
    • Perfusion restored
  • Bypass surgery of clogged hose
  • 3-6 hours
• CABG indications
  • Non-Emergent/Planned (before MI)
    • Left Coronary Artery “Left Main disease”
  • Emergent/Not Planned (after MI)
    • NSTEMI/STEMI = does not respond to interventions
  • Both have same plan of care (Emergent more fragile)
• Surgery → CVSICU → POD#2
  • Step Down (PCCN Care)

Pathophysiology:

• Vessels Harvested
  • Happens before & during surgery
  • Arteries & Large veins
    • Internal Mammary Artery
      • Either side of sternum
    • Radial Artery
      • Inner forearm
    • Saphenous Vein
      • leg/calf
• Sternotomy “Crack the Chest”
• Bypass Machine
  • Heart Stops: High KCL Solution/Ice
  • Perfusionist: Mechanical Heart/Lungs
    • 2 Tubes inserted into heart = circulation
    • Pumps blood & adds 02
  • Surgeon attaches bypass grafts

Noticing: Assessment & Recognizing Cues:

• Subjective Cues
  • #1 Concern = Chest pain
    • PQRST
• Objective Cues
  • Concern = ↓ Cardiac Output (must have a good perfusion/open hose)
  • Vital Trend
    • Q 2- 4 hours in PCU
      • Hypotension/Tachycardia/MAP >65
      • Temp >36.0 and <38.5
      • Temp >36.0 and <38.5
    • Pulses
  • Heart/Lung sounds
    • S3/crackles/rales = heart failure
    • Muffled heart sounds = Cardiac tamponade
  • Skin
    • Temperature & color
    • Sternotomy & Harvest site dressings
    • Temp Pacer
    • Tubes/Drains
      • Chest tube= > 70cc/hr & slow decrease
      • Foley =<30ml/h for 2 hours (DC?)

Interpreting: Analyzing & Planning:

• Labs
  • CBC (H/H)
    • Hemorrhage not obvious – Transfusion
  • Electrolytes
    • Replace KCL/MAG/Calcium
  • Blood Gasses
    • Poor Gas Exchange symptoms only
• ECG/Telemetry
  • Q Waves – Signs of scar tissue. Common.
  • Bradyarrhythmias
    • Temp Pacer
  • Atrial Tachyarrhythmias
    • Afib/Aflutter/SVT
      • AFIB =most common = Rate Control
  • Ventricular Tachycardias
    • VT and Vfib (rare) = ACLS algorithm

Responding: Patient Interventions & Taking Action:

• Lab & ECG Telemetry Interventions
• Pharmacological Interventions
  • Pain management PRN
    • IV → PO
  • Electrolyte replacement IVPB
  • Fluid Replacement
    • Albumin for low MAP
  • Blood Transfusions
    • Low Blood Count
  • Vasoactive Infusions – emergent only → ICU
• Non-Pharmacological
  • Incentive Spirometry
    • Q1 hour while awake
  • Cough & Deep breath
  • Incision Care/Tube Care
• Adjunct Medical Therapy
  • Rehabilitation Services: PT/OT
    • EARLY MOBILITY

Reflecting: Evaluating Patient Outcomes:

• Pain Free
  • Sign of good perfusion
• Labs/ECG/Telemetry
  • Baseline
• Vital Signs
• Heart Lung sounds
• Kidney Output
• Skin/Tubes/Drains
  • Incision Care
    • Sternotomy
    • Harvest Sites
    • Epicardial Pacing wires
  • Chest tube
    • Output reducing
  • Foley
    • Get D/C’d ASAP

Linchpins (Key Points):

• Notice
  • Symptoms of decreased perfusion
• Interpret
  • ECG/Labs
• Respond
  • ACLS & PRN Order Sets
• Reflect
  • ABCs
  • Perfusion/Hemodynamically stable first