Case A A is a 58 y Saudi gentleman presented with S.O.B with C.P class II, III Co – morbidity: HTN( >15 y), Hyperlipidemia (2 y), peptic ulcer. Diagnosed with IHD (EF=50%) Social Hx: Shisha smoker Family Hx: +ve brother died by cardiac arrest
Cont…. C/O: S.O.B with effort. O/E: good general condition Abd. Soft, chest clear No chest pain for the last 5 days No L.L. edema No neurological history
Vital Signs 3/327/ ºc Temp 128/84154/79 BP 90 Pulse
Plan: Need TT echo. Early morning CABG ×2 grafts using Left internal mammary artery Right internal mammary artery
Medication Pre-medication: Diazepam 5 mg PO Promethazine 25 mg IV
28/2 KCL 20mg IV PRN Morphin 2-5 IV PRN Mgso4 IV PRN 1/3 Furosemide 20mg IV 2/3 Furosemide 40mg IV Tramadol 50mg PO Hydrocortisone 200mg IV repeated same after 4 hr Bramasep 1.5mg PO 3/3 Paracetamol 1g PO PRN Once daily medication
Regular medication At 28/02 Cefurxime 1.5g q8h Ranitidine 150mg PO IV DC 2/03 Tramadol 100mg PO/IV/ q8h Metoclopromide 10mg PO/IV/ TID ASA 81mg PO OD (6h post operative) Mgso4 1g IV q8h DC 29/02 Paracetamol 1g PO/ IV/ q8h
At 1/03 Enoxaparin 40mg SC BID Simvastatin 40mg PO OD Fosinopril 10mg PO BID At 2/03 Ipratropium 500ml inh. q6hr Lactulose 20ml PO TID Ipratropium 5ml/1.5ml Neb. PO Multivitamine 1tab PO BID Amlodipine 5mg PO OD
At 3/03 Omeprazole 40mg PO OD Furosemide 20mg PO BID Budesonide 0.5mg inh q12hr
CABG Procedure Complication Post CABG management
CABG overview More than a half-million people each year. This procedure uses blood vessels from the patient’s chest or leg to go around or “bypass” clogged coronary (heart) arteries.
COMPLICATIONS Bleeding MI Heart failure Arrhythmia Stroke Changes in cognitive function Pulmonary problems Wound infection Renal failure and death.
1- Cardiac complications: MI after surgery Low cardiac output can occur during or after Surgery Tachyarrhythmias may occur after CABG. Pericarditis is accompanied by pericardial effusion
3- Infection Sternal wound Diabetes mellitus, obesity, and the use of both left and right internal mammary arteries are factors associated with an increased risk for sternal wound infection. 4- Renal failure Temporary reduction of renal function may occur in approximately 5 to 10 % of patients undergoing CABG.
5-Bleeding Exposure to aspirin in the week before surgery increases the risk of postoperative bleeding Clopidogrel and ibuprofen are generally discontinued for several days prior to coronary surgery. Patients taking warfarin should speak with their surgeon about how and when to stop it before surgery.
RISK OF COMPLICATIONS Cerebrovascular disease Diabetes mellitus Poor nutritional status Female gender, age Chronic renal failure Chronic lung disease Anemia Previous CABG
1- Reducing the Risk of Perioperative Infections Aggressive glucose control in patients with diabetes through the use of continuous intravenous insulin infusion Preoperative Ab. administration reduces by 5- fold the risk of postoperative infection. Cephalosporins are the agents of choice.
Prophylactic Antimicrobials for CABG Surgery
2 - Prevention of Postoperative Arrhythmias - Withdrawal of preoperative beta-blockers in the postoperative period doubles the risk of AF after CABG. - Prophylactic use of beta-blockers lowers the frequency of AF. - For patients who have contraindications to beta- blockers, amiodarone is appropriate prophylactic therapy.
3- Antiplatelet Therapy The aspirin should be started within 24 hours after surgery.100 to 325 mg per day appear to be efficacious. Ticlopidine offers no advantage over aspirin but is an alternative in truly aspirin-allergic patients. Clopidogrel has fewer side effects than ticlopidine as an alternative in aspirin-allergic patients.
4- Pharmacological Management of Hyperlipidemia Targeting LDL-C levels to less than 100 mg/dL. New data: * very high risk patients: LDL-C less than 70 mg/dL
Take home point After CABG, all patients should begin taking aspirin. Patients with a history of MI should also be given a beta- blocker, unless it is contraindicated. ACE inhibitors should be used in high-risk patients Statins should be used to achieve targets for LDL cholesterol Life style modification: diet, exercise, smoking cessation
Stimulating cAMP production Dopamine Dobutamine Thus, a rational choice of inotrope would take into account the effects that each drug has i.e. dobutamine – increase in heart rate greater than dopamine, otherwise similar. In practice, none of the newer inotropes has been shown to be more effective than epinephrine and, if we are to practice evidence based medicine, this is the drug of choice until proved otherwise.