1. Cardiac Surgery By Dr. Hanan Said Ali

2. Objectives  Identify types of cardiac surgery.  Describe the following procedures:  Transmyocardial Laser Revascularization  Coronary Artery Bypass Grafting(CABG).  Valvular heart disease surgery.  Describe the nursing management in: Preoperative Phase Intraoperative Phase Postoperative Phase  Explain how to prevent complication.

3. Cardiac Surgery Introduction Surgical intervention remains the treatment of choice in some patients. In particular, cardiac surgery is sometimes necessary in two common conditions: coronary artery disease (CAD) Valvular disease.

4. Transmyocardial Laser Revascularization (TMLR): The C0 2 TMR therapy is a surgical procedure that relieves chest pain in debilitated heart patients. A cardiac, surgeon utilizes the laser to create approximately 20 to 40 channels to allow oxygen-rich blood to reach prove deprived areas of the Patient's heart.

5. Coronary revascularization Cont.

6. Coronary Artery Bypass Grafting(CABG) It is still major intervention in the treatment of patients with coronary heart disease. Current CABG is a surgical procedure in which a blood vessel from another part of the body is grafted to the occluded blood vessel so that blood can flow around the occlusion.

7. Coronary Artery Bypass Grafting(CABG) Indications Chronic angina Unstable angina Acute myocardial infarction Acute failure of percutaneous transluminal coronary angioplasty (PTCA) Severe coronary artery disease

8. Coronary Artery Bypass Grafting(CABG)

9. Most common arteries bypassed: ◦ Right coronary artery ◦ Left anterior descending coronary artery ◦ Circumflex coronary artery

10. Coronary Artery Bypass Grafting(CABG) Conduits Used for Bypass Saphenous vein used for bypassing right coronary artery and circumflex coronary artery

11. Coronary Artery Bypass Grafting(CABG) Cont. Internal mammary artery (IMA) used for bypassing left anterior descending coronary artery ◦ Patency rate over 90% after 10 years If more veins are needed, alternative sites such as upper extremity veins can be used ◦ Patency rate as low as 47% after 4.5 years

12. Coronary Artery Bypass Grafting(CABG) Cont.

13. Valvular Heart Disease  Mitral Stenosis  Mitral Insufficiency  Aortic Stenosis  Aortic Insufficiency SURGICAL TREATMENT  Valve Reconstruction commissurotomy  Valve Replacement

14. Preoperative Phase Includes history, physical examination, chest radiography, and an ECG, chest radiograph. Laboratory tests include : Complete blood count (CBC), electrolytes, prothrombin time (PT), partial thromboplastin time (PTT), blood urea nitrogen(BUN), and creatinine. Pulmonary function tests and arterial blood gases.

15. Nursing Management Preoperative Effective preoperative teaching, which reduces anxiety and physiological responses to stress before and after surgery.

16. Intraoperative Phase The sternum is split with a sternal saw from the manubrium to below the xiphoid process, and the ribs are spread. Once the pericardium is opened and the heart and aorta are exposed, the patient is placed on cardiopulmonary bypass.

17. cardiopulmonary bypass The patient’s deoxygenated venous blood is brought to the pump by two cannulas, one of which is placed directly in the inferior vena cava and the other directly in the superior vena cava. Another cannula is placed in the ascending aorta to return oxygenated blood to the patient’s systemic circulation

18. cardiopulmonary bypass

21. Heparin is administered throughout cardiopulmonary bypass to prevent massive extravascular coagulation. Venous blood from the patient flows through the venous cannula to the cardiotomy reservoir and then into the oxygenator, where exchange of oxygen and carbon dioxide occurs.

22. cardiopulmonary bypass  The blood then travels through the heat exchanger, where it is cooled initially and later rewarmed. During bypass, the patient’s core body temperature is lowered to 28°C to 32°C to decrease metabolism.

23. cardiopulmonary bypass Oxygenated blood is filtered and returned to the patient’s ascending aorta through the arterial cannula. After surgery is completed, the heat exchanger rewarms the blood to return the patient’s core temperature to 37°C

24. cardiopulmonary bypass After air is vented from the heart chambers and the aortic root, the aortic cross-clamp is removed so that blood again perfuses the coronary arteries, warming the myocardium. Chest tubes placed in the mediastinum and pericardial space for drainage are brought out through stab wounds just below the median sternotomy.

25. Postoperative Phase Immediate postoperative care involves cardiac monitoring and maintenance of oxygenation/ hemodynamic stability. Priority Interventions Performed by the Critical Care Team on Arrival Attach patient to bedside cardiac monitor and note rhythm. Attach pressure lines to bedside monitor (arterial and pulmonary artery)

26. Priority Interventions Performed by the Critical Care Team on Arrival Connect ventilator and auscultate breath sounds bilaterally. Apply pulse oximetry device to patient and note SpO2 & O2 sat. value. Check peripheral pulses and perfusion signs.

27. Priority Interventions Performed by the Critical Care Team on Arrival Monitor chest tubes and character of drainage: amount, color, flow. Check for air leaks. Measure body temperature and initiate rewarming if temperature (36°C).

28. Priority Interventions Performed by the Critical Care Team on Arrival Once the Patient Is Determined to Be Hemodynamically Stable Measure urine output and note characteristics. Obtain clinical data (within 30 minutes of arrival). Obtain chest radiograph. Obtain 12-lead electrocardiogram (ECG).

29. Priority Interventions Performed by the Critical Care Team on Arrival Once the Patient Is Determined to Be Hemodynamically Stable Obtain routine blood work within 15 minutes of arrival; tests may include ABGs, potassium, glucose, PTT, hemoglobin (varies with institution). Assess neurological status

30. collaborative care guide Oxygenation/Ventilation Obtain arterial blood gases per protocol. Adjust ventilator settings after consulting with the respiratory therapist and physician. Wean from mechanical ventilation per protocol using the expertise of respiratory therapy.

31. collaborative care guide Oxygenation/Ventilation Extubate when patient is hemodynamically stable; able to protect airway. Provide supplemental oxygen after extubation. Encourage use of incentive spirometer, cough and deep breath q 2 to 4 hours after extubation. Milk chest tubes if necessary to facilitate forward clot movement.

32. collaborative care guide Circulation/Perfusion Regulate volume administration as indicated by CVP values. Evaluate effect of medications on BP, HR, and hemodynamic parameters. Monitor and treat dysrhythmias per protocol and physician orders. Anticipate need for temporary cardiac pacing; wires will be properly isolated for electrical safety.

33. collaborative care guide Circulation/Perfusion Assess for neck vein distension, pulmonary crackles, S3 or S4, peripheral edema. Assess temperature q 1 h. Warm patient 1°C per hour by using warming blankets, lights, and fluid warmer.

34. collaborative care guide Hematological Issues Chest tube drainage will be <200 mL/h. Monitor for signs of cardiac tamponade (hypotension,pulsus paradoxus ( inspiratory decrease in arterial blood pressure of more than 10 mm Hg from baseline), tachycardia

35. collaborative care guide Fluids/Electrolytes Renal function will be maintained as evidenced by urine output of approximately 0.5 mL/kg/h. Potassium will be replaced to maintain K+ >4.0 mEq/L.

36. collaborative care guide Fluids/Electrolytes Monitor intake and output q 1–2 h. Monitor BUN, creatinine, electrolytes, Mg. Record daily weights. Administer fluid volume or diuretics as ordered.

37. collaborative care guide Mobility/Skin Integrity Turn patient side to side every 2 hours while on bed rest and evaluate skin closely. Progress activity to chair for meals, bathroom privileges, increased distance walking, delegating to assistive personnel as indicated. Assess sternotomy and leg incision for redness, swelling, drainage

38. collaborative care guide Comfort and Pain Control Assess quality, duration, location of pain. Use visual analog scale to assess pain quantity. Provide a calm environment. Provide for adequate periods of rest and sleep

39. PREVENTING 0f COMPLICATIONS PREVENTING CARDIOVASCULAR COMPLICATIONS  Volume Resuscitation  Monitoring for Arrhythmias  Improving Cardiac Contractility  Controlling Blood Pressure PREVENTING PULMONARY COMPLICATIONS

40. PREVENTING 0f COMPLICATIONS PREVENTING NEUROLOGICAL COMPLICATIONS  MONITORING POSTOPERATIVE BLEEDING  PREVENTING RENAL COMPLICATIONS Oliguria Renal Failure

41. PREVENTING 0f COMPLICATIONS PREVENTING GASTROINTESTINAL COMPLICATIONS MONITORING FOR INFECTION