1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 22: Cardiac Surgery

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Aorto-Coronary Bypass Grafts

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Comparison of Common Conduits Used in Revascularization See Table 22-1.

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Off-Pump Coronary Artery Surgery Advantages Decreased length of hospital stay Fewer cognitive deficits Less need for blood transfusion Less trauma to brain, kidneys Disadvantages Unable to reach all lesions for grafting Grafts more likely to lose patency

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Transmyocardial Laser Revascularization (TMR) TMR is a procedure to revascularize the heart muscle by drilling channels into the outside of the heart’s left ventricle with a laser. –Angiogenesis –Direct channel endothelization Indications –Patient at high risk for second bypass or angioplasty –Blockages too diffuse to be treated with bypass

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Normal and Diseased Heart Valves

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Mitral Valve Dysfunction

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Aortic Valve Dysfunction

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Advantages of Mitral Valve Repair Improved long-term survival rate Optimal heart function No need for anticoagulation Lower risk of thromboembolic events Lower risk for endocarditis

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Advantages and Disadvantages of Replacement Cardiac Valves Type of ValveAdvantagesDisadvantages Biological valvesDon’t require anticoagulation No hemolysis Usually need to be replaced after 10 years Mechanical valves Last longerRequire anticoagulation

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Mechanical Valves

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Role of Nurse in Preoperative Teaching of Patient Undergoing Cardiac Surgery Instruct patient/family on ICU environment Instruct on procedure –Appearance of patient after surgery and reasons –Incision and chest tube care –Pain and discomfort management –Coughing and deep breathing and use of incentive spirometry –Importance of early mobilization and progression

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Blood Flow Through the Cardiopulmonary Bypass Machine

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Assessment Areas: Early Postoperative Period of Cardiac Surgery Assess VS, ECG monitor, ABC survey, neuro status Assess peripheral circulation and sensation Assess incisions, chest tube systems Assess hemodynamic parameters Assess fluid, electrolyte, and coagulation status Assess rewarming efforts Assess for pain Monitor for complications

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Differences Between SIRS and Infection

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Areas to Assess in Postoperative Hypotension Hypovolemia: hemodynamic parameters, intake/output Postoperative bleeding: chest tube drainage, Hgb/Hct Cardiac tamponade: Beck’s triad Low cardiac output: determine baseline reading for comparison; look for signs of hypoperfusion Dysrhythmias: follow ACLS guidelines Rapid vasodilation from rapid rewarming

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which statement about hypothermia right after cardiac surgery is correct? A. It leads to peripheral vasoconstriction and a shift of oxygen-hemoglobin dissociation curve to the left. B. It leads to peripheral vasoconstriction and a shift of oxygen-hemoglobin dissociation curve to the right. C. It can be monitored using a rectal temperature. D. Rewarming should be done quickly to promote hemodynamic stability.

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. It leads to peripheral vasoconstriction and a shift of oxygen-hemoglobin dissociation curve to the left. Rationale: Hypothermia leads to peripheral vasoconstriction and a shift of the O2-Hgb dissociation curve to the left, which means the O2 is released from Hgb to the tissues. Rectal temperatures are not accurate for 8 hours, so the pulmonary artery catheter or tympanic should be used. Rewarming should occur slowly to maintain hemodynamic stability. Rapid rewarming would lead to vasodilation and hemodynamic instability.

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Four days after cardiac surgery, a client is admitted from the doctor’s office after developing atrial fibrillation at 80/min. The client has complained of palpitations for the past day. The nurse should provide which measure first? A. Give 150 mg amiodarone IV followed by drip. B. Provide weight-based heparin per protocol. C. Send client for transesophageal echocardiogram (TEE) scheduled in 2 hours. D. Provide immediate cardioversion per standing orders.

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Provide weight-based heparin per protocol. Rationale: The length of time the client has been in atrial fibrillation is unknown, so the client is at high risk for embolization of clots. The patient’s rate is stable and there are no apparent signs of hemodynamic compromise, so immediate cardioversion is not warranted. It is best to start the weight-based heparin protocol and then send the client for the TEE. The TEE would be read by the cardiologist to determine whether it is safe to use amiodarone for cardioversion.

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A client is 2 hours post-CABG. The chest tube drainage has been 220 mL/hr for the past 2 hours. The nurse should first provide: A. Aggressive rewarming B. 6 units of platelets C. Protamine sulfate 1 mg for every 100 units of heparin given during surgery D. 6 units of fresh frozen plasma if PT >15 sec

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Protamine sulfate 1 mg for every 100 units of heparin given during surgery Rationale: The nurse should first give the protamine sulfate and then repeat the labs (CBC and aPTT/PT). If the protamine sulfate does not stop the bleeding, then the nurse should provide aggressive rewarming; however, as the patient rewarms, the heparin the patient had been given will become reactivated, and the client will need platelets. If the PT is >15 seconds, then the client will need fresh frozen plasma because the bleeding is due to a lack of fibrinogen.