1. Nursing Care: Robotic-Assisted Cardiac Surgery Jane C Whalen RN, MSN, CCRN, CCNS October 22, 2011

2. Objective Adapt nursing care and patient education for patients undergoing minimally-invasive / robotic – assisted cardiac surgery

3. Are They Different? What have you heard? What would you expect? What do you think patients want to know?

4. Pre-Operative Patient Education Incisions Yes, you will have them! They’re just different Pain Yes, you will have pain It can be more painful than a sternotomy

5. Sternotomy

6. Robotic / Minimally-Invasive Incisions

7. Femoral Cannulation Unilateral incision Bilateral incisions Radial Arterial Lines

8. Pre/Post-Operative Care: Prevent Infection Same as with sternotomy Intranasal mupirocin (Bactroban®) Pre-op skin prep Wound care post-op Insulin infusion / glucose management

9. Post-Operative Care: Activity Same progression as with sternotomy No “sternal precautions”, but… Limit lifting, affected side, for pain control Return to work in 2-4 weeks

10. Post-Operative Care: Pain Pain more severe in 1 st 48 hours Ketorolac (Toradol® ) IV 15-30 mg q6h x 24 hours 15-30 mg q6h x 24 hours If renal function OK If renal function OK Not with CABG (  risk of thrombosis) Not with CABG (  risk of thrombosis) IV Acetaminophen (Ofirmev®) 15 mg/Kg q6h x 24 hours 15 mg/Kg q6h x 24 hours D/C all other forms of acetaminophen D/C all other forms of acetaminophen

11. Post-Operative Care: Pulmonary Unilateral pulmonary edema common Crackles, diminished breath sounds Pulmonary toilet is critical

12. Case Study #1 Mr. S 68 yo male Elective robotic mitral valve repair Crossclamp time 80 minutes Extubated: 3 hours, 50 minutes post-op

13. Case Study: Mr. S POD #1 Hemodynamically stable SpO 2 96-98% on 2L nasal O 2 CT 310 ml /8 hrs To telemetry

14. Case Study: Mr. S POD #2 Small PTX SpO 2 93% 5L O 2

15. Case Study: Mr. S POD #3 Desaturated during night (POD #2 – POD #3) 0930 ABGs on 12L O 2 pH7.53 PCO 2 35.8 PO 2 60 HCO 3 30 Sat94%

16. Case Study: Mr. S POD #3 Pulmonology consult Furosemide (Lasix®) infusion Sputum culture Antibiotics 100% Non-rebreather

17. Case Study: Mr. S POD #4 Transfer to ICU ABGs on 100% non-rebreather mask ABGs on 100% non-rebreather mask pH7.49 PCO 2 41 PO 2 58 HCO 3 30.5 Sat92% Bi-PAPSteroids

18. Case Study: Mr. S POD #5 CXR improving POD #6 Weaned to 4L O 2 Up to chair PT/OT for deconditioning POD #8 Transfer to telemetry

19. Case Study: Mr. S POD #9-14 Weaning O 2 Continued needing increased O 2 with activity Changed furosemide to po dosing CXR improved POD #15-18 Improving Home day 18

20. Case Study #2: Ms. K 30 yo female, non-smoker Dyspnea, chest pain Work-up revealed left atrial myxoma

21. Case Study: Ms. K Robotic-assisted resection of LA myxoma Crossclamp time 15 minutes; CPB 1 hour Extubated 3 hrs, 5 minutes

22. Case Study: Ms. K POD #1 Chest tube D/C’d To telemetry POD #2 Home

23. Minimally-Invasive vs Sternotomy No difference in average extubation time Pain less after first 48 hours Less infection risk Length of stay 1-2 days shorter Full recovery in half the time (4-6 weeks)

24. Questions