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CARDIAC SURGERY

HISTORY
 First performed in 1967, CABG or myocardial revascularization
 Now, one of the most frequently performed operations, main surgical treatment for CAD, after medical management has failed
 Over half a million CABG performed annually in the U.S.
 Arteries and veins can be used as grafts
 Arteries have better patency rates than veins

CARDIAC REVASCULARIZATION SURGERY: TYPES

 Coronary Artery Bypass Graft (CABG)
 Cardiac Valve Replacement
 Minimally Invasive Cardiac Surgery
 Transmyocardial Laser Revascularization

CARDIAC SURGERY: CABG -ANATOMY

 Arteries used for grafting: internal thoracic or internal mammary artery
 Veins used for grafting: saphenous (leg/thigh)
 Arteries are stronger, thicker layered. More used to strong pressure

CARDIAC SURGERY: CABG -Phases

 Pre-operative
1. Pre-operative Teaching is of utmost importance for patient AND family
2. Baseline Diagnostic Tests: for comparison and if patient is healthy enough to go through a surgery.
o Blood: CBC, electrolytes, BUN/CR, coagulation studies (PT/PTT), cardiac enzymes, Type and
Cross (for blood)
o CXR
o EKG
o Pulmonary Function Test: Important esp. if patient is smoking and has history or lung disease, COPD.
Patient is to breathe in & out through a tube that is connected to various machines (spirometry and
inhaling helium).
o Weight (many of the medications are weight base)
o Vital signs
o Stop smoking 1 week to 1 month prior to surgery to improve respiratory function
o Stop aspirin or Coumadin 7 days before surery
o Stop long-acting insulin and start on sliding scale coverage with short acting insulin
o Preoprative antibiotics
o Shower several times with bacteriostatic soap
o
3. Other Diagnostic Tests:
o Cardiac Catheterization: test pressures in heart chambers, visualize structures with dye and x-ray
o Coronary Arteriography: in conjunction with CC, catheter into aorta, dye injected into coronary
arteries
o Echocardiogram: US visualizing structures/movement, valves, chamber size, ventricular function
o Stress Test: determine cardiac status prior to surgery
a. Chemical (dobutamine, persantine, adenosine) vs exercise
b. Thallium Stress Test: radioactive isotopes, ischemic cells uptake less and slower d/t reduced
coronary blood flow
o Venous Mapping: patency, size, length
o Doppler Studies: carotid arteries (high risk for stroke)
o Positron Emission Tomography (PET) Scan: non-invasive: detect , localize, describe the extend of
CAD impairing blood flow to myocardium, identifies injured myocardium and viability of tissue for
revascularization
o Cardiac MRI: (new) 3-D images, no dye injection or x-ray, can evaluate anatomy, contractility,
perfusion, valve function
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4. Pre-operative Teaching
o Before Surgery: Tests, skin prep, NPO, C/DB, Incentive Spirometry, leg exercises (to prevent DVT),
arrival time
o During Surgery: Type of procedure, time in OR, waiting area for family, how family will be contacted
o After Surgery: Name and location of ICU, External devices, such as:
a. ET tube and ventilator
b. NG tube (to decompress stomach)
c. ECG monitor
d. Pulmonary artery catheter
e. Arterial line, Pacing wires
f. Chest tubes
g. Foley catheter
h. Intra Aortic Balloon Pump (IABP)
o Procedures: Endotracheal Tube (ET) suctioning, pain management, blood administration
o PRE-OP Nursing Diagnoses:
a. Knowledge Deficit
b. Anxiety
 CABG Procedure
1. Main surgical treatment for coronary artery disease (CAD)
2. Indicated for the CAD patient with failed medical management or advanced cardiac disease
3. It is a palliative treatment for patients with CAD, not a cure. It decreases anginal pain, improves quality of life
and survival.
4. Construction of new vessels to transport blood from the aorta to the area beyond the obstructed coronary arteries
5. A coronary artery is considered “stenosed” if the diameter is narrowed by >75%-80%
6. New vessel is fashioned from the saphenous vein (from one of the patient’s legs) or from the internal mammary artery
7. Patient is placed on a heart-lung machine, also called cardiopulmonary bypass (heart is stopped (asystole) so the
surgeon can work on the heart; the CPB oxygenates and circulates the blood in place of the heart.
8. Patient’s body temperature is lowered (hypothermia).

 Intra-operative

1. Multidisciplinary Team: nurses, APNs, physicians, physician assistants, case managers, perfusionists, anesthesiologist
2. Two surgical teams: graft site, chest
3. Procedure: Several IV lines placed, ECG monitor, central line with pulmonary artery catheter, foley, ET tube for
mechanical ventilation, skin prep
4. Blood is diverted from the heart for a bloodless field
5. Cardio (heart) pulmonary (lungs) Bypass machine
6. Venous cannula in right atrium, arterial cannula in aorta (may cannulate femoral if aorta calcified)
7. Blood is diverted from the venous system to CardioPulmonaryBypass machine, then back to arterial system
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8. CPB oxygenates the blood as it goes thru the system

9. Blood requires anticoagulation with Heparin (to avoid clot)
10. Aorta clamped, heart is stopped with cooled cardioplegic solution (hypothermic and hyperkalemic)
11. Vessel bypass begins
12. Grafts harvested from either saphenous vein or internal thoracic (or IMA)
13. New vessels transport blood beyond the obstruction in the coronary artery
14. When complete, Heparin is reversed with Protamine Sulfate, CPB is removed, heart restarted. Give Protamine Sulfate
after CPB is removed, then put patient into normal blood clotting. RBC damage during CPB.

 Post-operative:
1. Managed collaboratively in ICU
2. Direct to ICU from OR with:
o Endotracheal tube and mechanical ventilation
o Pulmonary artery catheter
o Mediastinal tube (midchest)
o Pacemaker
o Intraaortic Ballon Pump
o Arterial Line
o ECG monitor
o Foley catheter
o Nasogastric tube
3. Care is directed at prevention and early detection of complications. Pay attention to details: Status change
4. Frequent assessment of VS, cardiac output, LOC, edema, O2 Saturation, circulation-movement-sensation checks (q 1hr
or more)
5. Effective pain management
6. Management of Hemodynamic Parameters: cardiac output, stroke volume, heart rate, central venous pressure
7. Endotracheal tube and mechanical ventilation
o Tube at mouth into the trachea
o Based on changes on ABG’s such as oxygen, carbon dioxide, acid, pH and bicarbonate.
o Fi O2 (Fraction Inspired O2 concentration) = inspired flow of oxygen, usually 50% is given to patient
o RN can increase Fi O2 if patient is having difficulty breathing
o Increased FiO2 may cause hypoventiallion in COPD patients
o Tidal volume= 10-15ml/kg (500-750ml)
o Based on weight
o TOO MUCH Tidal Volume can cause overexpansion of the lung
o Rate= breaths per minute (10-12)
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o PEEP (positive end-expiratory pressure)= 5cm
o Help alveoli to open and prevent atelectasis
o Ventilator settings changed based on ABG results
o Pulse Oximeter monitors Oxygen Saturation continuously
o Extubate within 2-4 hours per protocol, then 50% face mask, then 6L nasal cannula (NC)

8. Pulmonary Artery Catheter (Swan-Ganz)

o Centrally inserted: right superior vena cava, right internal or external jugular vein
o Pressure-filled system with transducer producing a waveform
o Allows for hemodynamic monitoring: measurement of pressure, flow, and oxygenation of blood with
in the CV system

Pulmonary Artery Catheters typically have 5 lumens

o DISTAL: advanced thru the heart, sits in pulmonary artery, used to monitor pressure and draw blood
(indicator of LV function)
o BALLOON: allows for periodic inflation of balloon surrounding distal lumen
o PROXIMAL: opens in right atrium, used to measure CVP (central venous pressure-indicates fluid
volume status), used also for infusing meds and blood
o PROXIMAL (injectate): also opens in right atrium, used to measure CO
o THERMISTOR: measures body temperature and with cooled injectate, measures CO via
thermodilution

Picture (anatomical heart) at the left side shows that

the catheter can temporarily occluding the
pulmonary artery and can lead to infarct of the lung
tissues.

9. Concepts of Hemodynamics:
o Preload: volume or pressure within a chamber generated at the end of DIASTOLE when the chamber is
full of blood (FLUID REPLACEMENT vs DIURESIS)
o Blood coming to the heart during rest

o Afterload: the force of resistance the heart has to pump against to eject blood during SYSTOLE
(VASODILATORS)
o Nitroglycerin
o Nitroprusside

o Contractility: the strength of contraction (INOTROPES)

o Frank- Starling
o Digoxin (+ inotropes) increase the force of contraction
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o Myocardial performance is increased when preload and contractility are enhanced, afterload is reduced:
medications are used to maintain/balance
o Cardiac Output: the amount of blood pumped by the heart in 1 minute
o CO = HR x SV
o HR= heart rate
o SV= stroke volume= amount of blood ejected each beat
o Normal 4-8 L/ min

10. Central Venous Pressure

o Measures right ventricular PRELOAD
o Normal range: 2-8 mm Hg
o Indicates FLUID VOLUME status (volume deficit or overload)
o Decreased CVP is a relative or actual HYPOvolemia: need volume replacement
Actual:
1. Loss of intravascular volume due to actual external fluid loss
2. External hemorrhage, GI volume losses, renal volume losses or loss of plasma
3. Dehydration, hemorrhage (blood loss), burns, vomiting, diarrhea, polyuria, diarrhea,
evaporation r/t surgery and sweating.

Relative: changing size of the system. Vasodilators (Nitrates)

1. Loss of intravascular volume due to internal fluid shift from the intravascular space to the
interstitial or intracellular spaces
2. Fluid has not left the body but has shifted from the intravascular space and is unavailable for
circulation.
3. Insufficient vascular volume resulting in a decrease in preload, stroke volume, and CO.
Circulatory insufficiency ultimately inadequate tissue perfusion. Less quantifiable
4. Internal hemorrhage, third spacing of fluid, massive vasodilation
5. Seen in patient with cirrhosis sequester fluid in the peritoneal cavity and will have relative
hypovolemic schock. Rupture spleen, hemothorax, hemorrhagic pancreatitis
o Increased CVP can indicate HYPERvolemia: need diuretics, nitrates

11. Non-Invasive Hemodynamic Monitoring

o Based on Impedance Cardiography
o Special Bioimpedance sensors placed on neck and chest
o These sensors monitor the electrical conductivity of the body-information that is converted into blood
flow data and is displayed in real time on a monitoring screen
o Can measure: CO, Systemic Vascular Resistance (SVR), Contractility, Fluid volume in chest
o Bio-Z developed by NASA
o Implications: less invasive for pts, cost effectiveness, reduce infection, outpatient use

12. Mediastinal Tubes

o The Mediastinum is the space in the center of the thoracic cage housing the trachea, heart, major
vessels, nerves, esophagus, thymus gland and lymph nodes. NO FLUID IN THE MEDIASTINUM
o Tubes are placed here for post-surgical drainage, one anteriorly, one posteriorly
o Closed drainage system or autotransfusion system – bring own blood back to the system
o Removed when drainage is <100ml for an 8 hour period
13. Pacemaker
o May be necessary in post-op period
o Cardiac dysrythmias d/t electrolyte imbalances, hypothermia, and edema of conduction pathways
o Bradycardia or Asytole most common
o Two sets of wires placed on epicardium of atria and ventricles, exit thru chest wall on either side of
sternum, attached to pacemaker
14. Intra-aortic Balloon Pump (IABP)
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o Provides mechanical support of cardiac output when chemical support is not as effective, not routine-
low CO syndromes
o Inserted thru femoral artery, positioned in thoracic aorta, inflates/deflates with cardiac cycle
o Inflates with DIASTOLE, displaces blood upward toward coronary arteries improving oxygenation to
heart and downward toward periphery improving perfusion to entire body ( Balloon inflates at the
opposite time of ventricular contraction: counterpulsation. Balloon inflation forces displaced blood
into the coronary arteries; increased coronary artery perfusion pressure causes increased
perfusion to the myocardium and vital organs)
o Deflates just prior to SYSTOLE, helps eject blood under less resistance improving CO
o Increases/enhances CO, decreases afterload
o Complications:
 Thrombus and embolus formation
 Dislodging of plaque
 Compromised circulation to distal extremity of insertion
 Peripheral nerve damage from insertion trauma
 Displacement of the balloon can cause blockage of the left subclavian, renal or mesenteric arteries
 Infection.
15. Arterial Line
o Catheter placed in radial, brachial or femoral artery
o Pressurized closed system for continuous blood pressure measuring: systolic, diastolic and MAP
(mean arterial pressure)
o Used for frequent arterial access for ABGs, other labs
16. EKG: continuous cardiac monitoring
17. Foley catheter: hourly urine output, .5ml/kg/hour, renal status ----- MONITOR FLUID STATUS
18. Nasogastric tube: decompression of stomach

19. Other considerations:

o Temperature regulation: heat lamps, air mattress, thermal blankets, hypothermia increases
vasoconstriction
o Pain management: short-acting Propofol (Diprivan), then morphine sulfate for 24-48 hrs, then oral
agents
o Diabetes Management: titrate insulin drips to keep BS <150. Evidenced Based Practice (EBP)
indicates less infection w/ tighter control of blood glucose
20. Monitoring for complications:
o Low cardiac output syndrome
o Cardiac tamponade
o Dysrhythmias
o Emboli
o Fever
o Intraoperative myocardial infarction

21. Post-Op Nursing Diagnoses:

o Risk for infection r/t chest wound, central line catheter

o Impaired skin integrity
o Decreased cardiac output
o Ineffective airway clearance
o Impaired gas exchanged
o Ineffective tissue perfusion
o Acute pain
o Fluid volume deficit or excess r/t hypovolemia and hypervolemia
o Imbalance nutrition
o Impaired mobility r/t femoral catheter in the artery (Patient MUST REMAIN FLAT on bed

 Intermediate Cardiac Care:

o Out of ICU in ONE day, to intermediate cardiac care unit
o Requires close monitoring by the nursing staff
o Extubated, weaned off O2, pulmonary artery pressures no longer monitored
o CV Assessment
1) EKG monitored for 3-5 days, atrial dysrythmias, especially atrial fibrillation (SA node not firing, No P wave,
atria quivering) common at this time
2) Vital signs q 4 hours, heart sounds, peripheral circulation. May hear pericardial friction rub
3) Beta Blockers initiated POD #1 (post op day 1) unless contraindicated
o Neurological Assessment
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1) Assess neuro status q 8 hours
2) Changes in mental status may indicate STROKE or EMBOLI
3) May not recall pre-op teaching, reinforce
o Pulmonary Assessment
1) Prevention of PNEMONIA is critical
2) Assess lung sounds q 4 hours
3) O2 saturation by pulse oximetry, should be >94%
4) Cough and deep breathe, splint incision, assess expectorant for color/consistency, Incentive spirometry
hourly while awake
5) Monitor chest tube insertion site for bleeding, hematoma, crepitus (crunching noise, usually on bending the
knee from standing, reminiscent of crushing a packet of crispie rice breakfast cereal.)
6) Monitor CT set-up for air leaks
7) Pulmonary effusions common if IMA(internal mammary artery) used
o GI Assessment
1) NG to low, intermittent suction until bowel sounds return, assess bowel sounds
2) Liquids soon after extubation and advanced to low-fat cardiac diet
3) Promote good nutrition, important for wound healing and function
4) Sliding scale for blood glucose management
o Renal Assessment
1) Intake and output monitored closely until discharge
2) Monitor electrolytes, especially POTASSIUM if diuretics are used to mobilize fluids
o Musculoskeletal Assessment
1) Assess strength
2) Up to chair on first post-op day, activity increased as tolerated. Walk daily
3) Shoulder and arm exercises
4) Cardiac rehab consultation for after discharge
o Integumentary Assessment
1) Assess incision sites at least daily: sternum, chest tube, graft site
2) Dressing usually removed first post-op day and left open to air
3) May clean dressings with saline if ordered
4) May have short term antibiotic therapy for prevention of wound infection
o Pain Management
1) Especially important with increasing activity
2) May use epidural agents, PCA, or intermittent analgesics
3) Pre-medicate for chest tube removal