Cardiac Surgery

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Cardiac Surgery

• By
• Dr. Hanan Said Ali

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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.

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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.

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Transmyocardial Laser Revascularization (TMLR)

• The C02 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.

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Coronary revascularization Cont.
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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.

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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

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Coronary Artery Bypass Grafting(CABG)
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Coronary Artery Bypass Grafting(CABG)

• Most common arteries bypassed
• Right coronary artery
• Left anterior descending coronary artery
• Circumflex coronary artery

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Coronary Artery Bypass Grafting(CABG)

• Conduits Used for Bypass
• Saphenous vein used for bypassing right coronary
  artery and circumflex coronary artery

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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

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Coronary Artery Bypass Grafting(CABG) Cont.
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Valvular Heart Disease

• Mitral Stenosis
• Mitral Insufficiency
• Aortic Stenosis
• Aortic Insufficiency
• SURGICAL TREATMENT
• Valve Reconstruction commissurotomy
• Valve Replacement

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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.

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Nursing Management

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

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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.

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cardiopulmonary bypass

• The patients 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 patients
  systemic circulation

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cardiopulmonary bypass
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cardiopulmonary bypass
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cardiopulmonary bypass
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cardiopulmonary bypass

• 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.

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cardiopulmonary bypass

• The blood then travels through the heat
  exchanger, where it is cooled initially and
• later rewarmed.
• During bypass, the patients core body
  temperature is lowered to 28C to 32C to
  decrease metabolism.

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cardiopulmonary bypass

• Oxygenated blood is filtered and returned to the
  patients ascending aorta through the arterial
  cannula.
• After surgery is completed, the heat exchanger
  rewarms the blood to return the patients core
  temperature to 37C

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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.

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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)

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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.

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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 (36C).

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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).

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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

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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.

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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.

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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.

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collaborative care guide

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

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collaborative care guide

• Hematological Issues
• Chest tube drainage will be lt200 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

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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 gt4.0
  mEq/L.

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collaborative care guide

• Fluids/Electrolytes
• Monitor intake and output q 12 h.
• Monitor BUN, creatinine, electrolytes, Mg.
• Record daily weights.
• Administer fluid volume or diuretics as ordered.

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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

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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

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PREVENTING 0f COMPLICATIONS

• PREVENTING CARDIOVASCULARCOMPLICATIONS
• Volume Resuscitation
• Monitoring for Arrhythmias
• Improving Cardiac Contractility
• Controlling Blood Pressure
• PREVENTING PULMONARY COMPLICATIONS

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PREVENTING 0f COMPLICATIONS

• PREVENTING NEUROLOGICAL
• COMPLICATIONS
• MONITORING POSTOPERATIVE BLEEDING
• PREVENTING RENAL COMPLICATIONS
• Oliguria
• Renal Failure

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PREVENTING 0f COMPLICATIONS

• PREVENTING GASTROINTESTINAL
• COMPLICATIONS
• MONITORING FOR INFECTION

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• Thank You