cardiac surgery by dr. hanan said ali. objectives identify types of cardiac surgery. describe the...
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Cardiac Surgery
ByDr. Hanan Said Ali
ObjectivesIdentify 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 PhaseExplain how to prevent complication.
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.
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.
Coronary revascularization Cont.
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.
Coronary Artery Bypass Grafting(CABG)
IndicationsChronic anginaUnstable anginaAcute myocardial infarctionAcute failure of percutaneous transluminal coronary angioplasty (PTCA)
Severe coronary artery disease
Coronary Artery Bypass Grafting(CABG)
Coronary Artery Bypass Grafting(CABG)
Most common arteries bypassed:◦Right coronary artery
◦Left anterior descending coronary artery
◦Circumflex coronary artery
Coronary Artery Bypass Grafting(CABG)
Conduits Used for BypassSaphenous vein used for bypassing right coronary artery and circumflex coronary artery
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
Coronary Artery Bypass Grafting(CABG) Cont.
Valvular Heart DiseaseMitral StenosisMitral InsufficiencyAortic StenosisAortic Insufficiency
SURGICAL TREATMENTValve Reconstruction commissurotomyValve Replacement
Preoperative PhaseIncludes 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.
Nursing Management
PreoperativeEffective preoperative teaching, which
reduces anxiety and physiological responses to stress before and after surgery.
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.
cardiopulmonary bypassThe 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
cardiopulmonary bypass
cardiopulmonary bypass
cardiopulmonary bypass
cardiopulmonary bypassHeparin 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.
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.
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
cardiopulmonary bypassAfter 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.
Postoperative PhaseImmediate postoperative care involvescardiac 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)
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.
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).
Priority Interventions Performed by the Critical Care Team on ArrivalOnce 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).
Priority Interventions Performed by the Critical Care Team on ArrivalOnce 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
collaborative care guide
Oxygenation/VentilationObtain 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.
collaborative care guideOxygenation/VentilationExtubate 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.
collaborative care guideCirculation/PerfusionRegulate 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.
collaborative care guide
Circulation/PerfusionAssess 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.
collaborative care guide
Hematological IssuesChest 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
collaborative care guide
Fluids/ElectrolytesRenal 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.
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.
collaborative care guideMobility/Skin IntegrityTurn 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
collaborative care guideComfort 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
PREVENTING 0f COMPLICATIONS
PREVENTING CARDIOVASCULARCOMPLICATIONS
Volume Resuscitation Monitoring for Arrhythmias Improving Cardiac Contractility Controlling Blood Pressure
PREVENTING PULMONARY COMPLICATIONS
PREVENTING 0f COMPLICATIONS
PREVENTING NEUROLOGICAL COMPLICATIONS
MONITORING POSTOPERATIVE BLEEDING
PREVENTING RENAL COMPLICATIONS
OliguriaRenal Failure
PREVENTING 0f COMPLICATIONS
PREVENTING GASTROINTESTINAL COMPLICATIONS
MONITORING FOR INFECTION
Thank You