Caring for the patient after CABG surgery Suppose youre caring for two patients whove just

had coronary artery bypass graph (CABG) surgery. One underwent surgery while on a cardiopulmonary bypass (CPB) machine; the other had surgery without CPB. In this article, Ill explain how differences in the two techniques affect the postoperative nursing care you provide for each patient. Operating while the patient is on CPB machine (also called on-pump surgery) allows the surgeon to work on a motionless heart. While the heart is still, the CPB machine oxygenates the patients blood and maintains circulation. To use the CPB machine, the surgeon performs a median-sternotomy, cross-clamps the aorta, and attaches the patient to the pump. He then arrest the hearts action with a cardioplegic solution, usually a potassium-rich solution delivered cold(39.4F[4C]) to protect the heart from ischemia After bypass grafting the blood in the CPB machine is gradually warmed and pumped back into the patients body. Internal paddles are used to shock the heart to restart it. Pacing wires are placed in the epicardium and chest tubes are inserted. Performed on a beating heart, off-pump surgery is becoming increasingly popular because it avoids the complications associated with CPB, such as platelet dysfunction, perfusion deficits to major organs and cognitive complications. Off-pump surgery may be especially appropriate for elderly patients, who are at higher risk for CPB-related complications such as stroke. The procedure isnt recommended for patients with small coronary arteries of diffuse cardiac disease. The surgeon usually performs a sterna incision. Before partial cross-clamps of the descending aorta, the patients arterial blood pressure (BP) is reduced to below 80mm hg either with nitroglycerin or mechanically. The surgeon uses stabilizers to hold the section of the beating heart still during surgery. The rest of the heart continues to work, supplying in the blood to the body. Common aspects of postoperative care The following aspects of postoperative care apply to all patients whove had CABG surgery. Maintain airway patency Monitor VS Assess the patients hemodynamic and cardiac status. Perform peripheral and neurovascular assessments Monitor his neurologic status and notify the surgeon and anesthesia provider if he hasnt awakened within 8 hrs after the surgery. Watch wounds signs of bleeding by checking the patients hemoglobin and hematocrit level at least every 4 hours Assess the incision and monitor for wound infection and abnormal bleeding Manage the patients pain. Morphine, the drug of choice may be given by patient-controlled analgesia pump.

Complications following on-pump surgery Systemic inflammatory response syndrome, possibly triggered by damage to red blood cells and platelets from contact with the pump surfaces. Signs and symptoms include hypothermia or fever, tachycardia, and hyperventilation. Perfusion insult to the brain, kidneys, liver and lungs which can lead to complications such as cognitive changes, embolic stroke, and renal insufficiency. Heparin induced thrombocytopenia, a serious complication of heparin use during on-pump surgery. Anticoagulation during surgery helps prevent thromboelic complications, but excessive bleeding can lead to thrombocytopenia. Researchers are investigating the use of Iloprost(a form of prostacyclin), a platelet aggregation inhibitor, to prevent bleeding and thrombosis in patients undergoing cardiac surgery. Coagulapathies caused by the destruction of platelets and large amounts of heparin administered during CPB. Because this can lead to hemorrhage, the patient may need blood transfusions. Electrolyte imbalances from excess sodium and water retention .administer diuretics, potassium replacement and fluids as ordered.

Off-pump considerations Acute occlusion or grafting failure. The development of newer cardiac stabilizers means that precise anastomosis is possible even with lateral and posterior bypass grafts. However the technical difficulties of beating heart surgery mean graft failure is a bigger risk following offpump surgery. Signs and symptoms include chest pain and ST-segment elevation. The surgeon may order an angiogram a few postoperatively to assess graft patency Postpericardiotomy syndrome, which can lead to life threatening cardiac tamponade. This complication is more common in patients whove had off-pump surgery because common of the use cardiac stabilizers. Signs and symptoms include fever, pericardial friction rub, pleuretic chest pain, pleural effusion, and oesinophilia. Watch ECG changes, including ectopy, bradycardia, and signs of cardiac tamponade(including alternating QRS amplitudes and venricular tachycardia) patients are treated with a nonsteroidal anti-inflammatory drug(NSAID) such as indomethacin;patients with renal failure or aspirin allergy can take milder NSAIDs

A patient who underwent off-pump CABG surgery is likely to be discharged from the hospital earlier than someone who had on-pump surgery. Plan to spend additional time teaching him and his family how to monitor his recovery at home, including what signs and symptoms to report and when to follow up with his surgeon.