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Caring for the patient after CABG surgery Suppose you’re caring for two patients who’ve 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, I’ll 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 patient’s 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 heart’s 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 patient’s 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 isn’t 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 patient’s 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 who’ve had CABG surgery.         Maintain airway patency Monitor VS Assess the patient’s hemodynamic and cardiac status. Perform peripheral and neurovascular assessments Monitor his neurologic status and notify the surgeon and anesthesia provider if he hasn’t 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 patient’s pain. Morphine, the drug of choice may be given by patient-controlled analgesia pump.

Coagulapathies caused by the destruction of platelets and large amounts of heparin administered during CPB. Signs and symptoms include hypothermia or fever. However the technical difficulties of beating heart surgery mean graft failure is a bigger risk following offpump surgery. pleuretic chest pain.administer diuretics. tachycardia. bradycardia. Because this can lead to hemorrhage. Watch ECG changes. a platelet aggregation inhibitor. Researchers are investigating the use of Iloprost(a form of prostacyclin).Complications following on-pump surgery  Systemic inflammatory response syndrome. and oesinophilia. . to prevent bleeding and thrombosis in patients undergoing cardiac surgery.     Off-pump considerations  Acute occlusion or grafting failure. Anticoagulation during surgery helps prevent thromboelic complications. which can lead to life threatening cardiac tamponade. This complication is more common in patients who’ve had off-pump surgery because common of the use cardiac stabilizers.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. 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. but excessive bleeding can lead to thrombocytopenia. including what signs and symptoms to report and when to follow up with his surgeon. Plan to spend additional time teaching him and his family how to monitor his recovery at home. The development of newer cardiac stabilizers means that precise anastomosis is possible even with lateral and posterior bypass grafts. pericardial friction rub. a serious complication of heparin use during on-pump surgery. and renal insufficiency. liver and lungs which can lead to complications such as cognitive changes. the patient may need blood transfusions. embolic stroke. kidneys. Heparin induced thrombocytopenia. Signs and symptoms include chest pain and ST-segment elevation. Electrolyte imbalances from excess sodium and water retention . Signs and symptoms include fever. and hyperventilation. Perfusion insult to the brain. including ectopy. possibly triggered by damage to red blood cells and platelets from contact with the pump surfaces. pleural effusion. potassium replacement and fluids as ordered. The surgeon may order an angiogram a few postoperatively to assess graft patency Postpericardiotomy syndrome.