Perioperative Care for CABG Patients

Adult Nursing 3 (section 2)

Dr: Mutaz Deredi

Students Name :

 Ayah Iyad Qattoush (21710082)

 Narjes Nael Jebreel Aljundi (21712065)
 Ruba Jeahd Musa Sweity (21711980)
Background

A coronary artery bypass graft (CABG) is a surgical procedure used to treat coronary

heart disease. It diverts blood around narrowed or clogged parts of the major arteries to improve

blood flow and oxygen supply to the heart.

Why they're carried out?

Like all organs in the body, the heart needs a constant supply of blood.This is supplied by

2 large blood vessels called the left and right coronary arteries. Over time, these arteries can

become narrowed and hardened by the build-up of fatty deposits called plaques. This process is

known as atherosclerosis. People with atherosclerosis of the coronary arteries are said to

have coronary heart disease. Your chances of developing coronary heart disease increase with

age. You're also much more likely to be affected if:

 you smoke

 you're overweight or obese

 you have a high-fat diet

Coronary heart disease can cause angina, which is chest pain that occurs when the supply

of oxygen-rich blood to the heart becomes restricted. While many cases of angina can be treated

with medication, severe angina may require a coronary artery bypass graft to improve the blood

supply to the heart. Another risk associated with coronary heart disease is the possibility of one

of the plaques in the coronary artery rupturing (splitting), creating a blood clot. If the blood clot
blocks the blood supply to the heart, it can trigger a heart attack. A coronary artery bypass graft

may be recommended to reduce your chances of having a heart attack.

The procedure

A coronary artery bypass graft involves taking a blood vessel from another part of the

body (usually the chest, leg or arm) and attaching it to the coronary artery above and below the

narrowed area or blockage.

This new blood vessel is known as a graft. The number of grafts needed will depend on

how severe your coronary heart disease is and how many of the coronary blood vessels are

narrowed. A coronary artery bypass graft is carried out under general anaesthetic, which means

you'll be unconscious during the operation. It usually takes between 3 and 6 hours.
Risks of surgery

As with all types of surgery, a coronary artery bypass graft carries a risk of

complications. These are usually relatively minor and treatable, such as an irregular heartbeat or

a wound infection, but there's also a risk of serious complications, such as a stroke or heart

attack.

Pre-operative care of patients undergoing cardiac bypass

The preoperative nursing management for patients usually begins before hospitalization.

Patients with nonacute heart disease may be admitted to hospital the day before or at the same

day of their surgery, and then nurses will begin with the preoperative assessment first with

includes:

1. Medical history, personal ID, any allergies that exists and an IV line.

2. Physical examination:

 General appearance and behaviour

 Vital signs and blood glucose will be checked

 Nutritional and fluids status, weight and height

 Inspection and palpation of the heart

 Auscultation of the heart

 JVP

 Checking for peripheral pulses and edema

3. Chest Xray examination especially the latest PA film ,an ECG ,Transthoracic

Echocardiography (TTE) ,Doppler ultrasound of carotids .

 4. Pt should be kept NPO a day prior the surgeryand yet have the right supplements to avoid

malnutrition

5. Laboratory analysis :

1. CBC,urinalysis, ABGs,Electrolytes, Liver Function Tests, Glucose, Creatinine,

Coagulation Studies, Hepatitis B & C Screening .These baseline data are

important for comparison of postoperative results and values.

2. Type and crossmatch four or more units of blood as ordered. Blood is made

available for use during and after surgery as needed.

3. Consent form for operation. (Including documentation of the major risks and

discussing them with the pt and his family).

4. Nose, throat swaps and, sputum and then given Bactroban to use at home and

once admitted pre operatively.

5. Chest physiotherapy priorsurgery in patients with known chest disease, chronic

airways disease. Sputum culture is particularly important in this group.

Roles on medication prior to surgery:

 Aspirin and Clopidogrel- it should be stopped 7-10 days before surgery, if not, should be

stopped on the day of admission of the patient - unless there is unstable angina.

 Anticoagulants - These are tailed off over a few days prior to operation.

 Beta Blockers, Calcium Antagonists, Long Acting Nitrates - Patients with coronary artery

disease will frequently be taking a combination of these drugs. It is important not to

interfere with these drugs in any way but to continue them until the day before operation.

 Monoamine Oxidase Inhibitors - Must be discontinued at least three weeks

preoperatively.
  Digoxin, Diuretics and potassium supplements- Continued until the day before operation.

 Antihypertensive - Maintain until operation.

Psychosocial assessment and Family support system:

Information when conducting preoperative teaching with a patient scheduled for CABG

surgery may include sights and sounds that will be experienced, invasive lines that will be

inserted, anticipated sensations from preoperative medications, and anticipated length of the

operation. During the preoperative teaching session, the nurse should also provide information

related to postoperative expectations.

Reassurance that pain will be managed during the postoperative period is important to

communicate to the patient and significant other. Teaching about incision splinting and

availability of effective pain medications should be emphasized.

Patients should be informed that an endotracheal tube will probably be in place

postoperatively, resulting in a temporary inability to speak. Assure the patient that a competent

caregiver will be in close proximity during the immediate postoperative recovery period and will

be able to anticipate and provide for needs. The patient should be assured that the endotracheal

tube will be removed as soon as it is no longer needed.

Pulmonary care is an important part of the postoperative care of the patient after CABG

surgery. Preoperative practice with the equipment (such as an incentive spirometer) that will be

used postoperatively is helpful. Teaching in the preoperative period assists the patient to

comprehend the necessity of coughing effectively in spite of incisional pain to achieve positive

outcomes postoperatively. Early mobilization is effective in improving postoperative pulmonary

outcomes. Preoperative teaching might include information related to the potential for

mobilization to a chair during the first evening postoperatively.

The significant other may be anxious and this may intensify as his/her loved one is taken

to surgery. Separation is inevitable, but communication with the significant other during the

intraoperative period is helpful to minimize anxiety. There are often questions about the length

of the operation, the condition of the patient, and when the anticipated reunion will be possible.

Nursing interventions important for significant others include teaching them about the

expected patient appearance. The patient may appear pale, cool, and edematous. The nurse

should also discuss equipment that will be connected to the patient. This equipment will include

the ventilator, chest tubes, nasogastric tube, invasive lines, and urinary catheter.

Intraoperative phase

Coronary bypass surgery generally takes between three and six hours and requires

general anesthesia. The number of bypasses you need depends on where in your heart and how

severe your blockages are.

For general anesthesia, a breathing tube is inserted through your mouth. This tube

attaches to a ventilator, which breathes for you during and immediately after the surgery.

Most coronary bypass surgeries are done through a long incision in the chest while a

heart-lung machine keeps blood and oxygen flowing through your body. This is called on-pump

coronary bypass surgery.

 The surgeon cuts down the center of the chest, along the breastbone. He or she then

spreads open the rib cage to expose the heart. After the chest is opened, the heart is temporarily

stopped with medication and a heart-lung machine takes over to circulate blood to the body.

The surgeon takes a section of healthy blood vessel, often from inside the chest wall or

from the lower leg, and attaches the ends above and below the blocked artery so that blood flow

is redirected around the narrowed part of the diseased artery.

Other surgical techniques your surgeon might use include:

 Off-pump or beating-heart surgery. This procedure allows surgery to be done on the

beating heart using special equipment to stabilize the area of the heart the surgeon is

working on. This type of surgery is challenging because the heart is still moving. It's not an

option for everyone.

 Minimally invasive surgery. A surgeon performs coronary bypass through small

incisions in the chest, often with the use of robotics and video imaging that help the

surgeon operate in a small area. Variations of minimally invasive surgery might be called

port-access or keyhole surgery.

After completing the graft, the surgeon will restore your heartbeat, disconnect you from

the heart-lung machine and use wire to close your chest bone. The wire will remain in your body

after the bone heals.

 After completing the graft, the surgeon will restore your heartbeat, disconnect you from

the heart-lung machine and use wire to close your chest bone. The wire will remain in your body

after the bone heals.

Coronary bypass surgery, and any heart surgery for that matter, is performed by a team

rather than just the surgeon.  It’s the same as when you take an airplane flight; the pilot depends

on many people behind the scenes to get the plane off the ground. 

Those required are:

1) The scrub nurse or scrub tech, who organizes and transfers the instruments to the surgeon. 

This individual is "scrubbed in", meaning that he or she has thoroughly washed the hands and

arms before putting on a sterile gown and gloves.  The scrub nurse is part of the clean “sterile

field” and is allowed to touch the patient, instruments, and instrument table. 

2) The circulating nurse, who remains outside of the sterile field. As a “circulator”, he or she

transfers sterile instruments and supplies to the instrument table, performs the documentation of

the case, and assists in other ways. 

3) The surgical assistant. This can be another physician, or a non-physician such as a physician

assistant (P.A.), nurse, nurse practitioner, or a surgical assistant (S.A.).  The assistant is

“scrubbed in” as part of the sterile field and assists the surgeon with the conduct of the

operation. 

4) The perfusionist. This highly trained individual has undergone years of instruction to operate

the heart lung machine. He or she also operates the cell saver, a machine that processes any

blood loss so that the patient's own blood can be given back to them.  
5) The anesthesiologist (a physician), possibly assisted by an anesthetist (a nurse or physician

assistant). They insert monitoring lines, administer the general anesthesia to the patient, and act

as critical care specialists during the surgery.

Additionally, the operating room team depends on other people, such as preoperative nurses,

technical specialists, workers in the instrument room where the instruments are sterilized,

administrative staff who keep disposables stocked, and on and on. 

While a patient is undergoing cardiac bypass surgery, a team of medical professionals

collaborates to try to get the best possible outcomes from the surgery. Among these professionals

are operating room nurses and technicians who support the cardiac surgeon as he or she performs

the procedure. Operating room nurses and technicians also monitor the patient’s condition and

work to make him or her as comfortable as possible.

 There will special monitoring and equipment in the Operating Room andthe Cardiac

Intensive Care Unit:

 Endotracheal (ET) Tube: A tube that helps you breathes during and immediately after

surgery. Once you can breathe on your own, the tube will be removed.

 Central Intravenous Line: Also called a central line, this larger IV tube is placed in a

large blood vessel and is used for giving medications, IV fluids, or blood.

 Intravenous Lines: Small tubes inserted into your blood vessels to give fluids and

medications.

 Arterial Catheters: Used to monitor blood pressure and draw blood samples.

 Foley Catheter: Thin tube inserted into your bladder to drain and monitor urine amounts

during and after your surgery. This tube will be removed as soon as possible to prevent

infection.
  Chest Tubes: Drain excess fluid from around your heart and lungs.

 External Pacing Wires: Small, fine, temporary pacemaker wires, placed in surgery, in

case your heartbeat needs to be regulated in the days after surgery. They are removed

before you go home.

 Nasogastric Tube: Thin tube inserted into your nose down into your stomach to prevent

your stomach from becoming too distended

 Chest Electrodes: Similar to the "sticky" buttons of an EKG, these attach to the skin on

the chest and are connected by wire to the heart monitor.

The Postoperative Phase

Postoperative care of the cardiac surgery patient is challenging in that changes can occur

rapidly. The preoperative condition of the patient as well as intraoperative events should be

considered in postoperative care. It is essential for the nurse to anticipate the possible

complications so that appropriate interventions are initiated in a timely manner in order to ensure

a positive outcome for the patient. There is a flurry of activity as the patient enters the recovery

room/ICU and the admitting nurse connects the patient and the invasive lines to the monitoring

equipment while another staff member connects drainage devices appropriately and draws

admission blood work. The operating room nurse and the anesthesiologist report the patient’s

condition to the receiving nurse.

The resident should be present in the ICU when the patient arrives from the operating

room to receive a sign-over from the anesthesiologist and the cardiac surgical team. During

this period, the ICU nurses will be transferring the patient to the ICU monitors and checking

all lines and infusions. The nurse will then do the initial set of hemodynamic readings. The

Respiratory Technician will place the patient on a ventilator. Unless the patient is unstable it
is best to stay out of the way of the nurses during this period, and wait until they are finished

with their assessment before examining the patient.

History :

Collect the following information from the anesthesiologist, surgeon, and the patient chart.

 Patient background (age, sex)

 Type of operation (CABG,)

 Indications for operation

 Pre-operative cath report (vessels involved, LVEF)

 Success of operation (completely or incompletely revascularized, difficulties,

complications)

 CPB time and aortic cross-clamp time

 Ease of separation from CPB ( dysrhythmias, need for inotropes, pacing, etc).
Difficulty coming off pump may imply problems with myocardial preservation or with the
revascularization.

 Current inotropes, vasopressors, or anti-hypertensives (if any)

 Need for cardiac pacing

 Use of Intra-aortic balloon pump (IABP), ventricular assist devices (VAD), or nitric
oxide (NO).

 Significant bleeding

 Other significant co morbidity, with emphasis on those conditions that may alter the
post-operative management or course (carotid artery disease, COPD, asthma, diabetes,
renal failure, hepatic failure, etc.)

 Pre-operative medications

 Allergies

Postoperative Pulmonary Management

 Pulmonary dysfunction and hypoxemia may occur in 30% to 60% of patients after

CABG.

 Patient history and intraoperative factors must be considered in the postoperative

pulmonary management.

 Desired outcomes include adequate oxygenation and ventilation while the patient is

intubated.

 Early extubation is also a desired outcome as long as the patient is hemodynamically and

neurologically stable.

 Routine postoperative care to promote oxygenation and ventilation involves prevention

and treatment of atelectasis and pulmonary infection as well as maintenance of effective

gas exchange and breathing patterns.

 Maintain airway patency. Monitor the patient's pulmonary status closely and report any

changes, such as pulmonary congestion, dyspnea, or SpO2 below 92%. Follow the

weaning protocol per orders

 Monitor chest tube drainage (generally serosanguineous) and report drainage of over 100

ml/hour.

 Shivering is usually managed by administration of sedation and neuromuscular blocking

agents while the patient is being mechanically ventilated.

 Postoperative management includes accurate and frequent physical assessment, arterial

blood gas analysis, continuous pulse oximetry, pulmonary care (including suctioning
 while the patient is intubated and coughing and incentive spirometry after extubation),

early mobilization, and control of pain and shivering.

 Most protocols require a chest x-ray after heart surgery to determine placement of the

endotracheal tube, thermodilution catheter, and nasogastric tube as well as information

about the width of the mediastinum, amount of atelectasis, presence of hemothorax or

pneumothorax, and size of the heart.

 Pain control is usually achieved with intravenous narcotics while the patient is intubated.

Oral and/or intravenous narcotics may be used after extubation.

 The nurse must balance the need for pain control without respiratory depression with the

patient’s need to have his/her pain minimized to allow an effective cough.

 The nurse must assess the patient for readiness for early extubation. Extubation should be

considered when the patient is arousable, able to follow commands, hemodynamically

stable, and initiating spontaneous ventilations without excessive respiratory effort.

 As the patient is being weaned from the ventilator, ventilatory support is gradually

withdrawn and the patient must sustain spontaneous ventilations.

 Physical assessment of effective ventilation, and laboratory analysis of arterial blood

gases and specific ventilatory parameters must be completed prior to extubation.

 During the weaning process, the nurse should assess the patient for an increase in

respiratory and/or heart rates, use of accessory muscles, fatigue, and color changes

because these findings may indicate the patient is not ready for extubation.

 An increase in pulmonary artery pressures can indicate an increase in PCO2 and give the

nurse an early indication prior to arterial blood gas analysis that the patient is not ready

for extubation. Early extubation is desirable but if parameters are not met and/ or the
 patient is hemodynamically unstable, there may be detrimental effects of early

extubation.

Postoperative Management of Hemodynamics

 Movement of the patient from the operating room to the recovery room/ICU can create

hemodynamic instability, and thus, reconnection to the monitoring equipment in a timely

manner is of the essence.

 A cuff BP is usually taken to provide correlation of the BP obtained from the arterial

line.

 Assess the patient's hemodynamic and cardiac status. Atrial fibrillation (AF) is a

common complication of cardiac surgery, although it's rarely life-threatening. Treat

persistent AF with medication or synchronized cardioversion as ordered

 Titrate drugs to optimize cardiac function and BP. Notify the surgeon of changes in

cardiovascular status as reflected by electrocardiogram (ECG) and hemodynamic

monitoring.

 Monitor the patient's electrolytes and report abnormal values. Provide replacement

electrolyte therapy as indicated

 The nurse must continually assess the patient for cardiac dysfunction and hemodynamic

instability.

 The receiving nurse must intensively monitor the interrelationship between heart rhythm

and rate, preload, afterload, contractility, and myocardial compliance to achieve this

outcome
 Blood pressure must be maintained within ordered parameters to provide tissue perfusion

and prevent disruption of the surgical anastomoses.

 The nurse must monitor the volume in the system, which is reflected by the right atrial

pressure (RAP) and pulmonary capillary wedge pressure (PCWP).

 If the BP is too low, there is either too little volume (preload), a decrease in contractility,

or the SVR is too low (the patient’s blood vessels are dilated). If the BP, CO, and

RAP/PCWP are all low, the patient probably needs volume .Volume is generally

replaced as needed with a colloid such as hetastarch unless the hematocrit is low and

then volume may be replaced with packed red blood cells. If the BP and CO are low but

the PCWP is high, the patient may be experiencing decreased contractility and inotropic

support may be instituted with an agent such as dopamine or dobutamine. If the BP is

low and the CO is adequate or elevated, the systemic vascular resistance may be low and

the patient may need a constrictive agent such as phenylephrine. Low BP can be

temporarily increased by turning off positive end expiratory pressure (to decrease

intrathoracic pressure and augment preload) and by position changes. The patient should

be put in the supine position with legs elevated to allow the BP to increase until the cause

of the low BP can be determined and corrective measures are taken. Although not

universally utilized, some institutions continue to place patients in the Trendelenburg

position. The Trendelenburg position can offer symptomatic relief from low BP,

especially in the early postoperative phase, by shifting volume from the legs to the chest

and increasing preload. The positive changes identified with Trendelenburg positioning

seemed to provide only temporary improvement in the clinical picture. If the BP

becomes too high, especially in the early postoperative period, the surgical anastomoses
 may become disrupted, which could cause significant intrathoracic bleeding,

hemodynamic instability, poor tissue perfusion, and necessitate a return to the operating

room. It is important for the nurse to carefully monitor the patient for high BP and

quickly intervene per institution protocol. Nitroprusside, a vasodilator, is often

administered to lower the BP to the ordered parameter. Nitroglycerine, a nitrate, may

also be used to cause vasodilation and lower the BP .These medications should be started

slowly so patient response can be evaluated.

 The patient must be monitored closely as the BP may drop as the patient’s body

temperature increases.

 The nurse must rewarm the patient after surgery if hypothermia persists. The negative

effects of hypothermia include depression of the myocardium, ventricular dysrhythmias,

vasoconstriction, and depression of clotting factors (increasing the risk of bleeding

postoperatively).

 If the patient is hypothermic, rewarming may be accomplished by the use of warm

blankets, warm humidified oxygen, convective air mattresses, and other individual

institutional approaches. Vasoconstriction induced by hypothermia may increase BP.

Because of the potential for issues with graft anastomoses and the importance of

maintaining BP within the reference range, a vasodilator may be needed while the

patient is rewarming.

 As normothermia is achieved, if the patient’s systemic vascular resistance decreases

significantly, additional intravenous fluids may need to be administered.

 The nurse should carefully monitor the pulmonary artery pressures and the CO as well as

the BP when interventions are instituted to assess the effect.

  The nurse must also use effective clinical assessment skills. Peripheral perfusion

assessment data are vitally important in the evaluation of effective CO.

 The nurse should regularly perform neurovascular assessments of the lower extremities

to provide information about the effectiveness of CO.

 Dysrhythmias are common after CABG surgery. Constant assessment of the patient, as

well as continuously monitoring the cardiac rate and rhythm, is imperative.

 Effectiveness of BP and CO should be considered when evaluating dysrhythmias.

 Often, cardiac surgeons place epicardial wires on the atrium and/or the ventricle during

the operation. Temporary pacing can be instituted to override a slow intrinsic rhythm so

CI and BP can be maintained.

 Atropine may be given to increase the heart rate in the absence of epicardial pacing

wires. Tachydysrhythmias are usually controlled pharmacologically.

 The specific medication utilized will depend on hospital protocols and physician

preference. The critical care nurse should utilize standing orders in the institution as well

as current advanced cardiac life support protocols.

Postoperative Management of Bleeding

The postoperative period may be complicated by excessive bleeding. Many factors

should be considered when assessing the patient’s potential for bleeding. Patients who were on

anticoagulants and antiplatelet agents (including glycoprotein IIb/IIIa receptor antagonists such

as abciximab) prior to surgery are at an increased risk of postoperative bleeding. The aorta and

the atrium are cannulated during surgery. The grafts have proximal and distal anastomosis sites.

Other potential sites for bleeding include the internal mammary site, the chest wall, and chest
tube sites. Induced hypothermia, the use of the CPB machine, and the administration of heparin

for anticoagulation can all contribute to postoperative bleeding.

 The nurse should be aware that heparin can be stored in adipose tissue and some patients

may have an increase in bleeding 4 hours postoperatively depending on the body’s

adipose composition.

 Some surgeons utilize an intravenous infusion of aprotinin intraoperatively to minimize

the risk of postoperative bleeding. This drug is a protease inhibitor that inhibits

fibrinolysis. Aprotinin may also have some anti-inflammatory effects and therefore be

beneficial to the patient after CABG.

 The nurse should monitor the patient for signs of bleeding from the chest tubes and the

surgical sites as well as clinical signs of hypovolemia related to blood loss.

 Hemoglobin and hematocrit should be monitored at regular intervals during the

postoperative period according to institution protocol.

 Sometimes the surgeon orders serial coagulation profiles for a patient at risk for bleeding.

If bleeding is an issue, drugs such as protamine sulfate (to reverse the effects of heparin)

or antifibrinolytic agents such as aminocaproic acid or desmopressin (DDAVP) may be

ordered.

 Blood products such as fresh frozen plasma and platelets may also be ordered.

 When bleeding occurs there is potential for the blood to accumulate in the pericardium,

and therefore, the nurse must be cognizant of the potential for cardiac tamponade. The

clinical manifestations of cardiac tamponade include lack of chest tube drainage,

decreased BP, narrowed pulse pressure, increased heart rate, jugular venous distention,
 elevated central venous pressure, and muffled heart sounds . So the nurse should assess

this signs

Postoperative Renal Management

There is a potential for renal dysfunction in the postoperative cardiac surgery patient.

One reference suggests that the incidence is approximately 8%.1 Renal insufficiency may be

related to advanced age, hypertension, diabetes, decreased function of the left ventricle, and

length of time on the CPB. One indicator of effective CO is adequate renal perfusion as

evidenced by urinary output of at least 0.5 mL/kg/h.

 The nurse must monitor the urinary output at least hourly during the early postoperative

period.

 The urine should be assessed for color and characteristics as well as amount.

 Diuresis is likely in the postoperative period when renal function is adequate, as the

fluids mobilize from the interstitial to the intravascular space.

 The patient’s potassium level should be monitored at least every 4 to 6 hours for the first

24 hours, as potassium is lost with diuresis. Intravenous potassium replacement should be

administered to keep the serum potassium levels within normal limits.

 The patient should be astutely monitored for cardiac dysrhythmias if the serum

potassium level is abnormal.

 Other laboratory values that should be monitored at least daily are the blood urea

nitrogen and serum creatinine.

Postoperative Neurologic Management

 Patients who require coronary artery bypass surgery are at an increased risk for

neurologic complications. Stroke can be caused by hypoperfusion or an embolic event during

or after surgery. Manipulation of the aorta has been implicated in embolic events. Other risk

factors for stroke may include age, previous stroke, carotid bruits, and hypertension. The

incidence of stroke is approximately 2.5%.

 The nurse should be particularly astute to neurologic assessment in the postoperative

period. When the patient is admitted to the intensive care unit, he/ she will likely be

intubated and unconscious.

 GCS, limb strength should be assessed

 Pupils should be assessed initially, however, normal size and reactivity may not

return until agents utilized intraoperatively have been metabolized.

 Neurologic status cannot be completely assessed until the patient is fully awake and

extubated. At that time, the patient should be assessed for orientation to person,

place, time, and circumstance.

 Perform peripheral and neurovascular assessments hourly for the first 8 hours. Then,

if the patient is stable, perform these checks every 2 hours for the next 8 hours and

every 4 hours for the following 8 hours

 A motor and sensory assessment should also be performed. A positive result is a

good indication that an intraoperative stroke can be ruled out.

 Neurologic assessments must continue because the risk of stroke does not end with

the operation.
  Patients presenting post-operatively with new confusion and agitation/delirium/post

pump ‘psychosis’/combativeness should be investigated for neurological compromise

.And followed-up appropriately by a neurological team.

Postoperative Gastrointestinal Management

Gastrointestinal Complications include peptic ulcer disease, perforated ulcer,

pancreatitis, acute cholecystitis, bowel ischemia, diverticulitis, and liver dysfunction. Some risk

factors for gastrointestinal dysfunction include age over 70, a history of gastrointestinal disease,

a history of alcohol misuse, cigarette smoking, heart valve surgery, emergent operation,

prolonged CPB, postoperative hemorrhage, use of vasopressors, and low postoperative CO.If the

gastroepiploic artery is used as a conduit for bypass, this may also increase the risk of

gastrointestinal dysfunction. Anesthetic agents, analgesics, and hypoperfusion of the gut during

surgery can also contribute to gastrointestinal dysfunction.

 The nurse should monitor the patient for bowel sounds, abdominal distention, and nausea

and vomiting.

 The intubated patient will have a nasogastric tube to low intermittent suction or Salem

sump to continuous suction.

 Placement and patency should be assessed as well as amount, color, and characteristics of

the drainage.

 Prior to extubation, if bowel sounds are present, the nasogastric tube will be discontinued

and the nurse should continue to assess the patient for potential gastrointestinal

disturbances.

 The nurse should administer antiemetic agents as ordered if the patient is nauseated.
  The comfort of the patient as well as the sterility of the sternal dressing must be

maintained.

 Some surgeons order a histamine blocker to minimize acid secretion until normal dietary

patterns are resumed. When the nasogastric tube is removed, the patient will be started on

a clear liquid diet and this can be advanced as tolerated by the patient.

Postoperative Pain Management

Dependent upon surgical approach, the patient may have a median sternotomy incision,

leg incision(s), and/or a radial incision. Manipulation of the chest cavity, use of retractors during

surgery, and electrocautery may all contribute to postoperative pain. In addition, positioning on

the operating room table and length of time of the surgery may also be factors in pain

experienced postoperatively.

Poorly controlled pain can stimulate the sympathetic nervous system and lead to

cardiovascular consequences. The heart rate and BP can increase and the blood vessels can

constrict, causing an increase in the cardiac workload and myocardial oxygen demand. Effective

pain control is essential for patient comfort, hemodynamic stability, and prevention of pulmonary

complications.

 Nurses must individualize pain assessment and control for each patient as responses vary

among individuals.

 Opioid analgesics, positioning, mobilization, distraction, and relaxation techniques are

among some of the methods of pain control.

 Keeping serum levels of opioid analgesics in the therapeutic range is beneficial.

  Nonsteroidal anti-inflammatory agents may be used in conjunction with opioid agents to

control pain and minimize the amount of narcotic needed. Ketorolac is a nonsteroidal

antiinflammatory agent that can be administered intravenously in the early postoperative

period while the patient is still intubated.

 The nurse must monitor renal status of patients taking ketorolac, and the drug may be

discontinued if the serum creatinine is elevated. The patient is at an increased risk of

gastrointestinal bleeding when a nonsteroidal antiinflammatory agent is used.

 Pulmonary care is more effective for the patient when pain is effectively managed.

 Teaching the patient to splint the incision when coughing and moving improves pain

control.

 The nurse should evaluate the effectiveness of pain management interventions regularly.

Significant others are often concerned about the postoperative pain experienced by the

patient.

 Explanations about interventions utilized and outcomes achieved can decrease anxiety.

 Another source of pain for the patient after CABG is the removal of the chest tubes. This

usually occurs 24 to 48 hours postoperatively when the amount and characteristics of

chest tube drainage meet ordered parameters as long as there is no air leak noted in the

water seal chamber. Pain medication should be administered prior to removal of chest

tubes per institution protocol to minimize the trauma of the procedure.

 Manage the patient's pain. Morphine, the drug of choice, may be given by patient-

controlled analgesia pump.

Additional Postoperative Management

 Risk factors for infection include diabetes, malnutrition, chronic diseases, and patients

requiring emergent surgery or prolonged surgery.

 Assessment for, and prevention of, infection is part of the nurse’s role in the

postoperative period.

 The patient should be assessed for local and systemic signs of infection.

 Postoperative antibiotics may be ordered.

 Dressings should be removed and incision care should be completed according to

institution protocols.

 Control of blood glucose level may help with prevention of infection. It is desirable to

control blood glucose levels of greater than 150 mg/dL with a continuous intravenous

infusion of insulin versus intermittent subcutaneous insulin injections. This practice is

thought to be helpful in the prevention of deep sternal wound infection.

 Some surgeons order corticosteroids postoperatively. When used, these drugs are

intended to minimize the potential risks of inflammation after heart surgery. Patients

should be monitored for suppression of the immune system, as this can be an adverse

effect of corticosteroid administration.

 Patients need to be taught how to slowly discontinue the medication after discharge per

physician orders. The other potential effect of corticosteroid administration is an

elevation in serum glucose levels. A sliding scale insulin order may be needed to

maintain blood glucose levels within normal limits while the patient is in the hospital.
  Gradually rewarm the patient with warmed blankets, but avoid temperature-regulating

blankets or devices. Warming him too rapidly can cause vasodilation and a rapid drop in

BP, possibly leading to hemodynamic compromise.

The nurse must intensively care for the patient in the early postoperative period. This

intensive monitoring and postoperative discomfort can interfere with the patient’s need for

sleep. There is a potential for sleep disturbance as the patient is recovering from CABG.

Lack of sleep may negatively affect postoperative outcomes. Organization of needed care

and provision of time for uninterrupted sleep cycles is important for effective outcomes.

Some of the postoperative confusion experienced by patients may be minimized and positive

outcomes maximized when time for sleep is provided. Hospital routines and too many visits

by well-meaning significant others may add to the sleep deprivation problem. Significant

others should be able to spend time with the patient.

 It is the role of the intensive care nurse to balance the need for visitation with the

need for rest and sleep. It can be frightening for significant others to visit the patient

during the early postoperative period because of the monitoring equipment and

appearance of their loved one. Explanations regarding the equipment and physical

appearance may be helpful. Often significant others need to overcome fear of

touching the patient postoperatively and receive reassurance from the professional

nurse that no harm will come from the touch.

Cardiac Rehabilitation After CABG

Post-CABG Rehabilitation after CABG has a number of benefits. The patients start in a

phase III program as soon as healing is completed. Because of the lower level of invasiveness
with new techniques, such as minimally invasive CABG, off- pump CABG, robotic surgery, and

other techniques, a larger number of patients with severe pre-existing cardiac disease can now

tolerate surgery. Unlike the past, patients with low EFs and CHF are also considered candidates

for revascularization. There is a role for a symptomlimited cardiac stress test if continued

ischemia is considered a risk. Testing can be safely performed at 3–4 weeks after surgery. The

exercise test should determine maximal functional capacity, maximal HR, exercise blood

pressure response, exercise-induced arrhythmias, and anginal threshold. A complete education

program to help modify risk factors and supervised and unsupervised home programs can help

with the management of risk of recurrent heart disease. Cardiac rehabilitation after CABG has

two stages: the immediate postoperative period and the later maintenance stage. The in-hospital

period usually only lasts 5–7 days. This phase has three parts: (1) intensive mobilization starting

postoperative day 1, (2) progressive ambulation and daily exercises, and (3) discharge planning

and exercise prescription for the maintenance stage.

Early mobilization should only be delayed for an unstable postoperative course or severe

CHF. Early mobilization has several benefits, including decreasing effects of immobility and

preventing cardiac deconditioning. Days 2–5 include progressive ambulation and daily exercise.

Initial ambulation aims for assistance with distances of 150–200 feet, followed by independent

ambulation by the third day. In the last few days prior to discharge, the patient is given a

program of self-monitored exercise that allows for a gradual return to previous levels of activity.

The at-home program for a CABG patient is usually conducted as an outpatient

procedure. Inpatient rehabilitation may be needed for high-risk patients or those who have had

postoperative complications or significant comorbidities. Patients should be stratified according

to risk into either low-, moderate-, or high-intensity programs. A low-intensity program is in the
area of 2–4 METs, with a target HR of 65–75% of maximum HR. A moderate-intensity program

is from 3 to 6.5 METs, with target HR 70–80% of maximum HR. Ahigh-intensity program is

from 5 to 8.5 METs with a target HR of 75–85% of maximum HR. In the presence of β-

blockade, the target HR is 20 bpm above the resting HR or at a target HR determined through an

ETT aiming at a target MET level. Assignment of level of exercise is determined by the

objective criteria and patient observation in the postoperative period. A level of exercise that

equals a rating of perceived exertion (RPE) of 13 on the Borg scale is a level of training where

the patient can be safely prescribed in the outpatient setting. The inpatient program for high-risk

patients has to be tailored to the specific needs of the patient in cooperation with the patient’s

cardiologist.

Physiotherapy

 Suctioning not attended until patient 4hrs post op to prevent unnecessary coughing

which may dislodge new grafts

 Suctioning then done PRN

 Patients who are haemodynamically stable and have no bleeding can be considered for

extubation 4-6 hrs. post-op

 Once extubated deep breathing and coughing is encouraged 2nd hourly to re-expand

The lungs and prevent atelectasis

 Always encourage patient to splint sternum with towel when coughing and moving to

Prevent sternal breakdown

 Education on not using arms to lift themselves

 Sit out of bed and mobilize on Day1

 Teds to both legs as prescribed.

Diet

 Day 1 patient commenced on clear fluid with 1500mL fluid restriction

 Day 2 commenced on low saturated fat no added salt diet and maintain fluid restriction

Nurse or Dietician should teach the patient about for:

1. According to the American Heart Association, the best bet is to choose a variety

of:

 Fruits

 Vegetables

 Whole grains

 Breads

 Lean meats (including fish)

 Low-fat dairy products

In general, heart patients should follow a low-fat, low-cholesterol, high-fiber diet.

2. Limit their consumption of saturated fat, sugar, and salt, and avoid:

 Processed meats

 Junk food

 Fast food

3. Tell the patient It’s not unusual to experience problems like nausea, lack of

appetite, and constipation following heart surgery. patient may be able to

counteract these issues by:

  Taking medications on a full stomach

 Drinking plenty of water and other healthy fluids

 Eating smaller, more frequent meals

POST op Medication

 Administer aspirin within 6 hours after CABG in doses of 81 to 325 mg daily. Continue

aspirin indefinitely to reduce graft occlusion and adverse cardiac events.

 After off-pump CABG, administer dual antiplatelet therapy (DAPT)  for 1 year with

combined aspirin (81-162 mg daily) and clopidogrel (75 mg daily) to reduce graft

occlusion.

 After CABG, clopidogrel 75 mg daily is a reasonable alternative for patients who cannot

take aspirin.

 In patients who present with acute coronary syndrome (ACS), it is reasonable to

administer combination antiplatelet therapy with aspirin and either prasugrel or ticagrelor

(preferred over clopidogrel)

 After on-pump CABG, combination therapy with aspirin and clopidogrel for 1 year may

be considered in patients without recent ACS, but the benefits are not well established.

 Warfarin should not be routinely prescribed after CABG for graft patency unless patients

have other indications for long-term antithrombotic therapy (such as atrial fibrillation [AF],

venous thromboembolism, or a mechanical prosthetic valve).

 Antithrombotic alternatives to warfarin (dabigatran, apixaban, rivaroxaban) should not be

routinely administered after CABG.

  CABG patients should receive statin therapy, starting in the preoperative period and

restarting early after surgery.

 Administer postoperative high-intensity statin therapy (atorvastatin 40-80 mg,

rosuvastatin 20-40 mg) to all CABG patients younger than 75 years.

 Administer moderate-intensity statin therapy for those patients who are intolerant of

high-intensity statin therapy and for those at greater risk for drug-drug interactions Pre- or

post-CABG discontinuation of statin therapy is not recommended unless patients have

adverse reactions to therapy.

 Administer beta-blockers as soon as possible around the time of CABG, in the absence of

contraindications, to reduce the risk of postoperative AF and to facilitate blood pressure

(BP) control early after surgery.

 Administer angiotensin-converting enzyme (ACE) inhibitor therapy after CABG for

patients with recent MI, left ventricular (LV) dysfunction, diabetes mellitus, and chronic

kidney disease. Carefully consider the patient's renal function in determining the timing of

postoperative ACE inhibitor initiation and dose selection.

 Routine ACE inhibitor therapy is not recommended early after CABG among patients

without a history of recent MI, LV dysfunction, diabetes mellitus, or chronic kidney

disease, because it may lead to more harm than benefit and an unpredictable BP response.

 Cardiac rehabilitation is recommended for all patients after CABG, with the referral

ideally performed early during the surgical hospital stay.

References :
 Martin, C. G., & Turkelson, S. L. (2006). Nursing care of the patient undergoing

coronary artery bypass grafting. The Journal of cardiovascular nursing, 21(2),

109–117.

 Hyett, J. M. (2004). Caring for a patient after CABG

surgery. Nursing2019, 34(7), 48-49.

 Gray RJ, Sethna DH (2012). Medical management of the patient undergoing

cardiac surgery. In RO Bonow et al., eds., Braunwald's Heart Disease: A

Textbook of Cardiovascular Medicine, 9th ed., vol. 2, pp. 1793–1810.

Philadelphia: Saunders.

 Hillis LD, et al. 2011 ACCF/AHA Guideline for coronary artery bypass graft

surgery: A report of the American College of Cardiology Foundation/American

Heart Association Task Force on Practice Guidelines. Circulation, 124(23):

e652–e735.

 Cornelissen, H., & Arrowsmith, J. E. (2006). Preoperative assessment for

cardiac surgery. Continuing Education in Anaesthesia, Critical Care & Pain,

6(3), 109-113.

 https://www.slideshare.net/harmeet_dad/cabg-teaching?

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