CORONARY ARTERY

BYPASS GRAFT
By: Charisma Bailey & Casi Rogers
Objectives
• By the end of this presentation, the viewer will be able to:
• Tell what a CABG is/does
• Name the indication for a CABG
• Describe how to properly care for a CABG patient.
CABG
• Coronary Artery Bypass Graft-Coronary artery bypass grafting
(CABG) is a type of surgery that improves blood flow to the
heart. Surgeons use CABG to treat people who have severe
CAD (coronary artery disease). During CABG, a healthy artery
or vein from the body is connected, or grafted, to the blocked
coronary artery. The grafted artery or vein bypasses (that is,
goes around) the blocked portion of the coronary artery. This
creates a new path for oxygen-rich blood to flow to the heart
muscle
Indications:
• MVD (70% greater blockage or more) in the greater vessels of
the heart
• AMI secondary to MVD (unstentable)
• Failure of previous PCI
Contraindications
• Non-ambulatory
• Age? (Higher mortality rate)
• Poor lung function (May not be able to wean off vent)
• Kidney function
• Severe CHF <20% (May require IABP pre-op)
• Moderate to severe aortic insufficiency
• Morbid obesity
• Hemodynamic instability
• Severe PVD
SCIP Measures
SCIP is a national quality partnership of organization focused on reducing the
incidence of surgical complications.
1. Prophylactic Antibiotic Pre-op Timing: administered within 1 hour of incision.
2. Prophylactic Antibiotic Selection: CABG (Cefalozin, Cefuroxime, Vancomycin)
3. Prophylactic Antibiotic Discontinuation with 48 hours of surgery end time.
4. Cardiac surgery patients with controlled 0600 post-op glucose on POD 1 and 2
5. Hair removal (with clippers ONLY acceptable)
6. Temperature management with immediate postoperative normothermia.
Temp must be equal to or greater than 96.8 within 30 minutes prior to
anesthesia end time or immediately 15 minutes after anesthesia end time.
7. Beta Blocker therapy. Should receive BB prior to arrival or during the
perioperative period.
8. Venous Thromboembolism Prophylaxis: Compressions stockings.
9. Urinary Catheter Removal: Removed on POD 1 or 2 (day of surgery being 0).
Exclusion: Patient needs physician exclusion for continued use of Foley.
Meet: J.R.
• 63 yo female with hx of CAD and previous PCI. Presented to ER
on Oct 23 with increasing SOB and CP. CXR in ER showed mild
pulmonary edema. Admitted to inpatient status on 2400.
Consulted Cardiology, CVT surgery.
Pre-operative phase
• Diagnostic testing:
• Echo
• Carotid US
• Diagnostic cath
• PFT’s
• Venous Mapping Studies
• Pa/Lat CXR (non-emergent) or PCXR (emergent)
• Labs: CBC, CMP, PFA, Plavix Assay, MRSA screen, PTT, PT/INR,
Type and Screen
• Education:
• What to expect
• Blood sugar check by 0600
• Hibiclens Shower at HS night before and morning of surgery
• Antibiotics and Beta Blocker given in holding (SCIP)
• CLIP groins, legs, and chest (SCIP)
J.R. Pre-op Testing
• Diagnostic cath (10/24/2012): 80% blockage of ostial left
main, 95% instent blockage, minimal right side disease.
• Echo (10/23/2012): EF 36% with worsening MVR, mild
pulmonary HTN, mild pulmonary regurgitation.
• Carotid US (10/25/2012): right and left carotid 0-39% stenosis
• Pa/Lat CXR (10/25/2012): cardiomegaly, slight atelectasis and
small pleural effusion.
Morning of Surgery: (10/26/2012)
• Labs drawn and sent to lab by 0400.
• Shower #1: 10/25/2012 @ 2000
• Shower #2: 10/26/2012 @ 0530
• 0600 Blood sugar: 176
• EKG: SR by 0500
• New gown on and linen applied.
• Do not put tele box back on patient. If must put leads back on
patient make sure to clean tele box before re-application.
• Make sure blood band on and necessary units are available in
Blood Bank.
• Morning meds, antibiotic and groin/chest clippings done in OR
Holding.
J.R. Pre-op Testing
Random Glucose: 235 WBC: 7.0
Sodium: 134 RBC: 3.19 L
Potassium: 5.0 Hgb: 9.5 L
Chloride: 97 L Hct: 27.9 L
Co2: 27 MCV: 87.6
Anion Gap: 10 MCH: 29.9
BUN: 36 H MCHC: 34.1
Creatinine: 1.42 H RDW: 14.1
PT: 10.1 PLT: 237
INR: 0.9 MPV: 8.3
PTT: 31
Type and Screen: O positive (10/25/2012)
MRSA by PCR: negative MRSA (10/24/2012)
Intraoperative Phase
• http://www.youtube.com/watch?v=GvGAgQOhQqY&feature=
youtube_gdata_player

SURGERY END TIME: 1417

Post-operative phase
• Upon arrival from Heart Room draw a CBC, BMP, Mg, Phos,
ABG. Repeat in 4 hours and replace electrolytes as needed per
protocol. At this point patient is on Stage I orders.
• Vasopressors/Vasodilators usage. Goal is to keep Blood
pressure high enough for perfusion but low enough to not
harm newly placed grafts.
• Ventilator management (coordinating with RT). Goal is
extubation within 4 hours of arrival to floor.
• For extubation turn SIMV mode off for CPAP trial making sure
to watch for tidal volume and rate. Sedation must be held and
CPAP trial should last 30 minutes before drawing ABG. Follow
extubation criteria per protocol. If uncertain or patient is
borderline call MD for orders.
Extubation
• RT at bedside (RN’s do not extubate).
• Extubate to NC (usually) to maintain SpO2 93%
• May progress to non-carbonated beverages when bowel
sounds present.
• IS every 1 hour while awake.
• Cough and deep breathing every 1 hour while patient awake.
• After extubation and patient successfully taking ice chips and
sips, transition patient to Stage II orders.
• 2 hours after extubation discontinue Swan-Ganz if
hemodynamically stable.
• 4 hours after extubation dangle patient on side of bed.
Extubation Criteria
• Extubate if patient MEETS all of the following:
• MAP greater than 65, SBP greater than 90 but less than 170, SpO2
greater than 94%. Hemodynamically stable and without arrhythmias.
• HR between 50-120 bpm
• PaO2 greater than 80 mmHg, PaCo2 less than 50 mmHg, pH greater
than 7.3
• Mental status intact
• CT output less than 100 ml/hr
• Contact MD before extubation when:
• COPD, emphysema, chronic lung disease present
• Documented hx of difficult extubation
• SpO2 less than 93%
• PaO2 less than 70 on FiO2 50%, PH less than 7.34 and/or paCO2
more than 50.
• IF patient doesn’t meet ALL of the above criteria:
• Return to previous settings and retry again in 30 minutes. If after
second try patient fails trial, call MD for orders.
Swan-Ganz
• Aka Pulmonary Artery Catheter
• Useful in monitoring:
• Cardiac Index (2.5-4.2)
• Cardiac Output (4-8)
• Systemic Venous Return (770-1500)
• CVP (2-6)
• PAP (18-30/6-12)
• While intubated collect CI/CO every hour. Upon extubation
collect every 2 hours until Swan discontinued.
• When d/c Swan, pull the catheter upon patient exhalation.
Watch the monitor for ectopy. Make sure canula tip intact.
Arterial Line
• Placed operatively
• Usually in left or right radial artery.
• Useful for second to second evaluation of blood pressure.
• Lab draws and ABGs
Chest Tubes
• Usual placement of chest tubes (2 mediastinal, 1 plueral).
• CT output immediately after surgery <100.
• Further out from surgery 10-50/hr. Output should drop off
further out from surgery patient is.
• Expect dumping with ambulation and coughing.
• Watch for tidaling and air leaks. If air leak is present notify MD
immediately. Possible pneumo formation (Medical
emergency). Assess your patient.
• If drainage suddenly drops or stops completely, check CT for
clot formation. MD may require you to strip tube.
• When MD gives order TRAINED RN’s can discontinue CT. Floor
RN’s may not.
Pacer wires
• Located in epicardium
• AV or V pacing depend on graft placement.
• If patient on external pacer evaluate underlying rhythm and
ventricular response Q shift.
• Once pacer on stand by, wires need to be capped and secured.
• MD or PA to d/c wires.
• For discontinuation patient must be lying flat in bed and
remain there for 1 hour. Risk of tamponade after removal.
Foley
• Watch UOP and characteristics of urine.
• Color, concentration and volume
• D/c on POD 1 or 2 (SCIP)
Insulin Drip
• Theory is… a stabilized blood sugar nurtures wound healing
and decreases bacteria. Because of the stressors on the body
during the postoperative phase an insulin drip in use for the
maintenance of glucose levels.
• Hourly glucose checks are required. Titrate drip per protocol.
• Drip remains on for 48 hours.
• Non-diabetic patients may d/c drip in 24 hours
• Diabetic patients d/c after 48 hours
• AC/HS for 72 hours
• 0600 blood glucose checks on POD 1 and 2 (SCIP)
Equipment
J.R. Post-operative (10/26/12)
• 1503-Patient received to floor. Labs drawn and sent to lab.
Assessment complete. Patient intubated, SWAN, Foley, Externally
paced at 80 bpm, CT, Insulin gtt.
• 1525-Lab results processed and no replacement required.
• 1535-ABG results back.
• 1600-Nitro discontinued
• 1700-Diprivan turned off (1706 pt begins to wake)
• 1750-Cpap 50%, peep 5
• 1846-ABG results from Cpap trial received.
• 1850-Extubated to 6L NC
• 2000-Dobutamine discontinued
• 2030: Taking adequate PO intake. Initiate Stage II orders.
• 2130-SWAN discontinued
• 2200-Patient dangled on side of bed. Heart hugger applied.
• 0245-Neo discontinued
POD 1
• Morning labs (electrolyte replacement): CBC, BMP, Mg, Phos
• PCXR
• Daily weight
• Up to chair TID
• 0600 Blood sugar (SCIP)
• Continuing education
• Ambulation in hallways with RN or Cardiac Rehab TID
• Attempt IV and d/c central line
• Pull CT with MD permission, no air leak, low CT output
• D/c foley if possible
• Wean off pressers/vasodilators.
• Goal: transfer to step down unit within 24 hours
J.R. POD 1 (10/27/2012)
• 0410-Morning labs drawn and sent to lab. No replacement
required.
• 0415: Art line discontinued. Pressure held for 5 minutes.
Bandage applied.
• 0600-Blood sugar 145
• 0615-PCXR ( no pneumo, possible atelectasis)
• 0715-Weight obtained
• Up to chair: 0730 1130 1720
• 0800-#18 gauge RFA IV placed
• Ambulate TID: 0833 1125 1941
• 1030-Foley discontinued
• 1100- discontinued chest tubes and cortis
• 1130-Transfer to 2400
Stepdown
• Ambulatory TID
• Tele box or bedside monitor
• Insulin drip maintenance
• Up to chair TID
• D/C pacing wires
• Antibiotics d/c’d in 48 hours (SCIP)
• Daily weight
• 0600 blood sugar on POD 2
• CHG showers daily
• D/c bandages on POD 2 if no drainage and apply TED hose (SCIP)
• EDUCATION!!!
• Upon d/c home: F/u appts, diet, activity, medications, perscriptions,
incision care, cardiac rehab, when to return to ER.
J.R. POD 2 (10/28/2012)
• Up to chair for meals: 0620 1115 1730
• Ambulated: 0740 1230 1800
• Tele box on (SR on evaluation of strip)
• 0603-Blood sugar 154
• Insulin drip maintenance until 48 hours post-op. Then ACHS
for duration of hospital stay.
• 0620: 220 lbs
• Antibiotic d/c: 10/28/2012 1153
• 1423-PA at bedside to d/c pacing wires
• 0800-Bandages and coban discontinued.
• 0810-CHG shower
• 0830-TED hose applied
Continual POC
• Daily weight
• ACHS blood sugar checks
• Up to chair for all meals
• Ambulate at least TID
• Ted hose while awake. Off at bedtime.
• Tele monitoring
• IS usage Q1 hour x10 while awake
• Stool softeners/laxative for BM
• Continual education: sternal precautions, diet, activity, pain
management, tobacco cessation, wound care, med
compliance.
Discharge
• CABG specific discharge instructions
• F/U appointments with CVT, Cardiologist, PCP
• Cardiac Rehab
• Prescriptions
• List of current and continued medication
• Care notes on new medications started during stay
• When to call your MD vs. ER
Review Questions
1. Patients post op CABG must have their Antibiotics discontinued with in how many hours?
a. 24 hours
b. 72 hours
c. 48 hours

2. What is the reason for the Insulin drip post op?

a. to keep the patients blood sugar between 70-110
b. because stressors cause a higher glucose level and the
body needs a normal glucose reading to nurture
healing and prevent infection post op
c. because SCIP says so

3. The patient must lay flat for 1 hour post pacer wire removal due to risk of what
complication?
a. pneumothorax
b. cardiac tamponade
c. severe bleeding at site
4. True or False: any RN on the 2400 floor can discontinue CT’s_______
5. True or False: it is normal to have dumping from CT’s during cough/ambulation_______
Review Questions Con’t
6. On POD 1, and 2, when is the Blood Glucose to be drawn?
a. 0400
b. 0600
c. 0800
7. The time-frame goal for extubation is?
a. 4 hours
b. 8 hours
c. 12 hours
d. When the patient seems ready
8. When weaning off the vent and the patient is on a CPAP trial, how long do you wait before drawing
an ABG?
a. 15min
b. 30 min
c. 60min
9. Immediately following the Hibiclens shower the morning of surgery, its very important to:
a. Place the telemetry box on to monitor heart rate
b. Place a clean gown on and have clean sheets on the bed
c. Shave every hair off the chest to comply with scip
10. Discharge teaching should include which of the following:
a. Sternal precautions, diet and activity
b. Follow up, when to call MD vs ER, tobacco cessation
c. Pain meds, medication compliance, patient concerns
d. All of the above
Questions????