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Caring for a patient after

coronary artery
bypass graft
surgery
Follow this system-by-system
approach to keeping your By Margaret Mullen-Fortino, RN, MSN,
patient stable and steering clear and Noreen O’Brien, RN, MSN
of complications.

EVERY YEAR, some 427,000 patients in the United States

have coronary artery bypass graft (CABG) surgery.1
Whether the surgery is done with the patient on or off the
cardiopulmonary bypass (CPB) machine (see On pump or
off?), the postoperative nursing care is the same. In this arti-
cle, we’ll outline your role in patient care by body system.
Reducing risks for surgical patients is one goal of the
Institute for Healthcare Improvement’s (IHI’s) 5 Million Lives
Campaign, which aims to prevent 5 million incidents of
medical harm in the period from December 2006 to Decem-
ber 2008. See the resources list at the end of this article for
more information.

Safeguarding cardiac function

Twenty-four to 48 hours after surgery, your patient will be
transferred from the intensive care unit to the cardiac sur-
gical unit and placed on continuous telemetry monitor-
ing. Your top priority is to keep him hemodynamically
stable so his vital organs are adequately perfused. Check

46 | Nursing2008 | March www.nursing2008.com

 CABG
ZEPHYR / PHOTO RESEARCHERS, INC.

www.nursing2008.com March | Nursing2008 | 47

his vital signs according to your facility’s protocol, or at
least every 4 hours, and assess for signs and symptoms of
adequate cardiac output. Investigate even subtle signs of
trouble, such as tachycardia and cool extremities. Other
signs of reduced cardiac output include diminished
peripheral pulses, changes in mentation, decreased urine
output, and hypotension.
Dysrhythmias, most often tachydysrhythmias, are
common after CABG and usually occur on the second or
third postoperative day. Atrial fibrillation (AF) occurs in
15% to 40% of patients after CABG, in 37% to 50% of
patients after valve surgery, and in up to 60% of patients
who’ve had CABG and valve surgery. A rapid ventricular
response and loss of atrial kick can cause myocardial
ischemia or reduce cardiac output and blood pressure
(BP). Patients with hypokalemia and hypomagnesemia
may be more prone to AF. Factors that increase your
patient’s risk of AF include:
• older age
• mitral valve disease
• history of AF
• chronic obstructive pulmonary disease (COPD)
• not having received preoperative beta-blocker or
angiotensin-converting enzyme inhibitor therapy or with-
drawal of previous therapy.2
Preoperative or early postoperative administration of
beta-blockers is considered standard therapy to reduce
the risk of AF after CABG.3 Amiodarone is an alternative
for patients who have contraindications to beta-blockers.
Rate control for AF is best achieved with beta-blockers.
Digoxin or calcium channel blockers are used to control
ventricular rate but haven’t shown a consistent benefit in
reducing the incidence of AF after CABG.
If your patient develops AF, his stroke risk is two to
five times higher. The American College of Cardiology/
American Heart Association provides consensus guide-
lines for administering anticoagulation to patients with
AF lasting more than 24 hours.4 Because heparin is asso-
ciated with increased bleeding risk, the patient may start
warfarin therapy without also starting heparin. However,
for high-risk patients, such as those with history of stroke
or transient ischemic attack, heparin should be consid-
ered as a bridging therapy to oral warfarin until the
patient’s international normalized ratio is therapeutic.
Ventricular dysrhythmias can occur any time after
CABG surgery but are more common in the early postop-
erative period. Hypothermia, electrolyte disturbances
(especially hypokalemia and hypomagnesemia), acidosis,
manipulation of the heart, and myocardial ischemia may
be factors in postoperative dysrhythmias. Bradycardias
and transient heart blocks usually resolve within several
hours after surgery. The patient will come out of the
operating room with epicardial pacing wires and a tempo-
rary pacemaker that are used for atrioventricular pacing
until normal conduction returns.
A pericardial effusion can result in cardiac tamponade,
a rare but potentially lethal complication following
CABG. Most cases occur in the early postoperative peri-
od, but tamponade can occur as late as 6 months postop-
eratively. Pericardial effusion puts pressure on the heart,
prevents diastole and filling of the chambers, and reduces
cardiac output. The hallmark of cardiac tamponade is the
Beck triad: muffled heart sounds, distended jugular neck
veins, and hypotension (see Assessing for cardiac tampon-
ade). Pulsus paradoxus greater than 12 mm Hg is a clas-
sic sign of tamponade. Patients may experience dyspnea,
chest pain, and dizziness.
If your patient has signs and symptoms of cardiac tam-
ponade, the physician may order a bedside echocardio-
gram. If it confirms tamponade, prepare your patient to

On pump or off?
During “on pump” CABG surgery, a CPB machine circulates oxygenated blood while diverting most of the patient’s blood
from the heart and lungs. This provides a bloodless, motionless surgical field while preserving tissue perfusion to vital
organs. The blocked coronary artery is bypassed using a graft from the saphenous vein or the IMA or radial artery.
However, CPB puts patients at risk for various problems related to the blood being in contact with the machine, including
atrial fibrillation, systemic inflammatory response syndrome, stroke, cognitive changes, renal failure, dysrhythmias, coagu-
lopathies, and microemboli.
The older “off pump” technique, in which surgery is performed on the beating heart, reduces the adverse reactions
associated with CPB and the need for RBC transfusions and positive inotropes. However, a meta-analysis found no signif-
icant differences in mortality rates, myocardial infarction, stroke, or renal dysfunction between the two types of CABG,
and no consensus has been reached on which procedure is better.
Source: Keenan TD, et al., Bypassing the pump: Changing practices in coronary artery surgery, Chest, July 2005.

48 | Nursing2008 | March www.nursing2008.com

 Assessing for cardiac tamponade
You may note these assessment findings in a patient with
cardiac tamponade.
return to the operating room for evacuation of
the clot and repair of the bleeding site. But if
the patient’s condition deteriorates to the
point that he’s at risk for cardiac arrest, the
physician may perform an emergency bedside
reexploration sternotomy.
Pulmonary problems
Between 30% and 60% of patients have pul-
monary dysfunction and hypoxemia after
CABG, usually as a result of fluid volume
overload, poor inspiratory effort, and atelecta-
sis. Risk factors for pulmonary problems
include a history of heart failure, COPD,
smoking, or diabetes; age over 65; and endo-
tracheal intubation. Common signs of respira-
tory impairment are shortness of breath and
decreased oxygen saturation as shown on
pulse oximetry.
Atelectasis, a common postoperative com-
plication, may be related to CPB, effects of
general anesthesia, and decreased surfactant production
from the patient being on CPB.
Pleural effusion, another common complication, occurs
in the immediate postoperative period in 41% to 87% of
patients. Effusions can result from bleeding secondary to
internal mammary artery (IMA) harvesting. Small effusions
(less than 500 mL) can be managed conservatively and will
usually resolve spontaneously. Larger effusions may require
thoracentesis, especially if they cause dyspnea or other
signs and symptoms. (See Picking up on pleural effusion.)
To reduce your patient’s risk of postoperative pul-
monary complications, assess breath sounds frequently,
monitor his SpO2, administer supplemental oxygen as
needed, and encourage him to perform incentive spirom-
etry every hour while he’s awake. Teach him to splint his
incision when coughing and moving. Be sure to provide
optimal pain control so he can move freely. Assisting the
patient with early, aggressive ambulation, coughing and
deep breathing, and turning from side to side while in
bed are simple but effective nursing interventions that
help prevent postoperative pulmonary complications.
Patients with copious pulmonary secretions or bron-
chospasm may also need chest physical therapy and neb-
ulized bronchodilators.
Patients who need mechanical ventilation are at risk
for ventilator-associated pneumonia (VAP). The Institute
for Healthcare Improvement (IHI) recommends a four-
pronged ventilator bundle of interventions:
• elevating the head of the bed 30 to 45 degrees except
www.nursing2008.com
Syncope, anxiety
Distended neck veins
Dyspnea,
tachypnea,
cough
Muffled heart sounds,
tachycardia,
pericardial friction rub
Pulsus paradoxus,
hypotension
when care is being given or if contraindicated; for exam-
ple, because of hemodynamic instability
• providing a daily “sedation vacation” to evaluate the
patient’s readiness for weaning
• taking steps to prevent venous thromboembolism
(VTE) (more on this later)
• administering daily medication (such as a histamine2-
receptor inhibitor) to prevent peptic ulcer disease.5
Keeping pain under control
Besides keeping the patient comfortable, effective pain
control helps maintain hemodynamic stability and pre-
vent pulmonary complications. (The pain of a sternoto-
my can impair breathing patterns.) The typical patient
will receive intravenous (I.V.) push opioids in the imme-
diate postoperative period, then switch to oral forms by
the second or third postoperative day as tolerated.
Analgesics, positioning, distraction, and relaxation tech-
niques also can be used to control pain.
Monitor the patient for adverse drug reactions, such as
oversedation and respiratory depression. Balance his need
for pain control without respiratory depression with his
need to cough and deep-breathe. Individualize pain man-
agement and frequently evaluate the patient’s pain, using
an appropriate pain intensity rating scale, to check the
effectiveness of interventions. Also use a sedation-rating
tool to monitor for sedation and respiratory depression.
Besides opioids, I.V. ketorolac, a nonsteroidal anti-
inflammatory drug (NSAID), may be used with caution
March | Nursing2008 | 49
 Picking up on pleural effusion
In pleural effusion, an abnormal volume of fluid collects in
the pleural space.
in patients who don’t receive adequate pain con-
trol from opioids alone. Check the patient’s
renal function before administering this drug
and expect to discontinue it if his serum creati-
nine increases. Also remember that NSAIDs can
increase the patient’s risk of gastrointestinal
(GI) bleeding. Monitor for signs and symptoms
of occult bleeding.
Another source of moderate to severe pain is
chest tube removal, which usually occurs on the
first or second postoperative day. Administer
adequate analgesia before chest tube removal.
Staying alert for coagulation problems
Bleeding is a common complication after CABG
surgery and can have many causes, including
platelet dysfunction from prolonged contact
with the artificial surface of the CPB machine,
high doses of heparin given during surgery, and
hypothermia.
A patient who’s actively bleeding and has a
hematocrit less than 26% needs a transfusion of
red blood cells (RBCs) to improve the blood’s oxygen-
carrying capabilities and to limit myocardial ischemia or
infarction.6 These benefits must be balanced with the risks
of RBC transfusion, including acute lung injury, prolonged
mechanical ventilation, infection, sepsis, and renal dys-
function. Six- to 12-month follow-up studies of patients
who’d undergone cardiothoracic surgery have shown that
the more packed RBCs a patient receives, the worse his
postoperative functional status.7
Also take steps to prevent VTE, which encompasses
deep vein thrombosis and pulmonary embolism. The
Surgical Care Improvement Project’s guidelines, which
are supported by IHI, call for prophylactic drug and
mechanical therapy to prevent VTE. As ordered, use
intermittent pneumatic compression devices and graduat-
ed compression stockings and administer low-dose
unfractionated heparin, low-molecular-weight heparin,
factor Xa inhibitor (fondaparinux), or warfarin. Aspirin-
only therapy isn’t recommended, and early ambulation
isn’t included in the recommendations because most
patients only make trips to the bathroom or take short
walks down the hall—insufficient activity to prevent
VTE.8
Renal troubles
Postoperative renal dysfunction occurs in as many as 8%
of patients after CABG. Predictors of renal dysfunction
include advanced age, history of moderate or severe heart
50 | Nursing2008 | March
Parietal pleura
Pleural space
Visceral pleura
Lung
Trachea
Rib
Parietal
pleura
Visceral
pleura
Pleural
effusion
Diaphragm
failure, prior bypass surgery, type 1 diabetes, and pre-
existing renal disease.
Because of fluid retention, most patients are still signif-
icantly above their preoperative weight when they’re
transferred to the medical/surgical unit after CABG. A
comparison of the patient’s postoperative daily weights to
his preoperative weight guides the use of diuretics.
Monitor his urine output, blood urea nitrogen level, and
serum creatinine level to assess renal function.
Diuretics typically are given on the first postoperative
day and are continued until the patient reaches his preop-
erative weight (usually in 5 to 7 days). Patients who need-
ed diuretics before CABG may need to continue taking
them after discharge. If the patient develops oliguria
(urine output of less than 0.5 mL/kg/hour), assess his car-
diac function and perfusion, vital signs, and lab results.
He may need fluids or medication dose adjustments.
GI glitches
Less common, GI complications affect 1% to 2% of
patients after CABG. The most common major complica-
tions are upper GI bleeding from gastritis or peptic ulcer
disease, pancreatitis, hollow viscus perforation, mesen-
teric ischemia, and cholecystitis.6 Monitor the patient’s
bowel sounds and notify the health care provider if the
patient develops abdominal pain, distension, nausea, and
vomiting. The patient may need diagnostic tests includ-
www.nursing2008.com
ing an abdominal X-ray, electrolyte panel, and complete
blood cell count.
Most patients have a nasogastric (NG) tube immediate-
ly after CABG surgery. The NG tube usually is removed
after the patient is extubated and after his bowel sounds
return. He then can be started on clear liquids and his diet
advanced as tolerated.
Anorexia and nausea are common postoperative com-
plaints and may be adverse drug reactions. Administer
antiemetics if the patient is nauseated and give histamine
blockers as prescribed to minimize gastric acid secretion.
Treat constipation, another common postoperative prob-
lem, with stool softeners or bulk laxatives as ordered.
Fighting infection
Superficial infections and deep sternal wound infection
(also called mediastinitis) occur infrequently but can
have a profound effect on patient morbidity, length of
stay, and cost of care. Infections usually occur within the
first 2 weeks after surgery. A
patient is at increased risk if
he’s obese, if he has diabetes Reassure the patient that temporary feelings of sadness
or COPD, if bilateral IMA
are normal and should go away within a few weeks as he gets back
grafts were used, or if
surgery was prolonged
(more than 90 minutes).
Although no consensus
has been reached on best practice for postoperative
wound care, best-practice guidelines recommend keeping
a sterile dressing on the wound for 24 to 48 hours after
surgery.9 Follow your facility’s policy for performing inci-
sion care and changing dressings. Monitor your patient
for signs and symptoms of infection, including fever,
increased chest wall pain or tenderness, an unstable ster-
num, and purulent discharge from the wound.
Administering prophylactic antibiotics for 48 hours
after cardiac surgery has been shown to minimize infec-
tion.10 The risk of deep sternal wound infections can be
reduced with continuous I.V. insulin infusions to aggres-
sively control perioperative hyperglycemia. Major infec-
tions such as mediastinitis require surgical debridement
and weeks to months of I.V. antibiotic therapy. Minor
wound infections can be treated with oral antibiotics and
local wound care. The choice of antibiotic and duration
of therapy depend on patient-risk factors and health care
provider preference.
Heading home
As the length of hospitalization decreases for patients
who’ve had CABG, patients go home sooner. As discharge
www.nursing2008.com
approaches, your patient and his family may be anxious
about how they’ll manage at home, so try to ease the
transition. Appropriate discharge planning should
involve the patient, caregivers, nurses, physicians, and
nutritionists because a team approach is the best way to
treat factors that contribute to heart disease. Give the
patient detailed instructions about:
• when to contact the hospital or health care provider.
Tell the patient to seek immediate medical attention if he
has chest pain, shortness of breath not relieved by rest, a
fast or irregular heartbeat, chills, fever, severe headache,
numbness or tingling in his arms or legs, fainting spells,
or if he coughs up bright red blood.
• what to expect and what’s normal after surgery. Mood
swings, diminished appetite, and difficulty sleeping are
common after CABG, but usually resolve in 4 to 6 weeks.
• lifestyle changes such as stopping smoking, eating a
low-fat diet, controlling BP, and losing weight. For exam-
ple, patients who continue to smoke have more
to normal routines and activities.
myocardial infarctions and reoperations. Smoking cessa-
tion interventions should be individualized and may
include drug therapy if the patient needs it.
• activity progression. For the first 6 weeks postopera-
tively, the patient can engage in light activities such as
setting the table, folding clothes, walking, and climbing
stairs. He can return to work part-time after 6 weeks and
can gradually increase his activity level to normal by 3
months after surgery.
• incision care, as directed by the surgeon.
• medication education. Most patients are discharged on
antiplatelet therapy, typically aspirin, which significantly
reduces saphenous vein graft closure through the first
year.4 Patients with dyslipidemia will also receive lipid-
lowering therapy. Explain what the drugs are for, how to
take them correctly, how to recognize signs and symp-
toms of adverse drug reactions, and what to report to his
health care provider.
• cardiac rehabilitation. Unless contraindicated, all
patients should receive cardiac rehabilitation after CABG.
This includes early, aggressive ambulation during hospi-
talization, outpatient exercise training, patient and family
education, and counseling about postsurgical sexual
March | Nursing2008 | 51
activity and lifestyle modifications. Patients who partici-
pate in cardiac rehabilitation have increased physical
mobility, feel in better health, and generally have a more
positive outlook on life.
About 20% of patients are depressed after a major car-
4. Fuster V, et al. ACC/AHA/ESC 2006 guidelines for the management of
patients with atrial fibrillation—executive summary: A report of the
American College of Cardiology/American Heart Association Task Force
on Practice Guidelines and the European Society of Cardiology Commit-
tee for Practice Guidelines (Writing committee to revise the 2001 guide-
lines for the management of patients with atrial fibrillation). Journal of
the American College of Cardiology. 48(4):854-906, August 15, 2006.

diac event such as CABG surgery. Reassure the patient
that temporary feelings of sadness are normal and should
go away within a few weeks as he gets back to normal
routines and activities. Tell the patient and his family that
if depression is persistent or severe and disrupts activities
of daily living, he should discuss this with his health care
provider.
A new beginning
A patient undergoing CABG has complex health care
needs. Knowing about the multiple system changes
caused by surgery will help you and the rest of the care
team anticipate postoperative problems and intervene
quickly and appropriately so that your patient can have
the best possible outcome. ‹›
REFERENCES
1. Heart disease and stroke statistics-2007 update: A report from the
American Heart Association Statistics Committee and Stroke Statistics
Subcommittee. Circulation. 115(5):e69-e171, February 6, 2007.
2. Mathew JP, et al. A multicenter risk index for atrial fibrillation after
cardiac surgery. JAMA. 291(14):1720-1729, April 14, 2004.
3. Eagle KA, et al. ACC/AHA 2004 guideline update for coronary artery
bypass graft surgery: A report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines (Commit-
tee to update the 1999 guidelines for coronary artery bypass graft
surgery). http://acc.org/qualityandscience/clinical/guidelines/cabg/
index.pdf. Accessed November 13, 2007.
5. Pruitt B, Jacobs M. Best-practice interventions: How can you prevent
ventilator-associated pneumonia? Nursing2006. 36(2):36-41, February
2006.
6 Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery, 4th
edition. Blackwell Publishing, Inc., 2005.
7. Koch CG, et al. Morbidity and mortality risk associated with red
blood cell and blood-component transfusion in isolated coronary artery
bypass grafting. Critical Care Medicine. 34(6):1608-1616, June 2006.
8. Daniels SM. Protecting patients from harm: Improving hospital care
for surgical patients. Nursing2007. 37(8):36-41, August 2007.
9. Odom-Forren J. Best-practice interventions: Preventing surgical site
infections. Nursing2006. 36(6):58-63, June 2006.
10. The Society of Thoracic Surgeons. Practice Guideline Series. Antibi-
otic Prophylaxis in Cardiac Surgery. Part I: Duration of prophylaxis, and
Part II: Antibiotic choice (http://www.sts.org/sections/resources/
practiceguidelines/antibioticguideline). Accessed December 5, 2007.
RESOURCES
Epstein AE, et al. Anticoagulation: American College of Chest Physicians
guidelines for the prevention and management of postoperative atrial fi-
brillation after cardiac surgery. Chest. 128(2, Suppl.):24S-27S, August 2005.
Institute for Healthcare Improvement. Protecting 5 million lives from
harm. http://www.ihi.org/IHI/Programs/Campaign.
Jensen L, Yang L. Risk factors for postoperative pulmonary complica-
tions in coronary artery bypass graft surgery patients. European Journal
of Cardiovascular Nursing. 6(3):241-246, September 2007.
Martin CG, Turkelson SL. Nursing care of the patient undergoing coro-
nary artery bypass surgery. Journal of Cardiovascular Nursing. 21(2):109-
117, March-April 2006.
Margaret Mullen-Fortino and Noreen O’Brien are clinical nurse specialists at
Penn at Presbyterian Medical Center in Philadelphia, Pa.
The authors have disclosed that they have no financial relationships related to
this article.

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Caring for a patient after coronary artery bypass graft surgery
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 2.0
ANCC/AACN CONTACT HOURS

Caring for a patient after coronary artery bypass graft surgery

GENERAL PURPOSE To provide nurses with an overview of patient care after coronary artery bypass graft (CABG) surgery. LEARNING OBJECTIVES After
reading the preceding article and taking this test, you should be able to: 1. Identify potential complications of CABG surgery. 2. Identify postoperative CABG
nursing care. 3. List CABG discharge instructions.

1. Which statement is correct about dysrhyth- 6. Which isn’t a common cause of pulmonary 11. The patient can be expected to reach his
mias following CABG? problems following CABG? preoperative weight within
a. Bradydysrhythmias are common on postoperative a. fluid overload a. 24 hours. c. 3 to 4 days.
days two and three. b. atelectasis b. 24 to 48 hours. d. 5 to 7 days.
b. Ventricular dysrhythmias are most common late in c. poor inspiratory effort
the postoperative period. d. excess surfactant production during CPB. 12. To minimize infection after cardiac surgery,
c. Atrial fibrillation occurs in 15% to 40% of patients. administer prophylactic antibiotics for
d. Overall, dysrhythmias are uncommon. 7. Which isn’t one of the IHI’s ventilator bundle a. 8 hours. c. 24 hours.
recommendations? b. 12 hours. d. 48 hours.
2. Which patients may be more prone to AF? a. Provide a daily “sedation vacation.”
a. patients with hypercalcemia b. Take steps to prevent VTE. 13. During the first month after discharge, the
b. patients with hypokalemia c. Keep head of bed elevated at 90 degrees. patient should notify the physician about
c. patients on angiotension-converting enzyme d. Administer medication to prevent peptic ulcer a. mood swings. c. diminished appetite.
inhibitor therapy disease. b. chills. d. difficulty sleeping.
d. patients who’ve received preoperative beta-blockers
8. Intravenous ketorolac may be administered 14. Which sign or symptom is considered nor-
3. Which drug is sometimes used to reduce the a. as an adjunct to opioids for pain management. mal after CABG surgery?
risk of AF after CABG? b. to manage pain in patients with gastric ulcers. a. mood swings c. syncope
a. amiodarone c. digoxin c. in place of opioids for uncontrolled pain. b. palpitations d. hemoptysis
b. lidocaine d. diltiazem d. to control pain in the patient with chronic kidney
disease. 15. After surgery, the patient can usually
4. A pericardial effusion can result in which resume all normal activity levels within
complication after CABG surgery? 9. Postoperative bleeding may be caused by a. 4 weeks. c. 2 months.
a. heart block c. pleural effusion dysfunction of b. 6 weeks. d. 3 months.
b. atelectasis d. cardiac tamponade a. lymphocytes. c. neutrophils.
b. platelets. d. macrophages. 16. Which isn’t a common complication of
5. The Beck triad consists of muffled heart CPB?
sounds, 10. Recommended interventions for VTE pro- a. AF c. cognitive changes
a. hepatomegaly, and hypotension. phylaxis include b. liver failure d. coagulopathies
b. distended neck veins, and hypotension. a. aspirin-only therapy.
c. hepatomegaly, and hypertension. b. early ambulation alone. 17. Which statement is correct about off pump
d. distended neck veins, and hypertension. c. aspirin and early ambulation. CABG surgery?
d. intermittent pneumatic compression devices and a. It provides a motionless surgical field.
low-molecular-weight heparin. b. It provides a bloodless surgical field.
c. It reduces the need for RBC transfusions.
d. It increases the need for inotropic support.

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2. Was the journal home study format an effective way to present the material? ❑ Yes ❑ No ❑ Charge my ❑ Mastercard ❑ Visa ❑ American Express
3. Was the content relevant to your nursing practice? ❑ Yes ❑ No
Card # _____________________________________________ Exp. date __________________
4. How long did it take you to complete this CE activity?___ hours___minutes
5. Suggestion for future topics __________________________________________________________ Signature _______________________________________________________________________
*In accordance with the Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of the CE offering may be submitted directly to the Iowa Board of Nursing.
N0308A