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CABG

Terms in this set (88)

what is CABG
Coronary Artery Bypass Graft is the use of vessels from the pts body placed into the heart to bypass occlusion and transport blood from the aorta to below the blockage
risk factors to need a cabage
smoking

obesity

diabetes

htn

hld
-diet high in fat/lipids

family history
-lot of time w/ younger ones
s/s of mi
chest pain

radiation down left arm

epigastric pain

n/v

jaw pain

sob

women:any pain from nose to belly
what can s/s of heart attack be similar to
GERD
what to do when pt. comes in complaint of chest pain
ekg immediately

blood work
-troponin
-bnp
-d dimer

cath lab for stenting

medication
-aspirin
-nitro
-o2
indications for cabg
left main disease

multi-vessel coronary artery disease

blockages higher up on the heart
-affect everything below it

no collateral blood flow
-heart can make it's own vessels

70% occluded arteries
-cannot stent

age
-elders cannot tolerate

chronic disease
-lung issues have trouble tolerating
why do those with copd struggle to recover from cabg
pt. lungs already damaged

do not want to cough/deep breath after surgery
preoperative risk factors for cabg
severity and increased blockages

chronic diseases
-copd
-chf
-dm
-htn

low ejection fraction

advanced age

bad attitude
what info do we need about the patient before cabg
height/weight
-meds
-Cardiac index

vital signs
-baseline bp/ekg

allergies
-morphine
-antibiotics (given pre and post op)

breath sounds
-baseline

cath lab report
-to know where bypass occurs

ejection fraction

carotids

home medications

labs
why do we need to assess carotids before cabg
risk for a stroke is increased if carotids are blocked
why do we need to know about home medications
blood thinners/metformin
-held before surgery

antidepressants/synthroid
-restart after surgery
what labs do we monitor for cabg
coagulation
-inr
-pt

baseline abgs

electrolytes
-k+
-mg+
why are we worried about k+ and mg+
pt. heart already irritated so we don't want to increase the risk of dysrhythmia w/ these electrolytes being decreased
what is a "y" graft
shaped like a y

can be used for 2 blockages
what is a mammary artery
usually LIMA

can reach to the heart and bypass the left anterior descending block
what vein is most common for cabg
saphenous vein
what to do before using the radial artery
allen's test
what is a complication of using the radial artery
b/c it causes spasms

*s/s of heart attack
How to prevent vasospasm
calcium channel blocker
devices used during cabg
heart-lung bypass machine (ecmo)

ventillator

swan-ganz

arterial line

foley cath

IABP (depending on pt)

central line
who is on the cardiac surgery team
surgeon

anesthesiologist

perustionist
-run ecom

circulator

lpn/rn
ecom
blood pumped in through aorta and sent out through inferior vena cava

full cardiac/respiratory support
treatment during surgery
hemodilution

hypothermia

heparinization

cardioplegia
hemodilution
dilutes the blood by priming the machine w/ 2-4L of crystalloid
why do we do hemodilution
-decreases hct -->decrease viscosity

-decrease blood required during surgery

-increased urinary output
**kidney's don't like ecmo so this helps

-increased third spacing (bad)
hypothermia
decreased body temperature--> decrease 02 demand
every 10 degree decreases leads to
50% less 02 demand
what is cardioplegia
stopping the heart during surgery
how to do cardioplegia
hypothermia- 4 degree celcius

stop heart- K+

energy- glucose

buffer

membrane stabilization- Ca+
what is inserted before the end of chest closure at the end of the operation
chest tubes
-pleural/mediostenum

pacing wires
-if pt. experiences dysrhythmia

sternal wires
-wire sternum shut

**leave chest open a little while to make sure no bleeding
what to monitor post op with cabg
vital signs

PA pressures

CVP

CO/CI

UO

chest tube output

labs

abgs

blood sugar
what is postop diuresis
loss of great amount of UO >1L that can cause

-electrolyte imbalance
-hypovolemia
why do we monitor blood sugar post surgery
infection risk increases if we don't control blood sugar
what to do for post op complications
follow orders from surgeon that are hospital protocols
postop complications
hypovolemia

mi

dysrhythmias

electrolyte imbalance

pulmonary complications

electrolyte imbalance

bleeding

fluid volume defecit

hypotension

hypertension

dysrhythmia

low co

mi
if pt. complication of bleeding cabg what do you do
give blood

*if jehovah witness can give fluid
if fluid volume deficit complication
give fluid

give albumin
-decrease 3rd spacing
if complication of hypotension
treat underlying cause
-blood
-fluid
-vasopressor
if complication of htn
give vasodilator

relieve pain

**can cause graft to rupture so treat cause
complication of low cardiac output
hypovolemia
-replace volume

decreased contractility
-give positive inotrope
why mi hard to diagnosis after cabg
heart is irritates so
-st elevation present
-increased bnp/troponin
causes of hypovolemia
volume loss

third spacing

diation d/t warming

diuresis
s/s of hypovolemia
tachycardia

hypotension

decreased
-UO
-CVP
what is cardiac tamponade
compression of the heart by an accumulation of fluid/blood in the pericardial sac
s/s of cardiac tamponade
chest tube
-excessive bright red blood
-sudden stop of drainage

becks triad

rule of 20s
can nurse stretch chest tube line
no but can press on it to help blood exit
How to treat cardiac tamponade?
emergency
-can go back to OR or open at bedside
becks triad
increased cvp/jvd

hypotension

distanced/muffled heart tones
rule of 20s
>20
-cvp
-paradoxial pulse
-pulse

<20
-pulse pressure
-sbp
causes of htn
preop htn

hypervolemia

anxiety/pain

hypothermic constriction
how to treat htn
vasodilator
-nipride
-cardene
most common dysrhythmia caused by cabg
a.fib d/t
-surgery
-anoxia
-electrolyte imbalance
pulmonary complications from cabg
atelectasis

pneumonia

*collapsed lungs during surgery/painful to breath afterwards
what to do for hyperglycemia post cabg
insulin drip

-educate pt. why they are getting this and that it is not longterm
how to treat shivering
morphine

*increases 02 demand so we want to control it
why neuro complications with cabg
brain doesn't like ecmo
-increased risk for stroke
gi complications with cabg
n/v/c

*zofran and stool softness
valvular stenosis
an obstruction of blood flow through the heart caused by narrowed valves

causes hypertrophy to the muscle upstream of the obstruction

results in poor flow downstream of the obstruction
s/s of valvular stenosis
tired

decreased co

poor exercise tolerance
valvular regurgitation
leaking of blood backward through a valve that does not close tightly

efficiency of the heart to pump decreases

heart enlarges to pump increasing volume

can lead to pulmonary htn
where is the mitral valve located
between left atrium and left ventricle
mitral valve stenosis values
normal: 4-6cm

mild stenosis: 2cm
-s/s w/ activity

critical stenosis: 1cm
-s/s at rest
mitral valve stenosis
blood cannot enter from the left atria into the left ventricle

-atrial hypertrophy
what can mitral valve stenosis lead to
pulmonary htn bc pressure backs up into lungs
s.s of mitral valve stenosis
30-40 years

increased hr

respiratory
-orthopena
-paroxysmal nocturnal dyspnea

decreased co

a. fib

right sided heart failure
why does mitral valve stenosis increase hr
to shorten diastole
why does mitral valve stenosis cause r side heart failure
right side is working extremely hard to overcome the pressure build up in the lungs/left atria/left ventricle
when to do valve replacement surgery
before the left ventricle fails
indicator for mitral valve stenosis surgery
critical area: 1cm
what is mitral valve regurgitation
the mitral valve does not close during systole as it should
chronic mitral valve regurgitation
atrial hypertrophy

pump inefficiency

ventricular hypertrophy d/t increasing volume ------------->ventricular failure
acute mitral valve regurgitation
-the sudden increase in pressure and volume transmits to the pulmonary bed.

cause: trauma/MI
s/s of mitral valve regurgitation
asymptomatic until LV failure
-low co
-a.fib
-dyspnea

EKG: P mitrale

systolic murmur
where is the aortic valve located
between left ventricle and aorta
aortic valve stenosis values
normal: 2.5-3.5

critical: 0.5-0.7
causes of aortic valve stenosis
- advanced age (degenerative change to valve leaflets)

- rheumatic heart disease

- congential aortic valve stenosis (most common cause of aortic valve stenosis)
aortic valve stenosis patho
obstruction of flow from left ventricle to aorta during systole

left ventricular hypertrophy
-increased myocardial O2 consumption

Left atria hypertrophy
-causes pulmonary hypertension, right sided HF
s/s of aortic stensosis
60s

heart failure

syncope
-decreased cerebral perfusion

angina

heart blocks

gi bleed

decreased co

EKG:systolic murmur
when to do aortic stenosis surgery
symptomatic

gradient greater than 50

critical stenosis: <1

left ventricular dysfunction

cardiomegaly
what is TAVR
transcatheter aortic valve replacement
-option if pt. not good candidate for open heart surgery

*only for aortic stenosis
aortic valve regurgitation
Incompetent valve allows blood to flow back into LV from Aorta during Diastole

volume overload into left ventricle

left ventricular hypertrophy

pressure backs up to affect left atrium/lungs/right side of heart
cause of aortic valve regurgitation
rheumatic fever

inffective endocarditis
-iv drug use

bicuspid valve

syphylis

marfans syndrome
-gigantic
s/s of aortic regurgitation
asymptomatic until 40s

orthopena

pnd

nocturnal angina **

forceful hearbeat

EKG:diastolic murmur
when to do surgery for aortic regurgitation
all symptomatic pt regardless of pmh need replacement
prosthetic considerations for tissue replacement
low thrombogenicity
-anticoag short term

poor hemodynamics in smaller size

failure=treatable

durable: 10-15 years

quiet
prosthetic considerations for mechanical replacement
lifelong anticoagulation therapy

good hemodynamics

failure=life threatening

durable: up to a lifetime

noisy
complications of valve replacement
low co
-might allow this if pt. already had low co d/t dilated lv

htn

arrythmia
-a.fib
-pvc

endocarditis

embolization

valve thrombosis

paravalvular leak
longterm valve replacement complications
anticoagulation therapy longterm

thrombi

endocarditis
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