Cardiac and Cardiovascular Surgery

Nursing 225-226

CardiacAnatomy:

R. heart… pulmonary & venous

L. heart… systemic & arterial

NO VALVEs in Pulmonary Arteries

Myocardial Blood Supply

Right Coronary Artery (RCA):

R atria, posterior L ventricle A-V septum SA node – 60% A-V node – 90%

Blockage dysrhythmias

Myocardial Blood Supply

Left Coronary Artery (LCA…two major branches)

LAD: Anterior R & L ventricle

Circumflex L atria Posterior L ventricle

High blockage angina, ischemia, infarction Low blockage dysrhythmias

Development of Plaque

Development of

Coronary Artery Disease (CAD)

Grade 1 = < 25 % … fatty streaks, risk factor

Grade 2 = ~ 50% … fibrous plaque

Grade 3 = ~ 75% … calcified plaque

Grade 4 = ~ 100%… complete occlusion

Arterial procedures Coronary artery bypass surgery Either open surgery or closed Angioplasty PCTA Atherectomy (PTRCA… percutaneous transluminal rotational coronary

angioplasty)

Which procedure to choose Location of the occlusion Consistency of the blockage Complexity of the blockage Pt underlying health occlusion to previous bypass graftsEvery situation is unique and all factors

are considered

Pre-operative management Same as all operative patients Physical and psychological assessment Informed consent Adherence to treatment and protocols Helping with coping and understanding of

procedure Maintain patient dignify Evaluate conditions effecting post op care

Pre operative management History and physical Cxr Ekg Lab tests- blood typing, cross and match,

blood donation Identify learning needs, usual functioning,

coping mechanism, support system. How this effects post op course and rehab.

Discharge planning

Pre operative care Planning: reducing fear. Learning

procedure and post op course, avoiding complications

Promoting home and community based care

Predictors of Increased Morbidity with Cardiac Surgery Extent of Disease Left Main Disease Unstable Angina Emergent Surgery Prior Cardiac Surgery LV Dysfunction Pre-surgery Cardiogenic Shock

Predictors Con’t Comorbidities Renal Dysfunction Diabetes Mellitus Cerebrovascular disease COPD PVD Obesity

Predictors Con’t Social Predictors Availability of Support Access to Community Resources

Post-op Predictors Atrial Arrhythmias Renal Insufficiency Prolonged Ventilation CHF Peri-operative MI Cerebrovascular incidents

Coronary Artery Bypass Graft (CABG) Performed under general anesthesia Surgical procedure Surgeon makes a median sternotomy

incision and connects the patient to cardiopulmonary bypass (CPB) machine Use vein or artery from patient Attach one end to aorta Attach other end of vein to the coronary

artery DISTAL to the blockage Candidates:

=/> 60% blockage of LCA/LAD > 70% blockage

Harvest the vein:

MammaryShort/narrowAtherosclerosis > 20 yr. Saphenous Long and wide Atherosclerosis 5 – 10 yr.

Other: cephalic, basilic, gastro-epiloic

Heart Valve Surgery True “Open” Heart surgery Valves may be either replaced or

repaired Can be done through minimally invasive

procedure or TAVI now May have valve procedure with CABG

Indications for valve surgery

When the valvular dysfunction causes symptoms that affect a person’s ability to function

When the heart and other systems begin to fail due to the faulty functioning valve. Critical stenosis or regurgitation

Valve Surgeries

Repair valve Balloon angioplasty Commisurotomy- separate the fused

leaflets Annuloplasty- where the valve adheres to

the heart wall Valvuloplasty- repair the valve

Replace valve

Types of Valves

Autograft … use patient’s own pulmonic valve & replace pulmonic valve with homograft

Homograft or Allograft … source is

cadaverXenograft … source is pig or cow

Mechanical valves

Aneurysm: weakness of musculature in wall of blood vessel …

Causes an out-pouching

Can rupture if under pressure

Abdominal Aortic Aneurysm:

Repaired with synthetic grafting procedure

Coronary Artery Bypass Graft: Intraoperative Procedure Sequence of Events

Intubation } Airway, gas exchangeGeneral Anesthesia } Skin preparation/scrub bacteria in

surgicalfield

Apply electrodes heart rate/rhythm

Insert linesPeripheral I Vs IV meds

Epicardial pacer Pace heart prn

Arterial line BP: systolic, (radial/femoral) diastolic, MAP

Swan Ganz PAP, CVP, PCWP

Manage fluids

Insert Chest Tube Drain surgical field Recapture blood for

autotransfusion

Insert NG tube Decompress stomach

Insert foley cath Decompress bladder urine output, fluid status, renal artery

perfusion

Harvest veins … Prepare donor graft s

Sternotomy: … Prepare an open

retract sternum, ribs surgical field and lungs … Lungs minimally inflate

Cannulate: bypass heart …Removes blood @ VC(must cross clamp aorta) …Returns blood @ Aorta D5/LR w/ Heparin …Prevents clotting

Extracorporeal CirculationOxygenates, filters, cools 28-320 C ( 82-920 F)

Also … warms the blood post procedure … allows blood draws q 1-15 minutes (what labs?)

Cardioplegia Solution …Bathe heart in FROZEN slush… metabolism & O2 consumption

Position/STOP heart … Need a still, stable

surface to attach grafts Incise pericardium … Arteries on surface of

& perform grafting myocardium

Check blood flow through newly grafted arteries Electrically restart heart … reverse the process

i.e., remove cannulas, reverse heparin (protomine), reinflate lungs, etc.

Effects/complications of Cardiopulmonary Bypass

Increased capillary permeability (interface of blood & bypass cannulas/tubing) …

fluid shifts to interstitial spaces… EDEMA & PULMONARY CONGESTION

Caused from: Inflamation of aterial membranesPlatelet release of vasoactive substances

Hemodilution…FLUID VOLUME OVERLOAD Solution used to prime bypass machine secretion of ADH secretion of renin 20 non-pulsatile (MAP)

renal perfusion

Alterations in Coagulation… BLEEDING/CLOTTING Heparin and protamine Damage to blood cells (interface w/ tubings)

RBC hemolysis and platelet damage Leukocyte damage Microemboli (tissue debris, air emboli)

Increase systemic vascular resistance (SVR)…. HYPERTENSION & CARDIAC OUTPUT Catecholamine & renin secretion Hypothermia

Alteration in glucose metabolism Insulin Glyconeolysis Altered glucose transport across cell

membrane

Post op picture:

Tubes everywhere

Nursing AssessmentNeuro: consider… anesthesia, hypothermia,

possible CVA 20 to cerebral ischemia hypertension (bleed) or emboli

LOC…responsiveness, grasp & movement,sensation, pupils, pain, tremor/seizure, fever

Respiratory: intubated, mechanical ventilation Airway …ET tube placement? Secure? Rate, rhythm, depth, breath sounds Skin color and temperature, nailbeds O2 sat and/or ABG Chest X ray Ventilator settings Chest tubes

Nursing Assessment: cardiac/cardiovascular

Heart Rate & Rhythm cardiac monitor AND auscultate

Blood Pressure Arterial line: sys/diastolic (if ?… manual ) MAP (mean arterial pressure)…

Organ perfusion is dependent on MAP Needs to be > 80 --

Cardiac output x systemic resistanceSystolic BP + 2 (diastolic BP) / 3BP = 125/75; MAP = 125 + 150/3 =

92

Nursing Assessment: cardiac/cardiovascular

Cardiac Index - value computed .. Cardiac output/meter2 body surface area

Cardiac Output – Volume of blood going into systemic circulation each

minuteSV (cc ejected w/ ea. contraction) X BPMSV= 60 cc x heart rate= 60 BPM =3,600cc/min. 3.6 liters/min.Normal cardiac output is 3 – 4 liters/minute

Nursing Assessment: cardiac/cardiovascularPulse Pressure – narrowing or widening

interval between systolic & diastolic BPs:Reflects cardiac output, i.e., stroke volume,

rate, systemic resistanceNormal is 30-40 mm Hg (ie. 140/80)Significance: 140/80 140/40, PP =

80 (anxiety-exercise-bradycardia-fever-atherosclerosis)

140/80 140/120, PP = 20(shock, heart failure, hypovolemia, aortic stenosis)

Other: Peripheral Pulses, CSM, Capillary Refill, skin color and temperature, cyanosis;Labs: H&H (CBC), Platelets, Clotting- APTT, PT, INR

Nursing Assessment: cardiac/cardiovascular

Pulse deficit – difference between apical rate and radial rate

Significance: NON-conducted beats Electrical stimuli/conduction intact but

may have volume/mechanical failure L Ventricle failure? low blood volume? High systemic resistance?

Compare EKG and physical assessment.

Nursing Assessment: cardiac/cardiovascular

Hemodynamic Monitoring

Central Venous Pressure (CVP) Sensor in SVC or R Atrium Measures pressure in the RIGHT atrium Reflects VENOUS pressure/volume

fluid coming back to the heart …preload Significance: used to determine and help

regulate fluid balance… Fluid volume deficit or overload? Normal is 0-8mm Hg

Swan-Ganz cath… CVP

PAP- pulmonary artery pressure PACWP-PAWP “wedge pressure”*Sensor wedged in pulmonary capillary*Reflects LEFT atrial &ventricular pressure (preload)(*Assesses hydration, regulate fluid status) *Normal–4-12 mm Hg*Complication: pulmonary infarct

Nursing Assessment

Renal: Hourly output, specific gravity, pink or bloody

urine; BUN/CreatinineElectrolytes:

Electrolytes: K+ Ca + +, Mg + +

EKG- K + = tall, peaked “T” waves K + = flat “T” waves

Musculo-Skeletal - tremor, seizure, etc.Endocrine: Blood glucose,

S & s of hypo/hyperglycemia Hyper/hypoglycemia

protocols

Nursing Care/Nursing Diagnoses

Risk for Decreased Cardiac Output re: Hemorrhage, hypovolemia

Swan- PAWP, CVP, HR, BP, Periph.Circ. CT drainage:< 200cc/hr (1st few hrs post-op) Hourly intake: I Vs, blood, plasma, etc.

output: DT, Foley, NG, incisions, etc.

Dysrhythmia – cardiac monitor, heart sounds Cardiac Tamponade – Blood collection

between pericardial layers…constricts/restricts ventricular filling & decreases cardiac output

(pulsus paradoxus – fluctuation with respiration)

Cardiac Tamponade/Pericardial Effusion:

CO, BP syncope, Narrow pulse pressure Venous pressure JVDMuffled heart sounds, Dyspnea, pain, anxiety

Pulsus paradoxus: Systolic pressure heard

during expiration but

NOT w/ inspirationDifference systolic BP

expiration inspiration> 10mm Hg is abnormal

Nursing Care/Nursing Diagnoses

Risk for decreased tissue perfusion (arterial flow, specify) Coronary MI Cerebral Stroke Renal Renal failure GI Ischemic bowel Extremities Arterial occlusion

Re: Hemorrhage/bleeding, emboli or clot formation

Nursing Care/Nursing DiagnosesRisk for Impaired Gas ExchangeRisk for Ineffective Airway ClearanceRisk for … Fluid Volume Deficit

… Fluid Volume Overload Risk for Electrolyte Imbalance (specify)Risk for Sensory Perceptual AlterationsRisk for … Decreased LOC

… Altered Thought processes Impaired Skin Integrity, Risk for InfectionKnowledge Deficit Impaired Home Maintenance Management

Cardiac/Cardiovascular Surgery : What’s

NEW?

Beating Heart Surgery Coronary artery revascularization

No need for cardiac bypass machine (avoid all the asssociated complications)

No aortic manipulation or cross clamping

Advantages of Off pump CABG Benefits high risk and elderly Thoracotomy vs Sternal incision NO cardioplegia arrest Decrease use of blood products Less damage to blood cells/coagulation Less myocardial invasion

Myocardial damage/dysrhythmia?) Reduced neuro/cognitive impairment Decreased LOS, cost, mortality

Disadvantages

Only 10% patients are eligible

Lesions HIGH LAD or RCA

Patent internal mammary artery

Conversion to traditional CABG… 5% to

10%

What else is “cutting edge?”

Robotic Cardiac Surgeryda Vinci Surgical systemEndoscopoic3-D optics and wristed instruments

Antiarrhythmic surgery

Carotid Artery Repair Stent Angioplasty Surgery Remember baroreceptors especially

with Carotid Artery manipulation

Procedures for Coronary Artery Blockage… first line in invasive procedures (less risk/expense than CABG)

Coronary angioplasty (PTCA… percutaneous transluminal coronary

angioplasty) Introduce catheter into artery Inflate a balloon to compress plaque Used with single, large, proximal occlusions

Complications Bleeding at sheath/catheter insertion site Bleeding… retroperitoneal Thrombus and fistula formation

Procedures for Coronary Artery Blockage

Atherectomy (PTRCA… percutaneous transluminal rotational coronary

angioplasty) Introduce catheter into artery Inflate a balloon to press a bladed surface

against plaque… blade rotates & shaves off the plaque.

Uses with single, large, proximal occlusions

Complications Dysrhythmias, myocardial ischemia with

possible myocardial infarction

Procedures for Coronary Artery Blockage Coronary Artery Stenting Introduce catheter into artery Can be used with multiple occlussions Several stents can be deployed into the

same artery Difficult to place at bifurcations Complications same as PTCA and PTACA

Stents

PTCA, PTCRA and Stent: advantages/disadvantages

Advantages: Minimally invasive Local anesthetic No need for bypass 90% success rate… initially

Disadvantages: 3 - 8 % close within the first 24 hours 33% close within first 6 months (damage to intima of artery causes rapid progression of recurring atherosclerosis)Need for anticoagulation with stent(s)

Nursing Care Post-Intervention

VS, Groin and Pulse Checks – every 15 minutes x 4, every 30 minutes x 2, then hourly

Monitor urinary output Assess for pain in groin, abdomen, and back Assess for chest pain and difficulty breathing

Medical/Nursing Interventions

Medical/Nursing Interventions