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Cardiac surgery

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Cardiac surgery

  1. 1. Medical – Surgical Department Master Program 2013-2014 CARDIAC SURGERY ( NUR 552 ) Presented by : AlJuhara AlMarzoog
  2. 2. Outlines * History of cardiac surgery . * Purpose of surgery . * Who is at risk ? * Surgical approaches . * Types and techniques . * Is your patient ready ? * What is expected during post - op phase ( ASA P OF S IONALNUR E) R ES S * Potential complications of cardiac surgery and nursing management ( CR ITICALTH ING E E CIS ) INK XR E
  3. 3. History of cardiac Surgery *( Ludwig Rehn , Germany 1896 ) the first successful repair of a stab wound to RV . *( Theodore Tuffier , Paris 1912 ) surgery on the aortic valve . * ( Elliot Cutter , Boston 1923 ) surgery on the mitral valve . * ( Alfred Blalock , Baltimore 1945 ) systemic pulmonary shunt for blue babies . * ( John Lewis , Minnesota 1952 ) closure of arterial
  4. 4. History of cardiac Surgery * ( Charles Hufnagel , Georgetown 1952 ) valve substitute implantation . * ( John Gibbon , Boston 1953 ) open heart operation . * ( Ake Senning , Sweden 1959 ) totally implanted pacemaker . * ( Michael DeBakey , Huston 1964 ) successful CABG .
  5. 5. Purpose of surgery * Revascularization , e.g. CABG . * Correct congenital defects , e.g. ASD closure . * Treat valvular disorders , e.g. MVR . * Heart transplantation . * Treatment of cardiac arrhythmias , e.g. Cox maze procedure . * Removal of cardiac tumors , e.g. Robotically assisted surgery .
  6. 6. W is at risk ? ho * Elderly . * Diabetic patients . * Patients with COPD . * Patients with ESRD . * Reoperative patients . * Concomitant PVD . * Poor LV function .
  7. 7. Surgical Approaches 1- Open – Heart Surgery : thoracic cavity is opened to expose the heart and the blood is recirculated and oxygenated through CPB ( heart – lung machine ) e.g. CABG . 2- Off – Pump Heart Surgery : this approach is like traditional open heart surgery . However , the heart isn’t stopped , and a CPM isn’t used . 3- Minimally Invasive Heart Surgery : surgeon makes small incisions in the side of the chest between ribs ,
  8. 8. Types & Techniques I – CABG : * CAD has been treated by myocardial revascularization since 1960s , and the most common CABG techniques have been performed for more than 35 years . * CABG is a surgery that increases blood flow to the heart by creating a detour and re-routing the blood flow around the blocked portion of the artery .
  9. 9. Types & Techniques I – CABG : * The major indications for CABG are alleviation of angina that cannot be controlled with medication or PCI , treatment of left main coronary artery stenosis or multivessel CAD , prevention and treatment of MI or heart failure , treatment for complications from unsuccessful PCI .
  10. 10. Types & Techniques I – CABG : * Performed less frequently in women . Compared with men , women referred for this surgery tend to be older and have more comorbidities . In addition , they have a higher risk of surgical complications such as MI and stroke ( Puskas , Kilgo , Kutner , et al., 2007 ) . Furthermore , women have smaller coronary arteries , which make the surgical procedure technically more difficult .
  11. 11. Types & Techniques I – CABG : * The recommendation for CABG is determined by a number of factors , including the number of diseased coronary vessels , the degree of LV dysfunction , comorbidities , severity of symptoms and any other previous treatment . Studies have shown that CABG may be the preferred treatment for high – risk patients such as those with sever three vessels CAD , ventricular dysfunction and diabetes ( Bravata , Gienger , McDonald , et la., 2007 ) . CABG to be considered if occlusion 70 % approximately especially
  12. 12. Types & Techniques I – CABG : * Traditional technique : surgeon performs a median sternotomy and connect patient to CPB machine . Next , a blood vessel from either saphenous vein or left/right internal mammary artery is grafted distal to the coronary artery lesion by passing the obstruction .
  13. 13. Types & Techniques I – CABG : * Alternative technique : Off – Pump CABG ( OPCAB ) involves a standard median sternotomy incision , but the surgery performed without CPB , β – blocker maybe used to slow the heart rate . The surgeon also used a myocardial stabilization device to hold the site still for the anastemosis of the bypass graft . Potential benefits include a decrease in the incidence of stroke and other neurological complications , renal failure .
  14. 14. Types & Techniques I – CABG : * Risks vs. Benefits : many benefits such as decrease in angina , improved life – span , and providing an effective route for blood with prevention of new plaques formation . Some complications seen after surgery are Atrial fibrillation , increased risk for stroke , and cognitive dysfunction . Some researches showed less than 2% chance of death , 5% stroke or other neurological injury , and 20-40% Atrial fibrillation .
  15. 15. Types & Techniques II – Valve repair and replacement procedures : * Valvuloplasty : the repair of cardiac valve , most Valvuloplasty procedures requires general anesthesia and often CPB . However , some procedures can be performed in the cardiac catheterization lab . The type of Valvuloplasty depends on the cause and the type of valve dysfunction .
  16. 16. Types & Techniques II – Valve repair and replacement procedures : * Types of Valvuloplasty 1- Commissurotomy : each valve has leaflets , site where leaflets meet is called commissure , so Commissurotomy is the procedure performed to separate the fused leaflets . There is two types open and closed ( ballon Valvuloplasty ) .
  17. 17. Types & Techniques II – Valve repair and replacement procedures : * Types of Valvuloplasty 1- Commissurotomy : a – Clo s e d : do not require CPB , valve not directly visualized , performed in the OR with the patient under GA , midsternal incision is made , a small hole is cut into the heart , and the surgeon's finger or dilator is used to open the commissure .
  18. 18. Types & Techniques II – Valve repair and replacement procedures : * Types of Valvuloplasty 1- Commissurotomy : a – Clo s e d : percutanous balloon Valvuloplasty is the technique most commonly performed in US . Balloon Valvuloplasty is beneficial for mitral stenosis in young patients , for aortic valve stenosis in elderly patients , and for patients with complex medical conditions that place them at high risk for post-op complications .
  19. 19. Types & Techniques II – Valve repair and replacement procedures : * Types of Valvuloplasty 1- Commissurotomy : b – O p e n : are performed with direct visualization of the valve , the patient is under GA , CPB initiated , a midsternal or left thoracic incision is made , the valve is exposed and the surgeon uses a scalpel , finger , balloon , or dilator to open commissures
  20. 20. Types & Techniques II – Valve repair and replacement procedures : * Types of Valvuloplasty 2- Annuloplasty : is the repair of the valve annulus ( ie, junction of the valve leaflets and the muscular heart wall ) . GA and CPB are required . The procedure narrows the diameter of the valve’s orifice and is useful for the treatment of valvular regurgitation .
  21. 21. Types & Techniques II – Valve repair and replacement procedures : * Types of Valvuloplasty 2- Annuloplasty : there are two techniques . The first one uses an annuloplasty ring , which may be preshaped ( rigid / semirigid ) or flexible . The leaflets of the valves are sutured to a ring , creating an annulus of the desired size . When the ring is in place , the tension created by the moving blood and contracting heart is born by the ring rather than by the
  22. 22. Types & Techniques II – Valve repair and replacement procedures : * Types of Valvuloplasty 2- Annuloplasty : the second technique involves tacking the valve leaflets to the atrium with sutures or tacking tucks to tighten the annulus .
  23. 23. Types & Techniques II – Valve repair and replacement procedures : * Types of Valvuloplasty 3- Leaflet Repair : valve leaflets damage may result from stretching , shortening , or tearing . The elongated tissue may folded over onto self and sutured . A wedge of tissue may be cut from the middle of the leaflets and the gab suture closed .
  24. 24. Types & Techniques II – Valve repair and replacement procedures : * Types of Valvuloplasty 4- Chordoplasty : is the repair of Chordae tendineae . Mitral valve is involved with Chordoplasty , tricuspid valve seldom requires Chordoplasty .
  25. 25. Types & Techniques II – Valve repair and replacement procedures : * Valve Replacement : GA and CPB are used , procedure performed through median sternotomy . Two types of valves may be used .
  26. 26. Mechanical vs. Tissue valve Mechanical 1st generation Tissue 2nd generation Descriptio Metal or plastic , bileaflet , Biological , most come from pigs n ball – and – cage , tilting – ( porcine ) or cows ( bovine ) . disk design . Xenografts , homografts, autografts . Advantag es Most durable , very low calcification risk ; therefore , are often used for younger patients Disadvant Risk for thromboemboli ages ,require long tern anticoagulation , sewing leaflets has potential to Eliminate the need of long term anticoagulation therapy in most patients , low mortality rate associated with re-do procedures Moderate to high calcification risk , life expectancy improving but still shorter than former mechanical valves .
  27. 27. Is your patient ready ???
  28. 28. Post Operative phase nursing * Neurologic status : assessment LOC , pupil size and reaction to light , facial symmetry , movement of the extremities , and hands grip strength . * Cardiac status : HR , rhythm , heart sounds , pacemaker status , ABP , CVP , hemodynamic parameters ( PAWP , CO , cardiac index , systemic and pulmonary vascular
  29. 29. Post Operative phase nursing * Respiratory status : assessment Chest movement , breath sounds , ventilator settings , RR , SaO2 , SpO2 , pleural chest tube drainage , and ABGs . * Peripheral vascular status : Peripheral pulses , color of skin , nail beds , mucosa lips , earlobes , skin temperature , edema .
  30. 30. Post Operative phase nursing assessment * Renal function : Urinary output , urine specific gravity and osmolality . * Fluid & electrolyte : I & O , all CO parameters , electrolytes . * Pain : Nature , type , duration , response to analgesia .
  31. 31. Nursing management of potential complications of cardiac surgery * Neurologic complications : Stroke . Impaired cerebral circulation . * Cardiac complications (  CO ) : Hypovolemia . Persistent bleeding . Cardiac tamponade . Fluid overload . Hypothermia .
  32. 32. Nursing management of potential complications of cardiac surgery * Cardiac complications (  CO ) : Hypertension . Tachydysrhythmias . Bradycardias . Cardiac failure . MI .
  33. 33. Nursing management of potential complications of cardiac surgery * Pulmonary complications : Impaired gas exchange . * Renal and electrolyte imbalance : Acute renal failure . Electrolyte imbalance . * Other complications : Hepatic failure . Infection .
  34. 34. Case study • A 72 year old gentleman is admitted to cardiac surgery ICU following 4 vessel CABG surgery . On endotracheal tube , Foley cath , Swan Ganz catheter , arterial line , mediastinal and plural chest tubes attached to suction , nasogastric tube . On assessment his BP 164/88 , O2 saturation 94 % , bilateral crackles , K= 2.9 , urine output 25 ml/hr . * Based on the assessment what is the nursing
  35. 35. Case study * After few minutes his BP drops to 92/60 mmHg , ECG shows sinus tachycardia , and his cardiac output decreased . * W is the most likely reasons for the drop in hat BP ? * W other parameter should be assessed ? hat * Describe your interventions for this
  36. 36. References Suzanne C. Smeltzer , et al . 2010 . Brunner & Suddarth's textbook of Medical – Surgical Nursing 12 th edition , chapter 26 . Mervyn Singer , Andrew R. Webb , et al. 2009 . Oxford handbook of critical care 3rd edition , cardiovascular monitoring section . Luca M. Bigatello , et al. 2006 . Critical Care Handbook of Massachusetts General Hospital 4 th edition , chapter 38 .

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