Cardiac Surgery

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Cardiac Surgery.:

Cardiac Surgery. History. 1925– Sir Henry Soultar of London Closed repair of stenosed mitral valve. 1 st . Open Heart Surgery in Mauritius 4 June 1984 by Pr. Hassen Raffa

Types of Cardiac Surgery:

Types of Cardiac Surgery Two types : Closed Open Heart Surgery Heart Lung Machine or Pump- oxygenato r Operate for longer time Direct Visualisation

Purposes of Heart Lung Machine:

Purposes of Heart Lung Machine To provide the surgeon with a bloodless operating field. To perform gas exchange functions. To filter, re-warm or cool the blood. To circulate oxygenated , filtered blood back to arterial system.

Procedure for ECC:

Procedure for ECC Pump tubing machine is primed with a balanced electrolyte solution. Midsternotomy . SVC , IVC & Aorta are cannulated . Patient blood is heparinised . Hypothermia is induced--- 28 to 32 degrees celcius . Aorta is clamped above coronary arteries. Cardioplegic solution is infuse (K+ rich and at 4 degrees Celcius ) into aortic root & coronary arteries.

Procedure:

Procedure 8. When starting the bypass blood from the IVC & SVC is pumped through a series of roller type pumps that maintains a non- pulsatile flow. 9. When procedure is completed, exchanger re-warms the blood, air is removed from the cardiac chambers & heparinisation is reversed with protamine sulphate .

Procedure….:

Procedure…. BLOOD FROM SVC & IVC Heat Exchanger Oxygenator Arterial filter Aortic canulla

Types of Open Heart Surgery:

Types of Open Heart Surgery valve repair Valvular surgery valve replacement Valvulotomy Valve repair Valvuloplasty Commisurotomy

Valve Replacement:

Valve Replacement Mechanical Valve prostheses Bioprosthetic Caged -ball valve Prostheses Tilting Caged - disc valve

Types ….:

Types …. 2. Repair of congenital defects ASD & VSD Coarctation of aorta Tetralogy of Fallot 3. Coronary Artery Bypass Graft (CABG) Saphenous vein Use of : Mamary veins I M A 4. Heart transplant.

Complications ….:

Complications …. Haemorrhage . Shock Cardiac tamponade Renal Insufficiency & failure due to shock, haemorrhage and arteriolar vasoconstriction during ECC procedure. Low cardiac output syndrome ( results from heart failure & metabolic acidosis)

Complications..:

Complications.. 6. Hypovolaemia (due to increase in body temp) 7. Hypervolaemia ( from fluid overload) 8. Cardiac arrhythmias ( from potassium imbalance, hypoxia & acidosis) 9. Pneumothorax ( inadequate lung expansion resulting from blockage of chest tubes)

Complications…:

Complications… 10. Wound infection 11 . Embolisation leads to convulsions, hemiplegia ) 12. Stress ulcers.( Reaction of the body to prolonged physiological stress).

Pre-operative preparation:

Pre-operative preparation Psychological 4 aspects Physiological Anatomical Preoperative teaching

Psychological Preparation:

Psychological Preparation Why? To relieve anxiety Confrontation 3 Psychological stages Self reflection Resolution How? Give verbal/ written information concerning health care facility service. 2. Introduce patient / relatives to health professionals. Reassure. Encourage the person to express what he feels & think

Physiological Preparation.:

Physiological Preparation. Laboratory Tests. (Urine, Urea, FBC, Coagulation studies, Blood grouping, Enzymes, Serum hepatitis, VDRL, HIV) 2. Diagnostic Studies. ( ECG, Chest X-ray, Ecchocardiogram , Cardiac catheterisation / angiography. 3. Daily weight & vital signs, Apical – radial pulse ( to eatablish baseline data).

Anatomical Preparation:

Anatomical Preparation Assessment of the teeth by dentist. Skin shaving from neck to toe– Anterior & lateral trunk. Several showers with anti-microbial soap. Skin prep. with betadine Any skin lesion reported to surgeon Enema in the evening. REMEMBER 1. Anaesthetist visit. 4 donors to bleed on day of operation.

Pre-operative Teaching.:

Pre-operative Teaching. Chest physiotherapy & leg exercise by Physiotherapist. Explain location & importance of chest tubes. Explain thet monitoring equipment will restrict movement. Explain that smoking increases chance post –operative complications.

Post-operative Care.:

Post-operative Care. Goals 0f Post – Op Care Promote : CVS function & tissue perfusion. Respiratory , Renal & Neurologic functions. Fluid, Electrolyte, & Nutritional Balance. Rest, Comfort & Relief from pain. Early Movement & Ambulation Psychosocial Adjustment Prevent: Post-operative Complications.

Intensive Care Unit:

Intensive Care Unit Check & secure all connections for lines & tubes. Connect endo -tracheal tube to ventilator ECG to monitoring system. Patient kept flat until systolic BP is 100mmHg--- Raised gradually & his response noted

Promote CVS Functions:

Promote CVS Functions Assess Arterial BP & record. Irrigate Arterial line ( continuous or at interval) with heparinised saline. In general BP maintained at 20 mmHg above or below baseline. Assess all pulses. Arrhythmias----- CHF Shock ------ Haemorrhage PULSE Fear. Fever Hypoxia.

Continued…:

Continued… Heart Block Slow Pulse Severe Anoxia Apical –Radial pulse deficit Atrial Fibrillation Absent Pedal pulses peripheral Emboli. 2. Assess CVP. Hypecrvolaemia CVP Ineffective myocardial contractions CVP Hypovolaemia .

CVS Functions Cont….:

CVS Functions Cont…. 3. Record temperature. Infection Temp. Haemolysis Atelectasis Shock Temp. Cardiac Decompensation 4. Immediate 12 Lead ECG 5. Observe carefully for abnormal ECG tracings.

Promote Respiratory Funct.:

Promote Respiratory Funct . 1. Adjust Rate, Tidal Volume, & O2 Level of ventilator. 2. Make sure the ventilator alarms are on & functioning 3. Observe whether persons assists the ventilator ( Usually assist light will come on) 4. Observe for dyspnoea Airway Obstruction Pain Anoxia Dyspnoea Acidosis Displaced Tube

When Patient is extubated.:

When Patient is extubated . Observe for respiratory distress. Check rate, depth, & character of respiration. Note person’s colour & vital signs. ABG to determine whether patient is breathing adequately.

Prevent Pulmonary. Complications:

Prevent Pulmonary. Complications 1. Frequent turning & suctioning the intubated patient 2. Help non- intubated patient to turn, take deep breaths & cough every two hours. 3. Chest physiotherapy to rid the lungs of secretions. 4. Report any abnormality from chest tubes. Measure drainage by collecting in calibrated cylinders Abnornal findings include: -- greater than 2 ml/ kg. bd.wt / Hr. -- sustained haemorrhage for more than 2 minutes. -- Sudden cessation of chest drainage accompanied by increased CVP, dyspnoea and oliguria .

Cont…:

Cont… 5. Milk chest tubes every hour to express clots. Check for kinks or bending. 6. Prophylactic antibiotics. 7. Daily portable chest X-ray until lung is expanded.

Promote Fluid, Electrolye & Nutritional Balance.:

Promote Fluid, Electrolye & Nutritional Balance. Prescribed i.v . fluids, blood and plasma expanders. Sips of water every 4 hourly after extubation if person is fully responsive & not nauseated. Clear liquid first followed gradually by solid food. Watch for signs of abdominal distension and paralytic ileus . Daily electrolyte studies to determine blood levels of sodium, potassium and chloride Obtain haemoglobin level, prothrombin time and blood gasses daily .

Promote Renal Function.:

Promote Renal Function. 1. Carefully observe & document Colour Volume --- Hourly for the first 8 to 12 hours. 2. Care of indwelling Foley catheter.

Promote Neurologic Function:

Promote Neurologic Function Carefully observe and record person’s --- level of consciousness --- pupil size and reaction --- orientation --- ability to move extremities. DOCUMENT IN NEUROLOGICAL CHART.

Promote Comfort & Rest.:

Promote Comfort & Rest. Relieve pain and restlessness with comfort measures and judicious administration of pain medication. Splint incision site during coughing and deep breathing exercise. Reassurance.

Promote psychosocial adjustment.:

Promote psychosocial adjustment. Address person by name. Calendar & clock at bedside Take interest in the person– Do not ignore the person as you work with monitors. Cardiac monitors out of person’s view Encourage person to freely discuss their fears & anxieties. Explain all interventions.

Early Movement & ambulation:

Early Movement & ambulation 1. Turning & Exercising. -- Side to side at intervals for back care -- Passive exercises and leg flexion every 2 hours. 2. Typical ambulation Schedule. -- day after surgery : dangles leg over the side of bed -- 2 nd . Day: sits on bed/ chair for short period. -- 3 rd to 5 th . Day :.Begins to ambulate in room -- 8 th to 10 th day: Fully ambulatory.

Discharge Planning & Health education:

Discharge Planning & Health education Remember : 6/52 for sternotomy to heal. Lift nothing during this period. Not to drive for 6-8 weeks. Individual’s arm not to bear weight while getting out of bed or chair. Diet: Low salt & Low cholesterol. Teach person or significant others to check pulse for regularity & rate. Report to physician for a resting heart rate rise of more than 20 beats / min. Teach person to inspect incision daily. ( Betadine swab).

Cont…..:

Cont….. 7. Medications: Label all medications. Explain purposes & side effects Pt with prosthetic valve will continue warfarin . Avoid use of aspirin… interferes with warfarin Activities increased gradually within limits. Avoid strenuous exercise until exercise stress testing. Increase walking time and distance each day.

THANK YOU:

THANK YOU