Module 4
Content
Module 4
Have you completed the quiz? If not then do this now as it is about to close-you have until midnight Friday Week 7.
Before we begin this module, we have one question for you. Have you come across patients in clinical with cardiac problems that are at the end of their treatment? It might be the diabetic person that has had CABs and now has some gout and this is difficult to manage because of their diuretics. They have some renal dysfunction and they are taking a multitude of medications. When and how does end stage cardiac stage begin? What is multisystem failure? Just some things to think about as we begin Module 4
Student Prep for the module We expect you to review and revise the following in preparation for this module: • Community nursing skills • Family care • Socio-cultural issues • Multi-system failure • Brain death
Check the Resource Folder now for what’s available for module 4 You will find power point lectures and other resource materials
Content areas for the next 2 weeks • Postoperative recovery issues from the OR, to ICU, the ward and home • Management of risk factors following surgery • Understanding cholesterol • What happens when it all goes wrong? • Future trends • Subject evaluation
Let’s get started then.
While cardiac rehabilitation programs generally are available, eligible patients often do not access them.
Why do you think this is?
This article might give you some clues. Baigi A; Bering C; Fridlund B; Almerud-Österberg S; Programs. Nordic Journal of Nursing Research & Clinical Studies / Vård i Norden, 2011 Spring; 31 (1): 29-33 The authors concluded Non-attendees lack knowledge about known risk factors and their importance for CHD regardless of sex and education level. There appears to be a need to develop more personal and flexible interventions in order to increase nonattendees' knowledge about risk factors for CHD (2011, p.1).
This article is from Australia and might provide more local insight. Wachtel, Tracey M.; Preferred models of cardiac rehabilitation in rural South Australia from a health consumer's perspective. Australian Journal of Advanced Nursing, 2011 Mar-May; 28 (3): 30-6
The National Heart Foundation of Australia and the Australian Cardiac Rehabilitation Association Recommended Framework for Cardiac Rehabilitation is accepted as the basis for designing and delivering cardiac rehabilitation services. Cardiac rehabilitation programs generally include three-phases: 1. inpatient; 2. outpatient 3. maintenance. So you have probably looked after people in the first phase of rehabilitation in hospital.
The aims of rehabilitation are recovery, education and secondary prevention. There is very strong support for ensuring that all patients access appropriate rehabilitation services. The current rate of uptake of rehabilitation programs by eligible patients varies but some providers estimate it is as low as 30%. The capacity of rehabilitation services may be inadequate if all eligible patients accessed them-scary thought! In the Melbourne metropolitan areas hospital-based cardiac rehabilitation is provided by Alfred Hospital Austin Hospital, Geelong Hospital, Monash Medical Centre Royal Melbourne St. Vincent’s Box Hill Western Frankston Hospital Northern Hospital HARP- CDM services currently deliver outpatient cardiac rehabilitation in community health settings and also provide multidisciplinary services, including cardiac outreach, home and site nursing. 83% of rural hospitals provide outpatient cardiac rehabilitation. In 2007 the American Heart Association launched Mission: Lifeline which is described as a community-based initiative aimed at quickly activating the appropriate chain of events critical to opening a blocked artery to the heart that is causing a heart attack. The goal of Mission: Lifeline is to develop community-based systems across the country so patients can access appropriate care more quickly. It comprises: patient education; improved pre-hospital diagnosis of STEMI; early activation of catheterisation laboratories; treatment according to standard protocols; working with policy makers to ensure appropriate reimbursement and accountability; development of a STEMI centre certification program with criteria for both STEMI referral receiving hospitals.
CSANZ and the National Heart Foundation have published two important consensus documents: • Guidelines for the Management of Acute Coronary Syndromes 2006 (the Australian ACS Guidelines); • Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006 (the Australian Heart Failure Guidelines).
The role of the nurse
What is the role of the nurse in rehabilitation then? Read this article which is from Australia. The authors found that if a nurse recommended a patient attend rehabilitation the patient was more likely to attend. Johnson NA; Inder KJ; Nagle AL; Wiggers JH; Attendance at outpatient cardiac rehabilitation: is it enhanced by specialist nurse referral? Australian Journal of Advanced Nursing, 2010 Jun-Aug; 27 (4): 31-7 Pretty powerful stuff really! I had no idea that nurses were so influential.
Sometimes things don’t always go as planned and there can be difficulties while the patient is still in the OR that delay them getting off the table. Sometimes we have difficulty restarting the heart and it is not as a simple as putting in pacing wires. So, sometimes the person dies in the theatre or shortly afterwards. We have the usual problems such as haemorrhage but it is are for people to die from this in open surgery because we preorder the blood we anticipate and we recycle the person’s blood during the procedure. Sometimes there are technical difficulties with the size of the patients vessels that may make sewing them together difficult or when we have to sew grafts onto the back of the heart it takes longer. If the person is Jehovah’s Witness they will not usually have blood or blood products so we have a protocol for that. There is information made available by the Department of Human Services that is accessible by every hospital in Victoria to guide medical personnel in treating these patients.
Here is a link to the Office of the Public Advocate Practice Guidelines http://www.dhs.vic.gov.au/health/best/downloads/jehovahs_witnesses_blood_transfusio ns.pdf
Have a look at Blood Matters-Better Safer Transfusion Program also on this site. Sometimes we delay sternal closure due to oedema and various other reasons so you can read about that in this article.
L; Bademci M; Sahin A; Kestelli M; Yesil M; Gurbuz A; Delayed sternal closure: an effective procedure for life-saving in open-heart surgery. Yasa H; Lafci B; Yilik. Anatolian Journal of Cardiology / Anadolu Kardiyoloji Dergisi, 2010 Apr; 10 (2): 163-7
Other problems We have not talked about this in detail but cardiac tamponade is an absolute emergency. Watch this short clip on cardiac tamponade http://www.youtube.com/watch?v=QwgfuDegC5Y The treatment is for the medical practitioner to insert a needle into the pericardial space and withdraw the fluid. This gives immediate relief. If you watched the TV series that was on recently called there was a story about a man with this in one episode.
Sternal instability Have a look at this clip on how the sternum is closed http://www.youtube.com/watch?v=v-oWBvnZ1Go this is just one example of how it is done but I think you can see the main principles. You can see why analgesia is so important postoperatively. atrial flutter atrial fibrillation infection in the sternum or venous graft site
Other Readings
Österberg, S Baigi, A Bering, C Fridlund B. 2010. Knowledge of heart disease risk in patients declining rehabilitation British Journal of Nursing, Vol 19, No 5 Kreikebaum, S. Guarneri, E. Talavera, G. Madanat, H. Smith, T.2011 Evaluation of a holistic cardiac rehabilitation in the reduction of biopsychosocial risk factors among patients with coronary heart disease. Psychology, Health & Medicine May; 16(3): 27690 Taylor, G Wilson, S Sharp, J 2011 Medical, psychological, and socio demographic factors associated with adherence to cardiac rehabilitation programs: a systematic review. Journal of Cardiovascular Nursing, May-Jun; 26 (3): 202-9 Doyle, F. McGee, H. Conroy, R. Delaney, M 2011 What predicts depression in cardiac patients: Socio demographic factors, disease severity or theoretical vulnerabilities? Psychology & Health, May; 26 (5): 619-34
When Post Surgery Goes Very Wrong
Above in the module you have been exposed predominantly to cardiac rehab and the importance of that. Now I want to take you through some of the complications that develop post operatively. This will also take you through some of the normal care that is provided for patients. The survival rate for CABG’s and valve repair surgery is high and most patients on the surface fly though the surgery and their recovery leaving both patient and family very happy. However it is a very different situation for nurses and doctors and can often have some very intense moments! Some patients take the road that is rough and more like a roller coaster ride. The patient post open heart surgery is provided with intense one of one care whilst on a ventilator. The care provided becomes a juggling act of various factors to keep the patient alive. A normal heart patient from the ICU nurse perspective should spend about 24-48 hours in the ICU. Let me now walk you through a normal patient returning to the ICU – I don’t expect this to be remembered in detail but it gives you an idea on paper how complicated these patients are from the beginning The patient returns to ICU post open heart surgery sedated and asleep The first thing the nurse normally does is decrease this sedation. Quiet often the anaesthetist is a bit heavy handed with the propofol – the problem with this is the patient is vasodilated from the propofol and post operatively heart patients often need vasoconstrictive drugs to have a blood pressure.
The patient has most likely had a push of metaraminol (aramine) prior to leaving theatre which increases the blood pressure. This helps to avoid any hypotensive episodes in the couple of minutes it usually takes to push the patient from the Theatre to the ICU The patient will have a GTN infusion – this is a must with arterial grafts as it prevents arterial spasm of the new graft and ensures coronary blood flow. GTN must run at a minimum of 17mcg/min. Quiet often this is either turned off (for the moment because their blood pressure was low) or at some screamingly high rate because the aramine pushed their blood pressure so high Now all the above is valid care from a theatre point as the patient is being moved and the aim is to get the patient safely to the ICU. The patient is handed over to the doctor and nurse caring for the patient whilst the nurse is doing the settling in phase (nurse has to listen and to do there is no time to stand back and listen!). There will be two nurses to set the patient up in ICU – it can be done with one however two makes it so much easier. Nurses check a magnitude of things from the ventilator, the monitoring lines, check all the infusions and quickly calculate the drug doses that are being administered – and correct them if needed. The patient is connected up to monitoring equipment in the ICU, nurses check the pacing box and how it is set, take bloods and check the chest drains whilst attaching them to suction. The patient is connected to a PCA and the nurse begins to provide analgesia to the patient. The first dose of panadol is given IV. The patient is then watched very closely for the next 4-6 hours constantly and the patient has vital signs measured constantly and recorded half hourly. The chest drain output is monitored very closely – minimum of half hourly for four hours. This is key to survival as patients haemorrhage very easily and they also stop draining which can be only one reason a blocked tube – Alert for a tamponade! The patient is cold on admission to ICU with a temperature of about 34 degrees – so a warming blanket is used – Baire Hugger which blows hot air on the patient. By rewarming the patient the patient vasodilates therefore may need more vasoactive drugs like noradrenaline. Normally with rewarming the patient body is better able to regulate its own blood pressure The patient has constant haemodynamic monitoring and a Swan Gans Catheter (SGC) (introduced to you in Complex Care) is used on patients to help monitor cardiac output. The patient becomes a juggling act of infusions in which to optimise
the heart’s pumping ability. These patients have highly irritable hearts they are not good at pumping generally and continuous infusions make the difference between a cardiac output and or not. The patient has a mixture of electrolytes given to correct the imbalance that results from the bypass machine. Potassium will most definitely be required (unless the patient has renal failure) and magnesium, calcium and phosphate are all given to correct the imbalance and try and restore normal cardiac function as well as assist with coagulation. Ideally by the four hour mark the patient has rewarmed and is haemodynamically stable, not draining much blood from the chest, has enough analgesia onboard normally about 5mg of morphine over the period since admission and is ready to be woken. This occurs in most patients (in some patients this has occurred by the 2 hour mark). Two things can happen when you wake the patient they can wake calmly and are easy to talk to require a little more pain relief but generally are stable and easy to manage. Or they wake and they become haemodynamically unstable with their blood pressure either plummeting or sky rocketing; they may be cognitively intact or impaired. These patients often dump a large amount of blood from the chest and if they don’t settle within 10 – 20 minutes are re-sedated and everyone takes a breath, restabilises the patient and prepares to start again in a couple of hours!!
Generally speaking things do go well in the post operative period however unfortunately they don’t always. This is what probably makes the job interesting – you never know what is going to happen and as the nurse caring for these patients you are juggling everything in your power to keep things moving well. Most patients once they are woken and off the ventilator spend the next few hours in bed then depending on the time of day if it’s evening they are left to sleep. But by the next morning it’s all out! As many monitoring lines as possible are removed – normally SGC removed and arterial line
Patient is gotten out of bed and sitting in the chair – this occurs either before 7am for those who were morning cases yesterday and after breakfast for those who were the pm case Patient is treated with CPAP to reinflate the lungs and get there oxygen requirements down to either 40% humidified or 2 l/min via the prongs. Even with 2l/min CPAP will be used to optimise their recovery for Day 1. Patients are walked around the unit allowed back to bed. Then out for lunch and a walk, then back to bed for a rest and out for tea and a walk. Then back to bed for the night. The PCA is removed by about lunch time and regular panadol and oral analgesia has them well controlled By Day two the patient has all central lines removed and chest drains come out as does the IDC. They are normally ready for the ward with a peripheral IV and a pacing box. By this point they are well on the way to recovery and taken the ward. For those that did really well post operatively they can go to the ward a day earlier. As you can tell these patients are moved early as this is the only way to help there body recover. Patients that are still requiring blood pressure support from Noradrenaline benefit hugely from getting up and moving. So whilst patients feel exhausted it is our job to push them within reason of course.
Unfortunately not everything goes right for these patients and sometimes things can go wrong. Below is a patient I cared for after it all went wrong during PCI
Jerry was admitted to ICU post Cath Lab for emergency CABG’s after he had a Left Main Coronary Artery (LMCA) dissection during an angiogram. Jerry was in his 40’s had a wife and young children and a family history of CAD. Jerry had some episodes of chest discomfort and failed a stress test – he was a fit man! Jerry had been booked in for a routine angiogram to assess his need for plasty or stenting. Instead during the angiogram the wire had rubbed against his LMCA (normally happens) and caused it to dissect (not normal). I remember picking Jerrry up from cath lab he was white as a sheet and his ECG looked horrible. The plan was for us to take Jerry to the ICU for monitoring until the cardiac theatre and surgeon were finished with the current patient (unlike in TV land there isn’t always a surgeon and theatre free). The time until Jerry went to theatre was heavily focused on providing emotional support to Jerry and his family including his young children. The greatest fear here was that Jery would have a
cardiac tamponade. Thankfully Jerry managed until he could be taken to theatre but his post operative period was very rocky. Jerry’s heart had endured a massive AMI then been stopped for the bypass this for Jerry meant along time in ICU and going home with a diagnosis of cardiac failure as a result of the complication. I tell you the above story so you are aware that angiograms have serious dangers attached to them and even post angiogram plasy or stenting you need to be vigilant for complications. Most people worry about the puncture site you need to remember the heart that is hidden underneath and monitor for function. Another complication that is lifethreatening and thankfully was not witnessed in Jerry is Acute Cardiac Tamponade (ACT). ACT can occur in patients post PCI, post open heart surgery or it may happen post blunt trauma. Whatever the cause it is an emergency situation. Thankfully if it occurs in a patient who has undergone open heart surgery the sternum can be easily reopened by the Cardiothoracic surgeon.
Read the article ‘Acute cardiac tamponade: anticipate the complication’. This will help you develop an understanding of what happens and how it can be identified or prevented.
Sometimes we are unable to avoid a tamponade and then the chest needs to be opened. Read the article ‘Emergency reopening of a median sternotomy for pericardial decompression and cardiac massage’ to see why and what happens when we reopen the sternotomy.
The article by Kern takes a look at the nurses role and discusses some vital nursing care that needs to be provided. Check out ‘Emergency exploratory sternotomy: the nurses role’ The use of the heart lung bypass machine is an amazing benefit to many patients. The capabilities of care that can be provided and the advances in heart surgery are mindblowing. However the reality is that a individuals heart needs to be stopped and then restarted in most open heart surgery. Last module we looked at LVAD’s and how they benefit individuals lives. What needs to be remembered as LVADs are normally put into assist beating hearts and individuals have adapted to poor cardiac function. Sometimes in heart surgery the heart whilst it restarts electrically does not mechanically function enough to sustain life. This is a risk of open heart surgery. The problem is then
complicated and difficult. What options are available? The reality is there are two options at hand withdraw the bypass machine and the patient will most likely die or attach the person to a heart lung or just heart bypass machine and wait and see. Obviously surgeons where they can will pick the wait and see option. The reality is this equipment buys the patient time. We cannot fix a hearts terrible function we can try and optimise it. Sometimes the heart post open heart surgery just needs some time it’s stunned and needs to get over the shock.
The article Temporary Extracorporeal membrane oxygenation in patiens with refractory postoperative cardiogenic shock – a single center experience discusses the benefits of providing this bridge to many patients. Unfortunately there are major complications associated with cardiopulmonary bypass. Few people will run into major complications often patients will just experience some coagulopathies as a result of the heparinisation, there might be come minor organ dysfunction as a result of the loss of pulsatile flow whilst on bypass or there might be some confusion. However all these and many other complications must be monitored and treated appropriately.
Read the article titled After cardiopulmonary bypass: watching for complications to develop your understanding of what and why
An article that is a must read is the article on ‘understanding ventricular assist devices: a self study guide’. This will provide you with a wealth of knowledge. Next year you may have a patient admitted to your ward who lives with a VAD or you may care for a patient who has previously had a VAD or is waiting for a VAD. This way you will be armed with knowledge that will enable you to better care for the patients. Remember to do the study guide at the back as this may help with your quiz!! Next look at pacing wires. These are attached to the heart at the end of surgery and are temporary. Most patients hearts stabilise over a few days and the pacing wires are able to be capped off then removed. Sometimes however patients develop problems such as Atrial Fibrillation that requires ventricular pacing. Some patients will develop heart blocks and need to move to a permanent pacemaker. But for those patients whose heart regains normal electrical function their pacing wires can be removed around day 5-7. This occurs on the ward and is done by nurses in Australia.
But there are dangers. You are removing wires that are attached to the heart and therefore complications can easily arise (however thankfully they are rare). A golden rule however is STUDENTS NEVER REMOVE PACING WIRES. Once you read about the complicaitons you will understand why. It’s not because it is a difficult procedure because it’s not it’s just like pulling out a tube or piece of string. It is because it can go horribly wrong through no ones fault and you don’t want that experience as a student. So the rule is there to protect you.
Story time!! As a Critical Care student I was on my rotation in Coronary Care and was asked did I want to remove the pacing wires from a patient. I was all set to do it then my patient had chest pain (how inconvient (joking!) – yet looking back I am so glad I never got to pull that set). The nurse looking after the patient did all the right things lied the patient flat had them hold their breath as the wires were removed. Everything looked great for about 4 minutes!!
Then the patients rhythm changed and the patient crashed. A code Blue was called the ICU team rushed in. As a regular ICU staff member at the time I was pushed in there to help (someone else was taking care of my patients chest pain). The patient was unresponsive with no cardiac output but he had a rhythm that fluctated between SR and VT – he was in PEA/EMD. CPR was commenced and we were ventilating the patient with air viva. The patient was given sedation and intubated; we began preparing for an emergency sternotomy. As the surgeon walked through the door he and the registra had barely enough time to get their sterile gloves on (no gown) and there was a sudden scurry for goggles. The patients chest was reopened and it was revealed that a graft had dislodged and was flapping about in the chest alot like a hose on the ground pouring out water does. The graft was clipped and the patient rushed to theatre for emergency CABG’s. The surgeon has placed the pacing wire to close to the graft as the wire was pulled the graft was dislodged. The story is an extreme and thankfully the only tamponade I have experienced post pacing wire removal (there have been many others but earlier in the post operative period) but it highlights the need to be aware of all the complications that can come from pacing wire removal
Read the article Complications of epicaridal pacing wire removal to develop your knowledge of things that can go wrong and what to do.
Post in the discussion area
The reality is alot of things can and do go right with Cardiothoracic patients. However some things do go wrong. Take the time now that you have completed the modules to go back over the content and see make sure you understand what we have covered. We have provided you with an abundance of resources and there are many more for you to find out there. Cardiac Nursing by Woods is a great resource thats an eBook available through the library – look back over complications of AMI, PCI and open heart surgery. Use this to answer those unanswered questions. Post on the discussion board. The last quiz will be a combination of all the content that has been provided as we are dealing with all the complications that apply to the content. Think about your essay the topics are fairly broad for a reason – we want you to be able to pick an area that you are interested in and apply that to the topic. Question 2 particularly allows you to do that – you might pick paed’s or adults. If you are stuck send us an email. And remember Cardiothoracic’s is not an easy area to master and you all have a knowledge that will grow. I have worked Cardiothoracics for over a decade and I can assure you I am yet to have it mastered so to speak. Everyday there is something new and exciting to learn.
Go to the multiple choice test when you are ready. Good luck and we really hope you enjoyed this unit. We are looking forward to reading your papers!!!
Have you completed the quiz? If not then do this now as it is about to close-you have until midnight Friday Week 7.
Before we begin this module, we have one question for you. Have you come across patients in clinical with cardiac problems that are at the end of their treatment? It might be the diabetic person that has had CABs and now has some gout and this is difficult to manage because of their diuretics. They have some renal dysfunction and they are taking a multitude of medications. When and how does end stage cardiac stage begin? What is multisystem failure? Just some things to think about as we begin Module 4
Student Prep for the module We expect you to review and revise the following in preparation for this module: • Community nursing skills • Family care • Socio-cultural issues • Multi-system failure • Brain death
Check the Resource Folder now for what’s available for module 4 You will find power point lectures and other resource materials
Content areas for the next 2 weeks • Postoperative recovery issues from the OR, to ICU, the ward and home • Management of risk factors following surgery • Understanding cholesterol • What happens when it all goes wrong? • Future trends • Subject evaluation
Let’s get started then.
While cardiac rehabilitation programs generally are available, eligible patients often do not access them.
Why do you think this is?
This article might give you some clues. Baigi A; Bering C; Fridlund B; Almerud-Österberg S; Programs. Nordic Journal of Nursing Research & Clinical Studies / Vård i Norden, 2011 Spring; 31 (1): 29-33 The authors concluded Non-attendees lack knowledge about known risk factors and their importance for CHD regardless of sex and education level. There appears to be a need to develop more personal and flexible interventions in order to increase nonattendees' knowledge about risk factors for CHD (2011, p.1).
This article is from Australia and might provide more local insight. Wachtel, Tracey M.; Preferred models of cardiac rehabilitation in rural South Australia from a health consumer's perspective. Australian Journal of Advanced Nursing, 2011 Mar-May; 28 (3): 30-6
The National Heart Foundation of Australia and the Australian Cardiac Rehabilitation Association Recommended Framework for Cardiac Rehabilitation is accepted as the basis for designing and delivering cardiac rehabilitation services. Cardiac rehabilitation programs generally include three-phases: 1. inpatient; 2. outpatient 3. maintenance. So you have probably looked after people in the first phase of rehabilitation in hospital.
The aims of rehabilitation are recovery, education and secondary prevention. There is very strong support for ensuring that all patients access appropriate rehabilitation services. The current rate of uptake of rehabilitation programs by eligible patients varies but some providers estimate it is as low as 30%. The capacity of rehabilitation services may be inadequate if all eligible patients accessed them-scary thought! In the Melbourne metropolitan areas hospital-based cardiac rehabilitation is provided by Alfred Hospital Austin Hospital, Geelong Hospital, Monash Medical Centre Royal Melbourne St. Vincent’s Box Hill Western Frankston Hospital Northern Hospital HARP- CDM services currently deliver outpatient cardiac rehabilitation in community health settings and also provide multidisciplinary services, including cardiac outreach, home and site nursing. 83% of rural hospitals provide outpatient cardiac rehabilitation. In 2007 the American Heart Association launched Mission: Lifeline which is described as a community-based initiative aimed at quickly activating the appropriate chain of events critical to opening a blocked artery to the heart that is causing a heart attack. The goal of Mission: Lifeline is to develop community-based systems across the country so patients can access appropriate care more quickly. It comprises: patient education; improved pre-hospital diagnosis of STEMI; early activation of catheterisation laboratories; treatment according to standard protocols; working with policy makers to ensure appropriate reimbursement and accountability; development of a STEMI centre certification program with criteria for both STEMI referral receiving hospitals.
CSANZ and the National Heart Foundation have published two important consensus documents: • Guidelines for the Management of Acute Coronary Syndromes 2006 (the Australian ACS Guidelines); • Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006 (the Australian Heart Failure Guidelines).
The role of the nurse
What is the role of the nurse in rehabilitation then? Read this article which is from Australia. The authors found that if a nurse recommended a patient attend rehabilitation the patient was more likely to attend. Johnson NA; Inder KJ; Nagle AL; Wiggers JH; Attendance at outpatient cardiac rehabilitation: is it enhanced by specialist nurse referral? Australian Journal of Advanced Nursing, 2010 Jun-Aug; 27 (4): 31-7 Pretty powerful stuff really! I had no idea that nurses were so influential.
Sometimes things don’t always go as planned and there can be difficulties while the patient is still in the OR that delay them getting off the table. Sometimes we have difficulty restarting the heart and it is not as a simple as putting in pacing wires. So, sometimes the person dies in the theatre or shortly afterwards. We have the usual problems such as haemorrhage but it is are for people to die from this in open surgery because we preorder the blood we anticipate and we recycle the person’s blood during the procedure. Sometimes there are technical difficulties with the size of the patients vessels that may make sewing them together difficult or when we have to sew grafts onto the back of the heart it takes longer. If the person is Jehovah’s Witness they will not usually have blood or blood products so we have a protocol for that. There is information made available by the Department of Human Services that is accessible by every hospital in Victoria to guide medical personnel in treating these patients.
Here is a link to the Office of the Public Advocate Practice Guidelines http://www.dhs.vic.gov.au/health/best/downloads/jehovahs_witnesses_blood_transfusio ns.pdf
Have a look at Blood Matters-Better Safer Transfusion Program also on this site. Sometimes we delay sternal closure due to oedema and various other reasons so you can read about that in this article.
L; Bademci M; Sahin A; Kestelli M; Yesil M; Gurbuz A; Delayed sternal closure: an effective procedure for life-saving in open-heart surgery. Yasa H; Lafci B; Yilik. Anatolian Journal of Cardiology / Anadolu Kardiyoloji Dergisi, 2010 Apr; 10 (2): 163-7
Other problems We have not talked about this in detail but cardiac tamponade is an absolute emergency. Watch this short clip on cardiac tamponade http://www.youtube.com/watch?v=QwgfuDegC5Y The treatment is for the medical practitioner to insert a needle into the pericardial space and withdraw the fluid. This gives immediate relief. If you watched the TV series that was on recently called there was a story about a man with this in one episode.
Sternal instability Have a look at this clip on how the sternum is closed http://www.youtube.com/watch?v=v-oWBvnZ1Go this is just one example of how it is done but I think you can see the main principles. You can see why analgesia is so important postoperatively. atrial flutter atrial fibrillation infection in the sternum or venous graft site
Other Readings
Österberg, S Baigi, A Bering, C Fridlund B. 2010. Knowledge of heart disease risk in patients declining rehabilitation British Journal of Nursing, Vol 19, No 5 Kreikebaum, S. Guarneri, E. Talavera, G. Madanat, H. Smith, T.2011 Evaluation of a holistic cardiac rehabilitation in the reduction of biopsychosocial risk factors among patients with coronary heart disease. Psychology, Health & Medicine May; 16(3): 27690 Taylor, G Wilson, S Sharp, J 2011 Medical, psychological, and socio demographic factors associated with adherence to cardiac rehabilitation programs: a systematic review. Journal of Cardiovascular Nursing, May-Jun; 26 (3): 202-9 Doyle, F. McGee, H. Conroy, R. Delaney, M 2011 What predicts depression in cardiac patients: Socio demographic factors, disease severity or theoretical vulnerabilities? Psychology & Health, May; 26 (5): 619-34
When Post Surgery Goes Very Wrong
Above in the module you have been exposed predominantly to cardiac rehab and the importance of that. Now I want to take you through some of the complications that develop post operatively. This will also take you through some of the normal care that is provided for patients. The survival rate for CABG’s and valve repair surgery is high and most patients on the surface fly though the surgery and their recovery leaving both patient and family very happy. However it is a very different situation for nurses and doctors and can often have some very intense moments! Some patients take the road that is rough and more like a roller coaster ride. The patient post open heart surgery is provided with intense one of one care whilst on a ventilator. The care provided becomes a juggling act of various factors to keep the patient alive. A normal heart patient from the ICU nurse perspective should spend about 24-48 hours in the ICU. Let me now walk you through a normal patient returning to the ICU – I don’t expect this to be remembered in detail but it gives you an idea on paper how complicated these patients are from the beginning The patient returns to ICU post open heart surgery sedated and asleep The first thing the nurse normally does is decrease this sedation. Quiet often the anaesthetist is a bit heavy handed with the propofol – the problem with this is the patient is vasodilated from the propofol and post operatively heart patients often need vasoconstrictive drugs to have a blood pressure.
The patient has most likely had a push of metaraminol (aramine) prior to leaving theatre which increases the blood pressure. This helps to avoid any hypotensive episodes in the couple of minutes it usually takes to push the patient from the Theatre to the ICU The patient will have a GTN infusion – this is a must with arterial grafts as it prevents arterial spasm of the new graft and ensures coronary blood flow. GTN must run at a minimum of 17mcg/min. Quiet often this is either turned off (for the moment because their blood pressure was low) or at some screamingly high rate because the aramine pushed their blood pressure so high Now all the above is valid care from a theatre point as the patient is being moved and the aim is to get the patient safely to the ICU. The patient is handed over to the doctor and nurse caring for the patient whilst the nurse is doing the settling in phase (nurse has to listen and to do there is no time to stand back and listen!). There will be two nurses to set the patient up in ICU – it can be done with one however two makes it so much easier. Nurses check a magnitude of things from the ventilator, the monitoring lines, check all the infusions and quickly calculate the drug doses that are being administered – and correct them if needed. The patient is connected up to monitoring equipment in the ICU, nurses check the pacing box and how it is set, take bloods and check the chest drains whilst attaching them to suction. The patient is connected to a PCA and the nurse begins to provide analgesia to the patient. The first dose of panadol is given IV. The patient is then watched very closely for the next 4-6 hours constantly and the patient has vital signs measured constantly and recorded half hourly. The chest drain output is monitored very closely – minimum of half hourly for four hours. This is key to survival as patients haemorrhage very easily and they also stop draining which can be only one reason a blocked tube – Alert for a tamponade! The patient is cold on admission to ICU with a temperature of about 34 degrees – so a warming blanket is used – Baire Hugger which blows hot air on the patient. By rewarming the patient the patient vasodilates therefore may need more vasoactive drugs like noradrenaline. Normally with rewarming the patient body is better able to regulate its own blood pressure The patient has constant haemodynamic monitoring and a Swan Gans Catheter (SGC) (introduced to you in Complex Care) is used on patients to help monitor cardiac output. The patient becomes a juggling act of infusions in which to optimise
the heart’s pumping ability. These patients have highly irritable hearts they are not good at pumping generally and continuous infusions make the difference between a cardiac output and or not. The patient has a mixture of electrolytes given to correct the imbalance that results from the bypass machine. Potassium will most definitely be required (unless the patient has renal failure) and magnesium, calcium and phosphate are all given to correct the imbalance and try and restore normal cardiac function as well as assist with coagulation. Ideally by the four hour mark the patient has rewarmed and is haemodynamically stable, not draining much blood from the chest, has enough analgesia onboard normally about 5mg of morphine over the period since admission and is ready to be woken. This occurs in most patients (in some patients this has occurred by the 2 hour mark). Two things can happen when you wake the patient they can wake calmly and are easy to talk to require a little more pain relief but generally are stable and easy to manage. Or they wake and they become haemodynamically unstable with their blood pressure either plummeting or sky rocketing; they may be cognitively intact or impaired. These patients often dump a large amount of blood from the chest and if they don’t settle within 10 – 20 minutes are re-sedated and everyone takes a breath, restabilises the patient and prepares to start again in a couple of hours!!
Generally speaking things do go well in the post operative period however unfortunately they don’t always. This is what probably makes the job interesting – you never know what is going to happen and as the nurse caring for these patients you are juggling everything in your power to keep things moving well. Most patients once they are woken and off the ventilator spend the next few hours in bed then depending on the time of day if it’s evening they are left to sleep. But by the next morning it’s all out! As many monitoring lines as possible are removed – normally SGC removed and arterial line
Patient is gotten out of bed and sitting in the chair – this occurs either before 7am for those who were morning cases yesterday and after breakfast for those who were the pm case Patient is treated with CPAP to reinflate the lungs and get there oxygen requirements down to either 40% humidified or 2 l/min via the prongs. Even with 2l/min CPAP will be used to optimise their recovery for Day 1. Patients are walked around the unit allowed back to bed. Then out for lunch and a walk, then back to bed for a rest and out for tea and a walk. Then back to bed for the night. The PCA is removed by about lunch time and regular panadol and oral analgesia has them well controlled By Day two the patient has all central lines removed and chest drains come out as does the IDC. They are normally ready for the ward with a peripheral IV and a pacing box. By this point they are well on the way to recovery and taken the ward. For those that did really well post operatively they can go to the ward a day earlier. As you can tell these patients are moved early as this is the only way to help there body recover. Patients that are still requiring blood pressure support from Noradrenaline benefit hugely from getting up and moving. So whilst patients feel exhausted it is our job to push them within reason of course.
Unfortunately not everything goes right for these patients and sometimes things can go wrong. Below is a patient I cared for after it all went wrong during PCI
Jerry was admitted to ICU post Cath Lab for emergency CABG’s after he had a Left Main Coronary Artery (LMCA) dissection during an angiogram. Jerry was in his 40’s had a wife and young children and a family history of CAD. Jerry had some episodes of chest discomfort and failed a stress test – he was a fit man! Jerry had been booked in for a routine angiogram to assess his need for plasty or stenting. Instead during the angiogram the wire had rubbed against his LMCA (normally happens) and caused it to dissect (not normal). I remember picking Jerrry up from cath lab he was white as a sheet and his ECG looked horrible. The plan was for us to take Jerry to the ICU for monitoring until the cardiac theatre and surgeon were finished with the current patient (unlike in TV land there isn’t always a surgeon and theatre free). The time until Jerry went to theatre was heavily focused on providing emotional support to Jerry and his family including his young children. The greatest fear here was that Jery would have a
cardiac tamponade. Thankfully Jerry managed until he could be taken to theatre but his post operative period was very rocky. Jerry’s heart had endured a massive AMI then been stopped for the bypass this for Jerry meant along time in ICU and going home with a diagnosis of cardiac failure as a result of the complication. I tell you the above story so you are aware that angiograms have serious dangers attached to them and even post angiogram plasy or stenting you need to be vigilant for complications. Most people worry about the puncture site you need to remember the heart that is hidden underneath and monitor for function. Another complication that is lifethreatening and thankfully was not witnessed in Jerry is Acute Cardiac Tamponade (ACT). ACT can occur in patients post PCI, post open heart surgery or it may happen post blunt trauma. Whatever the cause it is an emergency situation. Thankfully if it occurs in a patient who has undergone open heart surgery the sternum can be easily reopened by the Cardiothoracic surgeon.
Read the article ‘Acute cardiac tamponade: anticipate the complication’. This will help you develop an understanding of what happens and how it can be identified or prevented.
Sometimes we are unable to avoid a tamponade and then the chest needs to be opened. Read the article ‘Emergency reopening of a median sternotomy for pericardial decompression and cardiac massage’ to see why and what happens when we reopen the sternotomy.
The article by Kern takes a look at the nurses role and discusses some vital nursing care that needs to be provided. Check out ‘Emergency exploratory sternotomy: the nurses role’ The use of the heart lung bypass machine is an amazing benefit to many patients. The capabilities of care that can be provided and the advances in heart surgery are mindblowing. However the reality is that a individuals heart needs to be stopped and then restarted in most open heart surgery. Last module we looked at LVAD’s and how they benefit individuals lives. What needs to be remembered as LVADs are normally put into assist beating hearts and individuals have adapted to poor cardiac function. Sometimes in heart surgery the heart whilst it restarts electrically does not mechanically function enough to sustain life. This is a risk of open heart surgery. The problem is then
complicated and difficult. What options are available? The reality is there are two options at hand withdraw the bypass machine and the patient will most likely die or attach the person to a heart lung or just heart bypass machine and wait and see. Obviously surgeons where they can will pick the wait and see option. The reality is this equipment buys the patient time. We cannot fix a hearts terrible function we can try and optimise it. Sometimes the heart post open heart surgery just needs some time it’s stunned and needs to get over the shock.
The article Temporary Extracorporeal membrane oxygenation in patiens with refractory postoperative cardiogenic shock – a single center experience discusses the benefits of providing this bridge to many patients. Unfortunately there are major complications associated with cardiopulmonary bypass. Few people will run into major complications often patients will just experience some coagulopathies as a result of the heparinisation, there might be come minor organ dysfunction as a result of the loss of pulsatile flow whilst on bypass or there might be some confusion. However all these and many other complications must be monitored and treated appropriately.
Read the article titled After cardiopulmonary bypass: watching for complications to develop your understanding of what and why
An article that is a must read is the article on ‘understanding ventricular assist devices: a self study guide’. This will provide you with a wealth of knowledge. Next year you may have a patient admitted to your ward who lives with a VAD or you may care for a patient who has previously had a VAD or is waiting for a VAD. This way you will be armed with knowledge that will enable you to better care for the patients. Remember to do the study guide at the back as this may help with your quiz!! Next look at pacing wires. These are attached to the heart at the end of surgery and are temporary. Most patients hearts stabilise over a few days and the pacing wires are able to be capped off then removed. Sometimes however patients develop problems such as Atrial Fibrillation that requires ventricular pacing. Some patients will develop heart blocks and need to move to a permanent pacemaker. But for those patients whose heart regains normal electrical function their pacing wires can be removed around day 5-7. This occurs on the ward and is done by nurses in Australia.
But there are dangers. You are removing wires that are attached to the heart and therefore complications can easily arise (however thankfully they are rare). A golden rule however is STUDENTS NEVER REMOVE PACING WIRES. Once you read about the complicaitons you will understand why. It’s not because it is a difficult procedure because it’s not it’s just like pulling out a tube or piece of string. It is because it can go horribly wrong through no ones fault and you don’t want that experience as a student. So the rule is there to protect you.
Story time!! As a Critical Care student I was on my rotation in Coronary Care and was asked did I want to remove the pacing wires from a patient. I was all set to do it then my patient had chest pain (how inconvient (joking!) – yet looking back I am so glad I never got to pull that set). The nurse looking after the patient did all the right things lied the patient flat had them hold their breath as the wires were removed. Everything looked great for about 4 minutes!!
Then the patients rhythm changed and the patient crashed. A code Blue was called the ICU team rushed in. As a regular ICU staff member at the time I was pushed in there to help (someone else was taking care of my patients chest pain). The patient was unresponsive with no cardiac output but he had a rhythm that fluctated between SR and VT – he was in PEA/EMD. CPR was commenced and we were ventilating the patient with air viva. The patient was given sedation and intubated; we began preparing for an emergency sternotomy. As the surgeon walked through the door he and the registra had barely enough time to get their sterile gloves on (no gown) and there was a sudden scurry for goggles. The patients chest was reopened and it was revealed that a graft had dislodged and was flapping about in the chest alot like a hose on the ground pouring out water does. The graft was clipped and the patient rushed to theatre for emergency CABG’s. The surgeon has placed the pacing wire to close to the graft as the wire was pulled the graft was dislodged. The story is an extreme and thankfully the only tamponade I have experienced post pacing wire removal (there have been many others but earlier in the post operative period) but it highlights the need to be aware of all the complications that can come from pacing wire removal
Read the article Complications of epicaridal pacing wire removal to develop your knowledge of things that can go wrong and what to do.
Post in the discussion area
The reality is alot of things can and do go right with Cardiothoracic patients. However some things do go wrong. Take the time now that you have completed the modules to go back over the content and see make sure you understand what we have covered. We have provided you with an abundance of resources and there are many more for you to find out there. Cardiac Nursing by Woods is a great resource thats an eBook available through the library – look back over complications of AMI, PCI and open heart surgery. Use this to answer those unanswered questions. Post on the discussion board. The last quiz will be a combination of all the content that has been provided as we are dealing with all the complications that apply to the content. Think about your essay the topics are fairly broad for a reason – we want you to be able to pick an area that you are interested in and apply that to the topic. Question 2 particularly allows you to do that – you might pick paed’s or adults. If you are stuck send us an email. And remember Cardiothoracic’s is not an easy area to master and you all have a knowledge that will grow. I have worked Cardiothoracics for over a decade and I can assure you I am yet to have it mastered so to speak. Everyday there is something new and exciting to learn.
Go to the multiple choice test when you are ready. Good luck and we really hope you enjoyed this unit. We are looking forward to reading your papers!!!
