DECCAN EDUCATION SOCIETY’S

Smt. Subhadra. K. Jindal College Of Nursing

Second. Year. M. Sc Nursing

SUBJECT: Medical Surgical Nursing (CVTN)

SEMINAR ON

CARDIOTHORACIC SURGERY

SUBMITTED TO: SUBMITTED BY:

Mrs. Sharada Chavan, Ms. Shruti Dilip Kolte,

Associate Professor, Second. Year. M. Sc. Nursing,

DESCON, Pune. DESCON, Pune.

SUBMITTED ON:

10/9/22
  Name of the Student: Ms. Shruti Dilip Kolte.
 Year: Second Year M. Sc. Nursing.
 Subject: medical surgical nursing II (CVTN)
 Guide Name: Mrs. Sharada Chavan.
 Topic: Cardiothoracic surgery
 Date: 10/9/2022
 Time:
 Venue: First Year M.Sc. Nursing Class Room.
 Group: First Year M.Sc. Nursing Students.
 No. Of Students:
 Method of teaching: lecture cum discussion method
 A.V. Aids: black board, flannel board, chart, flash cards, PPT, leaflet
 Basic knowledge of students: Students have basic knowledge about anatomy and
physiology of cardiopulmonary system.

GENERAL OBJECTIVE:

 At the end of the practice teaching, students will gain in depth knowledge about
Cardiothoracic surgery and apply it in their clinical areas.

SPECIFIC OBJECTIVES:
At the end of the seminar, students will be able to,

1. Enlist various cardiac surgeries.

2. Enumerate indications for various cardiac surgeries.
3. Explain pre-operative care of patients undergoing cardiac surgeries.
4. Describe intraoperative care of patients undergoing cardiac surgeries.
5. Discuss post-operative care of patients undergoing cardiac surgeries.
6. List down complications of cardiac surgeries.
7. Enlist various thoracic surgeries.
8. Enumerate indications for various thoracic surgeries.
9. Explain pre-operative care of patients undergoing thoracic surgeries.
10. Describe intraoperative care of patients undergoing thoracic surgeries.
11. Discuss post-operative care of patients undergoing thoracic surgeries.
12. List down complications of thoracic surgeries.
13. Discuss nursing management for Cardio-vascular thoracic surgeries.
14. Enumerate latest trends and issues in Cardio-vascular thoracic surgeries.
 CARDIAC SURGERIES

ANATOMY AND PHYSIOLOGY OF HEART

 Heart is a roughly cone shaped hollow muscular organ.
 It measures about 12 cm in length, 8 to 9 cm in breadth at the broadest part, and 6 cm
in thickness.
 Its weight is 280 to 340 g in male and 230 to 280 g in female.
 The heart lies in the thoracic cavity in the mediastinum (space between the lungs).
 It lies obliquely, a little more to left than right and presents a base as above and apex
below.
 The apex is about 9 cm to the left of midline at the level of 5 th intercostal space, little
below the nipple and slightly nearer the midline.
 The base extends to the level of 2nd rib.

CARDIAC TISSUE
The heart wall is composed mainly of a muscular layer, the myocardium. The
epicardium and the pericardium cover the external surface. Internally, the endocardium
covers the surface.

Epicardium
 The epicardium is a layer of mesothelial cell that forms the visceral or heart layer of the
serous pericardium.
 Branches of the coronary blood and lymph vessels, nerves, and fat are enclosed in the
epicardium and the superficial layers of the myocardium.
 The epicardium completely encloses the external surface of the heart and extends several
centimetres along each great vessel, encircling the aorta and pulmonary artery together.
Pericardium
 Pericardium merges with the tunica adventitia of the great vessels, at which point it
doubles back on itself as the parietal pericardium.
 This continuous membrane thus forms the pericardial sac and encloses a potential space,
the pericardial cavity.
 The serous parietal pericardium lines the inner surface of the thicker, tougher fibrous
pericardial membrane.
 The pericardial membrane extends beyond the serous pericardium and is attached by
ligaments and loose connections to the sternum, diaphragm, and structures in the posterior
mediastinum.
 The pericardial cavity is usually filled with 10 to 30 mL of thin, clear serous fluid.
 The main function of the pericardium and its fluid is to lubricate the moving surfaces of
the heart.
 The pericardium also helps to retard ventricular dilation, helps to hold the heart in
position, and forms a barrier to the spread of infections and neoplasia.

Myocardium
 The myocardial layer is composed of cardiac muscle cells interspersed with connective
tissue and small blood vessels.
 Some atrial and ventricular myocardial fibers are anchored to the fibrous skeleton.
 The thin-walled atria are composed of two major muscle systems—one that surrounds
both of the atria and another that is arranged at right angles to the first and that is separate
for each atrium.
Endocardium The endocardium is composed of a layer of endothelial cells and a few
layers of collagen and elastic fibres. The endocardium is in continuation with the tunica
intima of the blood vessels.

Layers of the heart wall

CHAMBERS OF THE HEART
 The heart has four chambers.
 The two superior receiving chambers are the atria and the two inferior pumping chambers
are the ventricles.
 On the anterior surface of each atrium is a wrinkled pouch like structure called an auricle,
so named because of its resemblance to a dog's ear.
 Each auricle slightly increases the capacity of an atrium so that it can hold a series of
grooves, called sulci that contain coronary blood vessels and a variable amount of fat.
 Each sulcus marks the external boundary between two chambers of the heart.
 The deep coronary sulcus encircles most of the heart and marks the external boundary
between the superior atria and inferior ventricles.
 The anterior interventricular sulcus is a shallow groove on the anterior surface of the heart
that marks the external boundary between the right and left ventricles.
 This sulcus continues around to the posterior surface of the heart as the posterior
interventricular sulcus, which marks the external boundary between the ventricles on the
posterior aspect of the heart.

HEART VALVES
Atrioventricular Valves
 The tricuspid and bicuspid (mitral) valve complexes are composed of six components that
function as a unit—the atria, the valve rings or annuli fibrosi of the fibrous skeleton, the
valve cusps or leaflets, the chordae tendineae, the papillary muscles, and the ventricular
walls.
 The mitral and tricuspid valve cusps are composed of fibrous connective tissue covered
by endothelium.

Semilunar Valves
 The two semilunar (pulmonary or pulmonic and aortic) valves are each composed of three
cup- shaped cusps of approximately equal size that attach at their base to the fibrous
skeleton.
 The valve cusps are convex from below, with thickened nodules at the center of the free
margins.
 The cusps are composed of fibrous connective tissue lined with endothelium.
 The endothelial lining on the non-ventricular side of the valves closely resembles and
merges with that of the intima of the arteries beyond the valves.
 The aortic cusps are thicker than the pulmonic; both are thicker than the AV cusps.

Chambers and valves of heart

 CONDUCTION SYSTEM OF HEART
 An inherent and rhythmical electrical activity is the reason for the heart's lifelong beat.
 The source of this electrical activity is a network of specialized cardiac muscle fibers
called autorhythmic fibers because they are self-excitable.
 Autorhythmic fibers repeatedly generate action potentials that trigger heart contractions.
 They continue to stimulate a heart to beat even after it is removed from the body for
example, to be transplanted into another person and all of its nerves have been cut.
 Surgeons do not attempt to reattach heart nerves during heart transplant operations.
 For this reason, it has been said that heart surgeons are better "plumbers" than they are
"electricians."
 During embryonic development, only about 1% of the cardiac muscle fibers become
autorhythmic fibers; these relatively rare fibers have two important functions.
 They act as a pacemaker, setting the rhythm of electrical excitation that causes
contraction of the heart.
 They form the conduction system, a network of specialized cardiac muscle fibers that
provide a path for each cycle of cardiac excitation to progress through the heart.
 The conduction system ensures that cardiac chambers become stimulated to contract in a
coordinated manner, which makes the heart an effective pump.

Cardiac conduction system

 COMMON DISORDERS REQUIRING CARDIAC SURGERY

ISCHEMIC HEART DISEASES

 Coronary Artery Disease
 Myocardial Infarction
 Heart Failure

Coronary Artery Disease

Coronary artery disease (CAD) is an obstructed blood flow through the coronary
arteries to the heart muscle. The primary cause of CAD is atherosclerosis. The term acute
coronary syndrome (ACS) is used to encompass the continuum of CAD. ACS describes the
manifestations of CAD, such as unstable angina, non-ST elevation myocardial infarction, and
ST elevation. If blood flow reduction resulting from CAD is severe and prolonged, a
myocardial infarction (MI, heart attack) can occur, causing irreversible damage.

Myocardial Infarction
A myocardial infarction, commonly known as a heart attack, results in the death of
heart muscle. The affected myocardial cells in the heart are permanently destroyed. An MI
occurs from a partial or complete blockage of a coronary artery, which decreases the blood
supply to the cells of the heart supplied by the blocked coronary artery. The extent of the
cardiac damage varies depending on the location and amount of blockage in the coronary
artery. The ability of the heart to contract, relax, and propel blood throughout the body
requires healthy cardiac muscle. When the patient has an MI, part of the heart muscle no
longer functions as it should. Cardiac conduction, blood flow, and function can be
dramatically altered by an MI.

Heart Failure
Heart failure is defined as the inability of the heart to pump sufficient blood to meet
metabolic demands of the body.

VALVULAR DISORDERS
 Mitral Stenosis
 Mitral Valve Prolapse (Barlow Syndrome, Myxomatous Valve Syndrome, Click-
Murmur Syndrome)
 Mitral Regurgitation
 Aortic Stenosis
 Aortic Regurgitation

Mitral Stenosis
Mitral stenosis is an obstruction of blood flowing from the left atrium into the left
ventricle during diastole.

Mitral Valve Prolapse (Barlow Syndrome, Myxomatous Valve Syndrome,

Click-Murmur Syndrome)
In mitral valve prolapse, a portion of a mitral valve leaflet balloons back into the atrium
during systole. Rarely, the ballooning stretches the leaflet to the point that the valve does not
remain closed during systole (lie. ventricular contraction). Blood then regurgitates from the
left ventricle back into the left atrium.
Mitral Regurgitation
Mitral regurgitation involves back flow of blood from the left ventricle into the left
atrium during systole.

Aortic Stenosis
Aortic valve stenosis is narrowing of the orifice between the left ventricle and the aorta.
Narrowing or stricture of the aortic valve, causing resistance to blood flow in the left
ventricle, decreased cardiac output left ventricular hypertrophy and pulmonary vascular
congestion. The consequence aortic stenosis LV hypertrophy which leads to increased end-
diastolic pressure, resulting in pulmonary hypertension.

Aortic Regurgitation
Aortic regurgitation is the backflow of blood into the left ventricle from the aorta
during diastole.

CONGENITAL HEART DISORDERS

Atrial Septal Defect
Ventricular Septal Defect
Patent Ductus Arteriosus
Atrioventricular Canal Defect
Coarctation Of Aorta
Pulmonic Stenosis
Tetralogy Of Fallot (Tof)
Tricuspid Atresia
Transposition of Great Arteries
Total Anomalous Pulmonary Venous Connection
Truncus Arteriosus

Atrial Septal Defect

Abnormal opening between the atria and allowing the blood from high pressure left
atrium to low pressure right atrium.

Ventricular Septal Defect

Abnormal opening between the right and left ventricles.

Patent Ductus Arteriosus

Failure of the fetal ductus arteriosus (artery connecting the aorta and pulmonary artery)
to close within first week of life. The continued patency of this vessel allows flowing of
blood from the high pressure aorta to low pulmonary artery, causing left to right shunt.

Atrioventricular Canal Defect

It consists of a low atrial septal defect that is continuous with a high ventricular septal
defect and clefts of mitral and tricuspid valves, creating a large atrioventricular valve that
allows blood to flow between all four chambers.

Coarctation of Aorta
 Localized narrowing near the insertion of duct-us arteriosus resulting in increased
pressure proximal to the defect (head and upper extremities) and decreased pressure distal to
the obstruction (body and lower extremities).

Pulmonic Stenosis
Narrowing at the entrance to the entrance of pulmonary artery. Resistance to blood flow
causes right ventricular hypertrophy and decreased pulmonary blood flow. Pulmonary atresia
is an extreme form of pulmonic stenosis in that there is total fusion of commissures and no
blood supply to the lungs.

Tetralogy Of Fallot (Tof)

It is characterized by:  Ventricular septal defect  Pulmonic stenosis  Overriding of
aorta  Right ventricular hypertrophy

Tricuspid Atresia
Failure of tricuspid valve to develop, consequently no communication between right
atrium and right ventricle. Blood flows through an atrial septal defect of patent foramen ovale
to the left side of heart and though a VSD to the right ventricle out to the lungs. It often
associated with PS and TGA. There is complete mixing of deoxygenated and oxygenated
blood in the left side of the heart, resulting in systemic desaturation and varying amounts of
pulmonary obstruction, causing decreased pulmonary blood flow.

Transposition of Great Arteries (TGA)

The pulmonary artery arises from the left ventricle and aorta arises from right ventricle,
with no communication between systemic and pulmonary circulations.

Total Anomalous Pulmonary Venous Connection

It is characterized by failure pulmonary veins to join left atrium, instead the pulmonary
veins are abnormally connected to the systemic venous circuit via the right atrium or veins
draining to the right atrium, such as superior vena cava. The abnormal attachment results in
mixed blood being returned to the right atrium and shunted from the right to left through an
ASD.

truncus arteriosus
Failure of normal septation and division of the embryonic bulbar trunk into the
pulmonary artery and the aorta, results in single vessel that overrides the both ventricles.
Blood from both ventricles mixes in the common great artery causing desaturation and
hypoxemia. Blood ejected from the heart flows low pressure pulmonary artery causing
increased pulmonary blood flow and decreased systemic blood flow.
 INDICATIONS FOR CARDIAC SURGERY

Indications for CABG

 Asymptomatic or mild angina
 Stable angina
 Unstable angina
 Segment elevation myocardial infarction
 Presence of poor LV function
 Presence of life threatening ventricular arrhythmias
 Failed PCI
 Previous CABG

Asymptomatic or Mild Angina

 Left main coronary artery stenosis
 Proximal LAD and proximal left circumflex stenosis
 Triple-vessel disease
 Proximal LAD stenosis and one- or two-vessel disease.
 One- or two-vessel disease.

Stable Angina
 Left main stenosis
 Proximal LAD and proximal left circumflex
 Triple-vessel disease
 Disabling angina refractory to medical therapy
 Proximal LAD stenosis with one-vessel disease
 One-or two-vessel disease

Unstable Angina/NSTEMI
 Left main stenosis
 Proximal LAD and proximal left circumflex stenosis
 One- or two-vessel disease

Segment Elevation Myocardial Infarction (STEMI)

 Failed PCI with persistent pain or hemodynamic instability and anatomically feasible.
 Persistent or recurrent ischemia
 Post infarction ventricular septal rupture or mitral valve insufficiency.
 Cardiogenic shock
 Life-threatening ventricular arrhythmias
 Primary reperfusion in patients who have failed fibrinolytics

Presence of Poor L V Function

 Left main stenosis
 Proximal LAD and proximal left circumflex stenosis
 Proximal LAD stenosis and two- to three-vessel disease.

Presence of Life-Threatening Ventricular Arrhythmias

 Left main disease
 Triple -vessel disease
 Proximal LAD disease
 One or two-vessel disease

Failed PCI
 Ongoing ischemia
 Hemodynarnic instability.
 Foreign body in critical position
 Hemodynamic instability with coagulopathy

Previous CABG
 Disabling angina refractory to medical therapy
 Nonpatent previous bypass grafts
 Large amount of myocardium at risk

Indications for Cardiac Transplantation

 Severe heart failure refractory to medical therapy
 Severely limiting ischemia not amenable to revascularization
 Recurrent symptomatic ventricular tachyarrhythmias refractory to medical therapy,
devices, or surgery
 Cardiac tumors (rare). Diseases
 Systolic heart failure (EF less than 35 Percent)
 lschemic heart disease with intractable angina
 Refractory to maximal tolerated medical therapy
 Not amenable to revascularization (CABG, PCI, OI TMR)
 Unsuccessful revascularization intractable arrhythmia
 Uncontrolled with implantable cardioverter defibrillator
 Not amenable to electrophysiologic guided therapy
 Not a candidate for ablative therapy
 Hypertrophic cardiomyopathy Class IV heart failure symptoms persist despite maximal
medical therapy
 Alcohol injection
 Myomectomy
 Mitral valve replacement
 Maximal medical therapy
 Pacemaker therapy
 Congenital heart disease in which fixed pulmonary hypertension is not a complication
 Cardiac tumor Confined to myocardium
 No evidence of distant disease via extensive metastatic work-up.

Indications for Valve Replacement Surgeries

 Aortic valve replacement for
- Aortic stenosis (AS)
- Aortic regurgitation (AR)
 Mitral valve replacement for
- Mitral stenosis (MS)
- Mitral regurgitation (MR)
Aortic valve replacement
 Symptomatic patients with severe AS
 Patients with AS undergoing CABG
 Patients with AS undergoing surgery on aorta or other heart valves
 Severe AS and LV systolic dysfunction (EF < 50 percent).
 Asymptomatic patients with severe AS
 Symptomatic patients with AR
 Asymptomatic patients with AR
 AR while undergoing CABG or surgery on the aorta or other heart valves (Level C).
 Patients with AR while undergoing surgery on the ascending aorta (Level C).

Mitral valve replacement

 Symptomatic patients with moderate or severe MS
 Severe MS and severe pulmonary hypertension [PASP > 60 mm Hg)
 asymptomatic patients with moderate or severe MS
 Symptomatic patients with severe MR (Level B).
 Asymptomatic patients with chronic, severe MR
 PREOPERATIVE CARE
MEDICAL CARE:
 Evaluation of medication regimen. These patients are usually taking multiple
drugs:
 Digoxin may be given in large doses to improve myocardial contractility may be
stopped several days before surgery to avoid digitoxic dysrhythrnias from cardiopulmonary
bypass.
 Diuretics: Assess for potassium depletion and volume depletion, give potassium
supplement to replenish body stores. May be omitted several days preoperatively to avoid
electrolyte imbalance and consequent dysrhythmias postoperatively.
 Antihypertensives are usually continued.
 Psychotropic drugs (diazepam, chlordiazepoxide] postoperative withdrawal may
cause extreme agitation.
 Corticosteroids if taken within the year before surgery may be given supplemental
doses to cover stress of surgery.
 Prophylactic antibiotics may be given preoperatively.
 Drug sensitivities or allergies are noted.
 If patients are taking herbal supplements, they should be discontinued as far in
advance as possible in order to prevent interactions with certain types of anesthesia.

 Review of patient’s condition to determine status of pulmonary, renal

hematologic, and metabolic systems.
 Cardiac history, history of cardiac dysrhythmias.
Pulmonary history, patients with COPD may require prolonged postoperative
respiratory support.
Depression can produce a serious postoperative depressive state and can affect
postoperative morbidity and mortality.
Present alcohol intake, smoking history.
Preoperative studies
CBC serum electrolytes, lipid profile, and nose, throat, sputum, and urine cultures.
Antibody screening.
Preoperative coagulation test (platelet count, prothrombin time, partial thromboplastin
time) extracorporeal circulation will affect certain coagulation factors.
 Renal and hepatic function tests.
 Echocardiography.
 Angiogram.
 Exercise testing.
 Chest X-ray.

NURSING CARE:
 Improvement of underlying pulmonary disease and respiratory function to
reduce risk of complications.
 Encourage patient to stop smoking.
 Treat infection and pulmonary vascular congestion.
 Preparation for events in the postoperative period.
 Take the patient and family to intensive care unit (ICU). This lessens anxiety about
being in ICU.
 Introduce the patient to staff personnel who will be caring for him.
 Give family a schedule of visiting hours and times for phone contact.
 Teach chest physical therapy procedures to optimize pulmonary function.
 Have the patient practice with incentive spirometer.
 Show and practice diaphragmatic breathing techniques.
 Have the patient practice effective coughing and leg exercises.
 Prepare patient for presence of monitors, chest tubes, IV lines, blood transfusion, ET
tube, nasogastric (NG) tube, pacing wires, arterial line, and indwelling catheter.
 Explain to the patient that chest tubes will be inserted below incision into chest cavity
for drainage and maintenance of negative pressure.
 Explain to the patient that ET tube will prevent speaking, but communication will be
possible through writing until tube is removed (usually within 24 hours).
 Explain to the patient that diet will consist of liquids until 24 hours after surgery.
 Explain that monitoring equipment and IV lines will restrict movement and nursing
staff will position patient comfortably every 2 hours and as necessary.
 Discuss with the patient the need to monitor vital signs frequently and the likelihood
of frequent disturbances of the patient's rest.
 Discuss pain management with the patient, assure the patient that analgesics will be
administered as necessary to control pain.
 Tell patient that both hands may be loosely restrained for a few hours after surgery lo
eliminate possibility pulling out tubes and IV lines inadvertently.

 Evaluation of emotional state to reduce anxieties.

 Patients undergoing heal are more anxious and fearful than other surgical patients
(moderate anxiety assists patient to cope with stresses of surgery. Low anxiety level may
indicate that the patient is in denial. High anxiety may impair the patient‘s ability to learn and
listen).
 Offer support and help patient and family mobilize positive coping mechanisms.
 Answer questions and allay fears and misconceptions.

 Surgical preparation:
 Shave anterior and lateral surfaces of trunk and neck, shave entire body down to
ankles (for coronary bypass).
 Shower or bathe per policies.
 Give sedative before going to the operating room if ordered.
 NURSING DIAGNOSIS
1. Decreased cardiac related to output altered myocardial contractility as evidenced by
dysrhythmias and extra heart sounds.
2. Ineffective tissue perfusion related to decreased cardiac output as evidenced by pale
conjunctiva, nail beds and buccal mucosa.
3. Acute pain related to decreased myocardial blood flow as evidenced by chest pain,
restlessness and SOB.
4. Activity intolerance related to imbalance between oxygen demand and supply as
evidenced by fatigue, weakness and dyspnoea.
5. Fatigue related to imbalance between oxygen demand and supply as evidenced by
weakness and limited ROM.

INTERVENTIONS WITH RATIONALE

1. Decreased cardiac related to output altered myocardial contractility as evidenced by
dysrhythmias and extra heart sounds.
 Auscultate apical pulse, assess heart rate. Note  To obtain baseline data and plan further
heart sounds. Assess rhythm and document interventions.
dysrhythmias if telemetry is available.

 Give oxygen as indicated by the patient‘s  Supplemental oxygen increases oxygen

symptoms, oxygen saturation, and ABGs. availability to the myocardium and can help
relieve symptoms of hypoxemia, ischemia.

 Provide a restful environment and encourage  Physical and emotional rest allows the patient
periods of rest and sleep; assist with activities. to conserve energy.

 Encourage rest, semi-recumbent in bed or
chair. Assist with physical care as indicated.
 During acute or refractory HF, physical rest
should be maintained to improve cardiac
contraction efficiency and decrease myocardial
oxygen demand/ consumption and
workload. Enforce complete bed rest when
necessary to decrease the cardiac workload on
acute symptomatic attacks of HF.

 Provide a quiet environment: explain  Psychological rest helps reduce emotional

therapeutic management, help the patient
avoid stressful situations, listen and respond to
expressions of feelings.
 Provide bedside commode,
provide stool softeners as ordered. Have
patient avoid activities eliciting a vasovagal
response (straining during defecation, holding
breath during position changes).
stress, which can produce vasoconstriction,
elevating BP and increasing heart rate.
 Using a bedside commode decreases work of
getting to the bathroom or struggling to use a
bedpan. Patients with HF have autonomic
dysfunction. Valsalva maneuver or similar
behaviors reduces mean arterial blood pressure
and cerebral blood flow, leaving patients
vulnerable to hypoperfusion, ischemia,
and stroke.

 Encourage active and passive exercises.  For acute HF, bed rest may be temporarily
Increase activity as tolerated. indicated. Otherwise, a total of 30 minutes of
 physical activity every day should be
encouraged.

 Check for calf tenderness, diminished pedal  The risk for thrombophlebitis increases with
pulses, swelling, local redness, or pallor of enforced bed rest reduced cardiac output, and
extremity. venous pooling.

2. Ineffective tissue perfusion related to decreased cardiac output as evidenced by pale

conjunctiva, nail beds and buccal mucosa.
 Monitor vital signs, especially pulse and  To obtain baseline data and plan further
blood pressure, every 5 minutes until pain interventions.
subsides. Assess cardiac and circulatory
status. Monitor cardiac rhythms on patient
monitor and results of 12 lead ECG.
 Establish a quiet environment.  A quiet environment reduces the energy
demands on the patient.

 Elevate the head of the bed.  Elevation improves chest expansion and
oxygenation.

 Provide oxygen and monitor oxygen  Oxygenation increases the amount of

saturation via pulse oximetry, as ordered. oxygen circulating in the blood and,
therefore, increases the amount of
available oxygen to the myocardium,
decreasing myocardial ischemia and pain.

 Teach the patient relaxation techniques and  Anginal pain is often precipitated by
how to use them. emotional stress that can be relieved by
non-pharmacological measures such as
relaxation.

 Instruct patient on eating small frequent  To prevent heartburn and acid

feedings. indigestion.
 INTRAOPERATIVE CARE
MEDICAL CARE:
Anaesthesia
 After standard monitoring equipment is attached and peripheral venous access achieved
but before the arterial line is inserted, the midazolam dose is administered.
 Before placement of the arterial line, it should be ensured that a radial artery graft will not
be used for CABG.
 Cardiac surgery makes use of the following two forms of neuroaxial blockade:
-Intrathecal opioid infusion
-Thoracic epidural anesthesia
 During induction and tracheal intubation, it is important to maintain a steady heart rate
and blood pressure.
 To this end, patients should be preoxygenated.
 Induction of anesthesia is accomplished by using high doses of opioid [usually fentanyl or
remifentanil) to minimize the dose of propofol, etomidate, or thiopental and thereby
maximize cardiovascular stability.
 Although etomidate usually does not cause changes in blood pressure, it may cause
hypotension in cardiac patients.
 A number of agents may be used for muscle relaxation. However, they each have their
own associated complications, as follows:
 Pancuronium increases myocardial oxygen demand
 Vecuronium may cause bradycardia in association with opioids
 Rocuronium can cause tachycardia
 Atracurium (which is not considered suitable for operations of long duration) can
cause hypotension secondary to histamine release.
 The trachea should be intubated orally because nasal intubation may cause significant
bleeding once heparin is administered.
 A double-lumen endotracheal tube is required if CABG is being performed via a left
thoracotomy. Central venous access should be obtained.
 It is not uncommon for the patient to become hypotensive.
 To ensure that there is sufficient diastolic pressure to maintain coronary perfusion,
hypotension should be treated with IV fluids or with an alpha agonist if LV function is
depressed.
 Typically, maintenance of anesthesia is accomplished with an opioid infusion (fentanyl,
alfentanil sufentanil or remifentanil) combined with either a propofol infusion (total IV
anesthesia) or a volatile agent.
 Volatile agents are generally carried in an air-oxygen mixture because the use of nitrous
oxide as a carrier is controversial.
 Isoflurane may have a myocardial protective effect and therefore is especially useful in
off-pump surgery.

NURSING CARE:
 The nurse performs an assessment and prepares the patient for the operating room and
recovery experience.
 Any changes in the patient‘s status and the need for changes in therapy are identified.
Procedures are explained before they are performed, such as the application of electrodes
and use of continuous monitoring, indwelling catheters, and a SpO2 probe.
 Intravenous lines are inserted to administer fluids, medications, and blood products.
 The patient will receive general anesthesia, intubated and placed on mechanical
ventilation.
 In addition to assisting the surgical procedures, nurses are responsible for the comfort and
safety of the patient.
 Some of the areas of intervention include positioning, skin care, wound care, and
emotional support of the patient and family.
 Before the chest incision is closed, chest tubes are positioned to evacuate air and drainage
from the mediastinum and the thorax.
 Epicardial pacemaker electrodes are implanted on the surface of the right atrium and the
right ventricle.
 These epicardial electrodes can be used to pace the heart and to monitor it for
dysrhythmias through the atrial leads.
 Possible intraoperative complications include dysrhythmias, hemorrhage, MI, CVA
(stroke, brain attack), embolization, and organ failure from shock, embolus, or adverse
drug reactions.
 Intraoperative patient assessment is critical in preventing these complications and for
detecting symptoms and initiating prompt therapy.
 CARDIOPULMONARY BYPASS
Cardiopulmonary bypass is an external corporal circulation. It mechanically circulates
the blood by passing the heart and lung. It uses the heart—lung machine to maintain
perfusion of the body.

Indication for CPB:

 To provide bloodless field for cardiac surgeries like:
- CABG
- Cardiac valve repair or replacement
- Repair of large septal detect
- Repair of congenital heart defects
- Transplantation : heart, lungs, heart-lung, liver
- Repair of aneurysm
- Pulmonary thromboendartectomy
- Pulmonary thrombectomy

Different types of Cannulation

 Venous cannulation: A cannula may be place in the right atrium, superior vena-cava,
inferior vena-cava or femoral vein to drain the blood from the body.
 Arterial cannulation: A cannula may be placed in ascending aorta, arch of aorta or
femoral artery for returning of oxygenated blood from the heart-lung machine.
Completed cannulation for total cardiopulmonary bypass. The left ventricular venting
catheter has been insened adjacent to the right superior pulmonary vein (SPV). The
retrograde cardioplegia catheter is in the coronary sinus. The antegrade cardioplegia catheter
is in the ascending aorta proximal to the aortic occluding clamp. (IVC=inferior vena caval;
LV=left ventricle; SVC=superior vena caval).

Components of Cardiopulmonary Bypass Circuit

 Pumps: Pumps are used for circulation of blood at 21 constant speed. Pump may be roller
or centrifugal.
 Venous reservoir: It serves as a receiving chamber for venous return. During
cardiopulmonary bypass 1-3 litre of blood may be stored in the reservoir.
 Oxygenator: It used for oxygenating the venous the blood. The oxygenator may be
membrane or bubble oxygenator.
 Heat exchanger: It used for warming or cooling of blood.
 Filter: It is used to prevent the air embolism.
 Cardiotomy suction: It is the suctioning of blood from the surgical wound during the
surgery.
 Cardiotomy reservoir: The blood suctioned from the surgical wound is directed into the
cardiotomy reservoir for defoaming, filtering, storage and then the redirected to the
venous reservoir.
 Left ventricular venting: It is the process of removing blood from the left ventricle to
prevent left ventricular distention during aortic cross clamp. During cardiopulmonary
bypass left ventricle may be distended due to;
 Blood escaping from the atrial or venous cannula
 Blood from the coronary sinus and besian veins pass into pulmonary circulation
 Blood from aortic regurgitation
  Bronchial arterial and venous blood
 PDA.
 Cardioplegia delivery system: It is used for delivering the cardioplegia solution into the
coronary arteries. This is a separate perfusion system from the main perfusion it includes
reservoir, heat exchanger, roller pump, bubble trapper, filter. During the procedure the
patient receives the heparin dose of 3 mg/kg, after the termination of cardiopulmonary
bypass protamine sulfate is administered to reverse the effects of heparin.

Cardiopulmonary Bypass Circuit

Weaning from Cardiopulmonary Bypass

 The patient is fully rewarmed, mechanical ventilation is initiated with the resumption of a
normal sinus rhythm.
 If bradycardia or temporary heart block develops, then pacing wires are placed in the
right atrium and right ventricular outflow tract for temporary pacing.
 In addition, electrolyte abnormalities such as hypomagneseinia and hypokalemia are
treated.
 The transesophageal echo can be of great help in identifying regional or global
myocardial dysfunction as the perfusionist leaves blood in heart to allow ejection.
 By using the transesophageal echo, the patient is then weaned from cardiopulmonary
bypass as a greater percentage of the overall hemodynamic support is provided by the
native ventricular function.
 Gradual reduction of venous return and incremental volume loading of the heart assist in
this process until cardiopulmonary bypass is discontinued.
 After successful cessation of cardiopulmonary bypass, anticoagulation is reversed by
administration of protamine.

Complications
 Arrthymias  Gastroenteritis
 Air embolism  Bleeding
 Dislodgment of cannula  Aortic dissection
 Acidosis  Clotting within the circuit during
 Pulmonary edema perfusion
 Delirium
 INTERVENTIONAL DEVICES

PTCA (Percutaneous Transluminal Coronary Angioplasty)

It is a technique used for the treatment of CAD (coronary acting disease). A balloon-
tipped catheter is introduced through a guide wire into a coronary vessel and the balloon of
the catheter is then inflated, causing disruption of the intima and changes in the atheroma and
results in increased in the diameter of the lumen of the coronary vessel and improvement of
blood flow. Balloon inflation and deflation may be repeated until satisfactory results are
achieved.

Indications
Patients meeting these criteria are generally acceptable candidates for PTCA:
 Stable angina (less than 1 year) or unstable angina (less than 6 months), despite optimal
medical therapy.
 Single-vessel or multi-vessel disease (balloon dilatation of the most severe culprit lesion
is initially attempted to determine if successful angioplasty can be achieved); surgery to
bypass the lesion may be recommended if PTCA is unsuccessful.
 Proximal, accessible non-calcified lesions; rnid-vessel lesions may also be attempted with
success.
 Suitable candidate for heart surgery and has consented to heart surgery as an alternative
treatment.
 Evolving MI (may be in combination with thrombolytic therapy) and obstructed coronary
bypass grafts.

Procedure
 This procedure is carried out in the cardiac catheterization laboratory.
 The coronary arteries are examined by angiography, as they are during the diagnostic
cardiac catheterization, and the location, extent, and calcification of the atheroma are
verified.
 Hollow catheters, called sheaths, are inserted, usually in the femoral vein or artery (or
both), providing a conduit for other catheters.
 After the presence of atheroma is verified, a balloon-tipped dilation catheter is passed
through the sheath along a guide catheter and positioned over the lesion.
 The interventional cardiologist determines the catheter position by examining markers on
the balloon that can be seen with fluoroscopy.
 When the catheter is properly positioned, the balloon is inflated with a radiopaque
contrast agent to visualize the blood vessel and to provide a steady or oscillating pressure
within the balloon.
 The balloon is inflated to a certain pressure for several seconds and then deflated.
 The pressure "cracks" and possibly compresses the atheroma and the coronary artery s
tunica media and militia adventitia layers are also stretched.
 Several inflations and several balloon sizes may be required to achieve the desired goal,
usually defined as an improvement in blood flow and a residual stenosis of less than 20
percent.
 Other gauges of the success of a PTCA are an increase in the artery's lumen, a of less than
20 mm Hg in blood pressure from one side of the lesion to the other, find no clinically
obvious arterial trauma.
 Because the blood supply to the coronary artery decreases while the balloon is inflated,
the patient may complain of chest pain (often called stretch pain), and the ECG may
display significant ST-segment changes.

Coronary Artery Stent

 After PTCA, a portion of the plaque that was not removed may block the artery.
 The coronary artery may recoil (constrict) and the tissue remodels, increasing the risk for
restenosis. A coronary artery stent is placed to overcome these risks.
 A stent is a woven mesh that provides structural support to a vessel at risk of acute
closure. The stent is placed over the angioplasty balloon.
 When the balloon is inflated, the mesh expands and presses against the vessel wall,
holding the artery open.
 The balloon is withdrawn, but the stent is left permanently in place within the artery.
 Eventually, endothelium covers the stent and it is incorporated into the vessel wall.
 Because of the risk of thrombus formation in the stent the patient receives arm platelet
medications [e.g. clopidogrel (Plavix) therapy for 2 weeks and lifetime use of aspirin].

Bare Metal stents

 These are metallic scaffolds that are vascular complications at the femoral
inserted into a diseased vessel segment arterial entry site.
in their collapsed form and are then
deployed by balloon inflation or self-
expansion (after removal of an external
constraining membrane).
 The metallic stems are prone to
thrombotic occlusion, either acute (24
hours) or subacute (1 to 14 days with a
peak at 6 days), requiring an
aggressive anticoagulation regimen
(aspirin, dipyridamole, and warfarin) to
reduce such thromboses to 3 percent.
 This aggressive anticoagulant regimen
prolongs the hospitalization and
increased the incidence of local

Self-expanding Stents
 Self-expanding stems are able to expand without balloon dilatation.
 The stents are covered by a retaining sheath that, when removed, allows the stent to
expand.
 The protective membrane covering the stent allows passage through tortuous segments of
preformed catheters and the coronary vasculature.
 Once at the site of the coronary stenosis, the retaining sheath is gradually removed,
allowing the stent to expand fully and its residual elastic force dilates the artery.
 Dilatation continues until equilibrium is reached between the circumferential elastic
resistance of the vessel and the dilating force of the stent.
 To achieve optimal coronary dilatation, balloon expansion of the device is commonly
performed.
Drug-Eluting Stents
 Drug-eluting stents were developed in
the early 2000s to provide sustained
local delivery of an antiproliferative
agent at the site of vessel wall injury.
 The three components of current DES
are the balloon-expandable stent, a
durable or resorbable polymer coating
that provides sustained drug delivery,
and the pharmacologic agent employed
to limit intimal hyperplasia.

Sirolimus-Eluting Stents
 The CYPHER stent (Cordis Corp.,
Warren, NI) contains sirolimus, a
naturally occurring
immunosuppressive agent that causes
cytostatic inhibition of cell
proliferation. Sirolimus is released
from a biostable polymer for 30-days.

Paclitaxel-Eluting Stents
 The TAXUS stent (Boston Scientific) is composed of a stainless steel stent platform, a
poiyolefin polymer derivative, and the microtubular stabilizing agent paclitaxel that has
antiinflammatory effects while also inhibiting both cell migration and division.
 Paclitaxel release is completed within 30 days of implantation, although a substantial
portion (>90 percent) of the paclitaxel remains within the polymer indefinitely.
Zotarolimus-Eluting Stents
 Zotarolimus (previously knovm as
ABT-578) is a rapamycin analogue
released from a phosphorylcholine
(PC)-coated stent it has both
immunosuppressive and
antiproliferative effects.

Everolimus-Eluting Stent
 The Xience stent (Abbot Vascular,
Santa Rosa, Calif) uses the cobalt
chromium vision stent, a durable
fluoropolymer, and everolimus, which
is a rapamycin analogue that has both
immunosuppressive and
antiproliferanve effects.
Coronary Atherectomy
 The atherectomy catheters reduce the severity of coronary stenoses by removing the
atheromatous plaque rather than compressing or fracturing the plaque or stretching the
arterial wall.
 In theory, this approach permits a more controlled vascular injury and minimizes the
degree of arterial mural stretch.
 Removal of plaque creates a smoother surface by debulking the vessel and removes
atherosclerotic plaque that is frequently resistant to balloon dilatation.

Indications for coronary atherectomy

- Atherosclerosis
- Calcified plaque

Types of coronary atherectomy

- Directional coronary atherectomy
- Rotational ablation
- Transluminal extraction atherectomy

Directional Coronary Atherectomy

 The directional coronary atherectomy (DCA) catheter or Simpson Athero Cath
(Guidant/Advanced Cardiovascular Systems, Santa Clara, CA), consists of a catheter-
mounted, cylindric metallic housing unit (i.e. collection chamber, window, and cupshaped
cutter) and a small balloon attached to the housing.
 A hand-held motor-drive unit is attached to the end of the catheter, and the cutter in the
housing is rotated at 2,000 rpm through the driving cable.
 When this catheter is placed at the stenotic lesion, a balloon is inflated at low pressure
against one wall of the vessel to stabilize the housing chamber and the window against
the opposite vessel wall of atherosclerotic plaque.
 Plaque that protrudes into the housing unit through the window is then excised with the
rotating cutter, which is advanced manually.
 The device is then rotated and plaque is excised from around the vessel lumen.

Rotational Ablation
 The rotational atherectomy device (Rotablator) was developed by David Auth (SClMED/
Boston Scientific, Maple Grove, MN).
 The Rotablator is a flexible catheter-deliverable system that can be used transluminally.
 The Rotablator system uses a high-speed, rotating, elliptical bur coatedwith diamond
chips 20 to 30 mm in diameter that forms an abrasive surface.
 When the bur is spun at a high speed (140,000 to 180,000 rpm, depending on bur size), it
preferentially removes atheroma because of its selective differential cutting of inelastic
plaque rather than elastic normal tissue.
 The process involves a stepwise incremental increase in bur size to provide a "sanding
effect' Gradual advancement and withdrawal of the bur ir1 2- to 5-second intervals for up
to 20 to 30 seconds in the lesion allows for heat dissipation, improved distal perfusion,
and washout of particulate debris.
 The postablation vessel diameter is equal to the largest bur size used.
 Adjunctive PTCA is frequently used to maximize final coronary artery luminal diameter
or stent placement.
 Rotational atherectomy has been shown to be particularly effective in the treatment of
calcified coronary lesions by ablating the fibrocalcific plaque, which is difficult to dilate
with an angioplasty balloon.
 To maximize luminal diameter, stent implantation is used adjunctively after ablation. \
 Rotational ablation has also been used for in-stent restenosis.

Transluminal Extraction Atherectomy

 The transluminal extraction catheter (TEC) was developed by interventional technologies.
 The device consists of a motorized, rotating, hollow catheter equipped with a distal cone-
shaped head.
 The cutting head is mounted on a flexible torque tube, which incorporates a vacuum
system that allows retrieval of the excised material.
 As the cone is rotated at 750 rpm, continuous suction is applied at the proximal end of the
catheter thereby removing the atheromatous debris, which is flushed with saline through
the central lumen of the drive shaft and collected in a vacuum bottle.
Transmyocardial Revascularization
Indication:
 Patients who have cardiac ischemia and who are not candidates for CABG may benefit
from transmyocardial laser catheterization (TMR).

Procedure:
 The procedure may be performed percutaneously in the cardiac catheterization laboratory
percutaneous transmyocardial revascularization [PTMR]) or through a midsternal or
thoracotomy incision in the operating room.
 The tip of a fiberoptic catheter is held firmly against the ischemic area of the heart while a
laser burns channel into but not through the muscle.
 If the procedure is percutaneous, the catheter is positioned inside the ventricle.
 If the procedure is surgical, the catheter is positioned on the outer surface of the ventricle.
 Each procedure usually involves making 20 to 40 channels.
 It is thought that some blood flows into the channels, decreasing the ischemia directly.
 Within the next few days to months, the channels close as a result of the body's
inflammatory process of healing wound.
 The long-term result is the formation of new blood vessels (angiogenesis) during the
inflammatory process follows the laser bums.
 The new blood vessels provide enough blood to decrease the symptoms of cardiac
ischemia.
 Nursing care before, during, and after the procedure depends on the approach: if the
approach was percutaneous, the patient care is the same as following a PTCA; if the
approach was surgical, the patient care is the same as following CABG.

Transmyocardial Revascularization
 CORONARY ARTERY BYPASS GRAFT SURGERY
CABG surgery consists of the construction of new conduits (vessels to transport blood)
between the aorta, or other major arteries, and the myocardium distal to the obstructed
coronary artery (or arteries). The procedure involves one or more grafts using the internal
mammary artery, saphenous vein, radial artery, gastroepiploic artery, and/or inferior
epigastric artery, splenic artery.

Indications
 Triple vessel disease
 Severe left main artery stenosis

Positioning
For a standard sternotomy, the anterior thorax is exposed with the patient in a supine
position. A roll is placed in the interscapular region to improve access to the sternum by
extending the neck and elevating the sternal notch.

Harvesting of Conduit
Saphenous Vein
 The great (long) saphenous vein (GSV) is located 2 cm anterior to the medial malleolus,
traverses the tibia, and ascends posteriorly up the tibial border before emptying into the
femoral vein.
 It receives numerous tributaries, notably at the knee, and contains 10 to 20 valves.
 Key associated structures are the saphenous nerve, femoral cutaneous nerve, and
saphenous branch of the genicular artery.
 The small (short) saphenous vein (SSV) is located 1 cm posterior to the lateral malleolus,
runs centrally up the posterior calf, and drains into the popliteal vein.
 As CABG conduits, the saphenous veins have an 80 to 90 percent early patency rate,
which decreases to 50 percent at 10 years.
 The saphenous vein is generally acceptable as a conduit in the absence of other vascular
pathologies in the leg (varicosities in the vein, venous insufficiency, previous deep vein
thrombosis [DVT], or small lumen diameter) of overlying infection.
 The GSV can be procured either via an open harvest technique, starting from either the
ankle or groin and using a vein stripper, or via an endoscopic technique.
 Likewise, the SSV vein can be harvested either with an open procedure or
endoscopically.
 The legs and groin should be shaved, prepared and draped in the operating room.
 Care should be taken to avoid getting skin preparation solution on the diathermy plate;
this can result in diathermy burns.
 Once the anesthetist is ready for surgery to start and the surgeon has confirmed the
number of lengths (25 cm) of vein required, the vein harvest can begin.

Internal Mammary Artery

 The LIMA (left internal mammary artery) and the RIMA (right internal mammary artery)
arise from their respective subclavian arteries. The internal mammary artery can be
harvested either by itself or as a pedicle.
 LIMA is most commonly harvested as a pedicle, the RIMA is generally skeletonized
because an RIMA pedicle may interfere with sternal wound healing.
 The LIMA is useful in left anterior descending (LAD) artery anastomosis and has a good
patency rate in this setting (98 percent at 1 year and 90 percent at 10 years).
 The RIMA has a good patency rate when anastomosed to the LAD (96 percent at 1 year
and 90 percent at 5 years) but a reduced rate when grafted to the circumflex or the right
coronary artery (75 percent at 1 year).

Sephanous and Mammary Artery Grafting

Coronary Artery Bypass

The usual incision for CABG is a midline sternotomy, although an anterior
thoracotomy for bypass of the LAD or lateral thoracotomy for marginal vessels may be used
when an off-pump procedure is being performed.

Cardiopulmonary Bypass
The first step in cardiopulmonary bypass is to cannulate the aorta and right atrium.
Postoperatively, myocardial infarction, shock, and conduction defects can be seen.

Placement of Graft
 After the initiation of cardiopulmonary bypass, the distal coronary bypass targets are
identified.
 As a rule, anastomosis to the right coronary artery and the marginal branches of the
circumflex are completed first.
 The circumflexis accessed by retracting the heart laterally, whereas the posterior
descending artery and posterolateral circulation are accessed by retracting the heart
cephalically.
 The LIMA is usually anastomosed to the LAD. The saphenous vein can be grafted to all
coronary arteries except LAD in rare circumstances (e.g. CABG performed for acute
anterior myocardial infarction), a saphenous vein graft may be placed to the LAD artery
for expediency.
 To accomplish the bypass, an incision is made in the distal coronary artery, and the
conduit ostium is sutured around the full circumference of the anastomosis.
 The conduit is then infused with cold cardioplegia solution, and the end is tied with a
polypropylene suture.

Techniques of Anastomosis
 Distal anastomosis Technique: It is anastomosis of vein or artery graft to the diseases
coronary artery is called distal anastomosis.
 Proximal Anastomosis Technique: It is anastomosis of vein or artery graft to the aorta.

Early Complications
 Cardiovascular dysfunction or low output syndrome can occur as a result of decreased
preload, Increased afterload, arrhythmias, cardiac tamponade, or myocardial depression
with or without mycardial necrosis.
 Postoperative bleeding can occur secondary to coagulopathy, uncontrolled hypertension,
or inadequate hemostasis.
 Cardiac tamponade results from bleeding into the pericardial sac or accumulation of
fluids in the sac, which compresses the heart and prevents adequate filling of the
ventricles. Cardiac tamponade should be suspected when there is low CO postoperatively.
 Myocardial depression (impaired myocardial contractility), which can be reversible
occurs secondary as a result of myocardial necrosis in 15 percent of all CABG surgeries.
 Perioperative Ml continues to be a serious problem that can occur in 5 percent of patients
with stable angina and up to 10 percent of patients with UA postoperatively as a result of
the surgical procedure.
 Cardiac dysrhythmias commonly occur after heart surgery ischemia, hypoxia, electrolyte
imbalances, alterations in autonomic nervous system, hypertension increased
catecholamine levels, among others, may attribute to dysrhythmia development.
 Atrial arrhythmias may occur anytime during the first 2 to 3 weeks postoperatively,
but peak incidence is 3 to 5 days.
 PVCs occur in 8.9 to 24 of patients, most frequently after CABG.
 Hypotension may be caused by inadequate cardiac contractility and reduction in blood
volume or by mechanical ventilation all of which can produce a reduction in C0.
 Pulmonary complications occur as a result of intubation and cardiopulmonary bypass.
-Continuous pulse oximetry, arterial blood gas (ABG) studies, and chest X-ray are done
frequently in order to monitor pulmonary function of a patient after heart surgery.
 Noncardiac pulmonary edema can occur immediately after surgery and can occur the
first several days after surgery as a result of increased pulmonary capillary permeability.
 Pneumothorax can occur anytime postoperatively, especially when chest tubes are
removed
 Phrenic nerve damage can occur, resulting in diaphragmatic paralysis.
 Pulmonary emboli, although uncommon, can result from atrial fibrillation, heart
failure, obesity, hypercoagulability, and immobilization.
 Elderly patients are at increased risk of developing pneumonia, atelectasis, and
pulmonary effusions.
 Renal insufficiency or failure can occur as a result of deficient perfusion, hemolysis, low
CO before and after open heart surgery, and by use of vasopressor agents to increase
blood pressure.
 GI postoperative complications can include abdominal distention, ileus, gastroduodenal
bleeding, Cholecystitis, hepatic dysfunction shock liver syndrome, pancreatitis,
mesenteric ischemia, diarrhea, or constipation.
 Neuropsychological complications postoperatively include neuropsychological
dysfunction, postcardiotomy delirium, and peripheral neurologic deficits.

Late Complications
 Postpericardiotomy syndrome (Dressler's syndrome) is a group of symptoms occurring
several weeks to months after cardiac and pericardial trauma and Ml.
 The cause of postpericardiotomy syndrome is not certain, but it may result from
anticardiac antibodies, viral etiology, or other cause.
 Postpericardiotomy syndrome occurs as the result of tissue trauma, which triggers an
autoimmune response and inflammation of the pericardial cavity resulting in pericardial and
severe pleural pain.
 Manifestations fever, malaise, arthralgias, dyspnea, pericardial effusion, and pleural
effusion and friction rub.
 Cardiac tamponade that occurs as a late complication of cardiac surgery, 1.3 of patients
and is commonly associated with administration of anticoagulants or antiplatelet therapy,
usually occurring within 2 weeks of surgery.
 Wound infections, including sternal wound infections and mediastinitis, occur in 0.4 to 5
of all patients having cardiac surgery.
 Wounds infections usually appear 4 to 14 days postoperatively with symptoms of
fever, leukocytosis, inflammation, and purulent drainage.
 Staphylococci organisms are the most common causative organism.
 VALVE SURGERY

A. Valvuloplasty
The repair, rather than replacement, of a cardiac valve is referred to as valvuloplasty.

Indications of valvuloplasty
 Aortic valve stenosis
 Mitral valve stenosis
 Pulmonary valve stenosis
 Tricuspid valve stenosis

Types of Valvuloplasty
Commissurotomy: The most common valvuloplasty procedure is commissurotomy.
 Each valve has leaflets: the site where the leaflets meet is called the commissure.
 The leaflets may adhere to one another and close the commissure (i.e. stenosis).
 Less commonly, the leaflets fuse in such a way that, in addition to stenosis, the leaflets
are also prevented from closing completely, resulting in a backward flow of blood (i.e.
regurgitation).
 A commissurotomy is the procedure performed to separate the fused leaflets.

Closed commissurotomy: Closed commissurotomy does not require cardiopulmonary

bypass.
 The valve is not directly visualized.
 The patient receives a general anesthesia, a midsternal incision is made, a small hole is
cut into the heart, and the surgeon's finger or a dilator is used to break open the
commissure.
 This type of commissurotomy has been performed for mitral, aortic, tricuspid, and
pulmonary valve disease.

Balloon valvuloplasty: Baloon valvuloplasty is another type of closed commissurotomy.

 Beneficial for mitral valve stenosis in younger patients, for aortic valve stenosis in elderly
patients, and for patients with complex medical conditions that place them at high-risk for
the complications of more extensive surgical procedures.
 Balloon valvuloplasty also has been used for tricuspid and pulmonic valve stenosis.
 Mitral balloon valvuloplasty involves advancing one or two catheters into the right
atrium, through the atrial septum into the left atrium, across the mitral valve into the left
ventricle, and out into the aorta.
 A guide wire is placed through each catheter, and the original catheter is removed.
 A large bulloon catheter is then placed over the guide wire and positioned with the
balloon across the mitral valve.
 The balloon is then inflated with at dilute angiographic solution.
 When two balloons are used, they are inflated simultaneously.
 The advantage of two balloons is that they are each smaller than the one large balloon
often used, making smaller atrial septal defects.
 As the balloons are inflated, they usually do not completely occlude the mitral valve
thereby permitting some forward flow of blood during the inflation period.
 All patients have some degree of mitral regurgitation alter the procedure.
 Other possible complications include bleeding front the catheter insertion sites, emboli
resulting in complications such as strokes, and rarely, left-right atrial shunts through an
atrial septal defect caused by the procedure.

Mitral Balloon Valvuloplasty

Leaflet repair: Damage to cardiac valve leaflets may result from stretching, shortening, or
tearing.
 Leaflet repair is for elongated, ballooning, or other excess tissue leaflets is removal of the
extra tissue.
 The elongated tissue may be folded over onto itself [i.e. tucked) and sutured (i.e. leaflet
plication).
 A wedge of tissue may be cut from the middle of the leaflet and the gap sutured closed
(i.e. leaflet resection).
 Short leaflets are most often repaired by chordoplasty.
 After the short chordae are released, the leaflets often unfurl and can resume their normal
function of closing the valve during systole.
 A piece of pericardium may also be sutured to extend the leaflet. A pericardial patch may
be used to repair holes in the leaflets.

B. Valve Replacement
If the dysfunctional valve is not suitable for repair, valve replacement may be
considered.

Types of Valve Prostheses

Bio-prosthesis valves: Bio-prosthetic heart valves are most commonly either made up of
bovine or porcine tissue.
 The main advantage of bio-prosthetic valve is that there is not typically the need for life
long blood thinning medication and therefore a significantly lower risk of bleeding.
 Although the bio-prosthetic heart valves have a lower risk of bleeding they don‘t last
long.
 The tissues of the valve itself undergo degradation and over the time valve fails.
 The structural deterioration begins typically after around 5 years and by 10-15 years a
significant number of patients have deterioration that interferes with acceptable valve
function.

Types of bio-prosthesis valves

 Xenografts: Xenografts are tissue valves; most are from pigs (porcine), but valves from
pigss (bovine) may also be used. Their viability is 7 to l0 years. They do not generate
thrombi, thereby eliminating the need for long term anticoagulation. Xenografts are used
for patients older; than 70 years of age patients with a history of peptic ulcer diseases, and
others who cannot tolerate long-term anticoagulation. Xenografts are used for all tricuspid
valve replacements.
 Homografts: Homografts, or allografts (i.e. human valves), are obtained from cadaver
tissue donations. The aortic valve and a portion of the aorta or the pulmonic valve and a
portion of the pulmonary artery are harvested and stored cryogenically. Homografts are
not always available and are very expensive. Homografts last for about 10 to 15 years,
somewhat longer than xenografts. Homografts are not thrombogenic and are resistant to
subacute bacterial endocarditis. They are used for aortic and pulmonic valve replacement.
 Autografts (i.e. autologous valves): They are obtained by excising the patient's own
pulmonic valve and a portion of the pulmonary artery for use as the aortic valve.
Anticoagulation is unnecessary because the valve is the patient's own tissue and is not
thrombogenic. The autograft is an alternative for children (it may grow as the child
grows), women of childbearing age, young adults, patients with a history of peptic ulcer
disease, and those who cannot tolerate anticoagulation.

Mechanical valves: The mechanical valves are of the ball and cage, bileaflet or disk design.
 Mechanical valves are thought to be more durable than tissue prosthetic valves and often
are used for younger patients mechanical valves are used if the patient has renal failure,
hypercalcemia, endocarditis, or sepsis and requires valve replacement.
 The mechanical valves do not deteriorate or become infected as easily as the tissue valves
used for patients with these conditions.
 Thromboemboli is significant complications associated with mechanical valves, and long-
term anticoagulation with warfarin is required.

Types of mechanical valves:

 Caged ball valve: Metal cage with several struts mounted on a circular ting, hollow metal
or plastic hall (poppett) inside of cage. For example, Start-Edwards,Sutlet,Magnvern-
Cromie valves.
 Tilting-disk valve: Mobile, lens-shaped disk attached to a circular sewing ring by two
offset transverse struts; pyrolytic carbon composition. For example, Lillehei-Kastet.
Medtronic- Hall, Chitra valve
 Bi-leaflet valve: Two pivoting semicircular disks that open centrally, mounted directly
onto a sening ring. For example, St. Jude, On-X, Carlios Medic.
 CARDIAC TRANSPLANTATION

Indications of heart transplantation

 Cardiomyopathy
 Class IV angina
 Non-obstructive hypertrophic heart disease
 Inoperable valvular heart disease
 Congenital heart disease

Selection of Heart Donors

 Brain death: Healthy young patients with complete unresponsiveness, unreceptive,
without reflex and spontaneous movements of breathing.
 Age: Younger than 55 years of age and in smokers less than 45 years of age.
 No cardiac arrest or profound hypotension after injury.
 Normal echo function and morphology.
 No valvular lesion.
 No wall movement abnormality.
 No sepsis, HIV, Hepatitis C, active malignancy, drug abuse, carbon monoxide poisoning.
 No injury to heart or concussion to heart.

Procedure
Orthotopic transplantation is the most common surgical procedure for cardiac
transplantation.
 The recipient's heart is removed and the donor heart is implanted at the vena cava and
pulmonary veins.
 Some surgeons still prefer to remove the recipient's heart leaving a portion of the
recipient's atria (with the vena cava and pulmonary veins) in place.
 The donor heart, which is usually preserved in ice, is prepared for implant by cutting
away a small section of the atria that corresponds with the sections of the recipient's heart
that were left in place.
 The donor heart is implanted by suturing the donor atria to the residual atrial tissue of the
recipient's heart, then recipient's pulmonary artery and aorta are connected to the donor
heart.

Heterotropic transplantation is less commonly performed.

 The donor heart is placed to the right and slightly anterior to the recipient's heart.
 Initially, it was thought that the original heart might provide some protection for the
patient in the event that the transplanted heart was rejected.
 Although the protective effect has not been proved, other reasons for retaining the
original heart has been identified a small donor heart or pulmonary hypertension.
 The transplanted heart has no nerve connections with the recipient's body (i.e. denervated
heart), and the sympathetic and vagus nerves do not affect the transplanted heart.
 The resting rate of the transplanted heart is approximately 70 to 90 beats per minute, but
it increases gradually if catecholamines are in the circulation.
 Patients must gradually increase and decrease their exercise (i.e. extended warm-up and
cool-down periods), because 20 to 30 minutes may be required to achieve the desired
heart rate. Atropine does not increase the heart rate of these patients.
 MINIMALLY INVASIVE CARDIAC SURGERY

 In standard cardiac surgery, the heart is arrested and circulation is maintained by placing
the patient on CPB.
 Although this procedure has been used successfully for over four decades, it has
drawbacks such as physiologic derangements associated with CPB and long hospital
stays.
 Minimally invasive cardiac surgery has evolved out of laparoscopic techniques originally
used in general and gynaecologic surgery.
 The term minimally invasive covers a variety of techniques rather than referring only to
one surgical procedure.
 Minimally invasive techniques include CABG surgery done by standard sternotomy or
rninistemotorny but without the use of CPB (off- purnp or beating heart bypass), CABG
surgery done off-pump through a small left or right anterior thoracotomy or mini-
sternotomy is called as minimally invasive direct coronary artery bypass (MIDCAB) and
port-access techniques that allow CABG and valve replacement to be done on-pump
through a small incision with videoscopic assistance and femorofemoral bypass.
 Techniques are rapidly evolving that are geared toward multi-vessel revascularization
through port access on a beating heart.
 Rather than in one approach for all patients, cardiac surgeons have a variety of surgical
techniques available depending on the patient‗: anatomy, medical history, and comorbid
conditions.

Indications of minimally invasive cardiac surgery

 Aortic valve replacement
 ASD, VSD
 CABG

Types of Minimally Invasive Cardiac Surgery

 Minimally invasive direct view CABG
 Off-pump CABG
 Robotic assisted surgery
 Port access technique

Minimally Invasive Direct CABG (MIDCAB)

 MIDCAB follows the basic premise of traditional coronary artery bypass graft surgery
(CABG), but in a truly minimally invasive fashion.
 Traditional CABG requires cardioplegia to stop the heart, the use the heart lung machine
for cardiopulmonary bypass, and long sternum-splitting incision, MIDCAB doesn't utilize
the heart lung machine; cardioplegia and only uses a tiny incision that sometimes avoids
splitting the sternal bone.
 Through small I0 to 12 cm incision in the patient‘s chest, the surgeon connects a graft to
diseased coronary arteries on a beating heart without any artificial support to the
circulation.
 Due to the nature of the operation, suturing must be done under direct vision and the
coronary artery to be bypassed must lie directly beneath the incision.
 Consequently, this procedure is only designed to bypass one or two coronary arteries.
 MIDCAB

Advantages
 Faster recovery
 Reduced morbidity/ mortality
 No risk of sternal wound infection
 LIMA/RIMA more resistant to ather0sclerosis/ increased longevity of patency
 No adverse effects related to CPB
 Lower cost
 Shorter hospital stay
 Decreased blood loss
 No aortic manipulation
 Lower intraoperative morbidity/mortality in patients with cardiogenic shock, acute
MI, or LV dysfunction
 Capable of revascularization of multiple-vessel lesions.
 Disadvantages
 Limited access and exposure to the operative area
 Technical difficulty with beating heart
 Need experienced surgeon
 Increased risk of incomplete revascuiarization
 Unable to access/visualize posterior heart for revascularization
 Procedure limits target vessels
 Acute graft occlusion and incomplete revascularization.
 OPCAB (Of Pump Coronary Artery Bypass Grafting)
 The off-pump technique, also known as OPCAB, is very similar to the conventional
coronary artery bypass grafting (CABG) procedure. OPCAB still utilizes a median
sternotomy, however the important difference is that the cardiopulmonary bypass
pump is no longer employed.
Robotically Assisted Heart Surgery
 Robotically assisted bean surgery, also called as closed-chest heart surgery, is a type of
minimally in surgery.
 The cardiac surgeon uses a specially designed computer console to control surgical
instruments on thin rob arms.
 Robotically assisted technology allows surgeons to perform certain types of complex
heart surgeries with smaller incisions and precise motion control, offering patients
excellent outcomes.
 In robotic surgery, small incisions—less than 2 inches- are used, compared with the 6 to 8
inches incision used in traditional heart surgery.

Robotically Assisted Heart Surgery

Benefits of Robotically Assisted Heart Surgery

 Small incisions
 Small scars
 Shorter hospital stay after surgery: The average stay is 3 to 5 days after robotic surgery,
while the average stay after traditional heart surgery is 7 to 10 days.
 Low risk of infection
 Low risk of bleeding and blood transfusion
 Shorter recovery time and faster return to normal activities/work: The average recovery
time after robotic surgery is 1 to 4 weeks, while the average recovery time after
traditional heart surgery is 6 to 8 weeks
 Sternotomy is not needed for robotically assisted heart surgery.
Port Access Coronary Artery Bypass Graft
 Port access CABG is another alternative to traditional CABG.
 The surgeon makes three or more incisions (ports) to perform the CABG.
 One 0.5- to 1-inch incision in the groin provides access to a femoral artery and vein.
 The femoral artery is used for a multipurpose catheter threaded retrograde through the
aorta to the ascending aorta.
 The catheter is used to return blood from CPB to the patient, to occlude the aorta by
inflating a balloon near the end of the catheter, to provide a cardioplegia solution to the
coronary arteries, and to vent air from the aortic root during the surgical procedure.
 The femoral vein is used for a catheter threaded through the vena cava to the right atrium
to drain blood from the patient for CPB, Another 0.5 to 1.0 inch (1.3 to 2.5 cm) incision
in the neck provides access to the jugular vein for two catheters.
 One catheter is threaded into the pulmonary artery to remove air, fluid, and blood that
may enter the right heart during surgery.
 The other catheter is threaded into the right atrium and the tip positioned in the coronary
sinus for retrograde infusion of the cardioplegia solution.
 One or more thoracotomy incisions, usually 2 to 3.5 inches (5 to 9cm) long, are made for
insertion of the surgical instruments.
 One of the thoracotomy ports may be used for video assisted imaging equipment.
 CPB is begun when the equipment is in place through the groin, neck, and thoracotomy
incisions.
 The balloon on the aortic catheter is inflated, and the cardioplegia solution is injected into
the coronary arteries.
 One lung may be temporarily collapsed to assist with exposing the surgical site.
 The CABG is performed through a thoracotomy incision.
 When the CABG is complete, air is vented from the pulmonary artery and aorta.
 The balloon on the aortic catheter is deflated, and CPB is discontinued.
 The surgical instruments are the catheters are removed.
 The incisions are closed.
 The patient‘s postoperative care is similar to that after traditional CABG.
 POSTOPERATIVE CARE
Patient Arrival
 Connect the patient to the monitoring system
 Connect chest tubes to suction apparatus
 Note the type and rate of intravenous infusions, isolate volume line
 Validate respiratory settings on ventilator with respiratory therapy
 Attach warming apparatus.

Initial Postoperative Assessment

To be completed within 15 minutes of arrival to ICU. Perform a brief physical
assessment and validate the status of the following:

Cardiovascular Status
 Obtain vital signs
 Obtain a cardiac profile
 Verify ECG rhythm; verify evidence of pacer capture if appropriate
 Invasive monitoring of pressures by Swan-Ganz catheter
 Note amount/quality of chest tube drainage
 Note quality of peripheral pulses, temperature and color of extremitics
 Demand pacemaker settings.

Respiratory Status
 Check ETT size and position
 Auscultate bilaterally for breath sounds, note presence of adventitious breath sounds
 Obtain O2 saturation via probe
 Obtain ABG analysis values
 Note peak pressures, expiratory volumes and minute ventilation on current ventilator
settings

Neuromuscular Status
 Validate level of conscious
 Check for pupil reactivity
 Check for quality and quantity of motor response
 Identify type and time of last dose of anesthesia, narcotic or paralyzing agent used.

Genitourinary Status
 Measure urine output.
To be completed within 60 minutes of arrival Perform a brief physical assessment and
validate the status of the following:

Integumentary Status
 Note presence and characteristics of wounds in chest, legs and arms
 Note presence and characteristics of exit sites of catheters, drains and pacemaker
wires
 Assess pressure points for erythema/potential points of break down.

Gastrointestinal Status
  Check bowel sounds
 Verify placement of nasogastric tube, if available.

Ongoing Assessment
 Obtain vital signs every I5 minutes for 4 hours and then every 1 hour until patient is
stable. Discontinue warming measures when temperature reaches 98.6 ―F.
 Obtain cardiac profiles as per hemodynamic monitoring protocol. Evaluate need for
volume, medications of withdrawal of medications.
 Monitor respiratory status as per ventilator protocol. Initiate weaning protocol when
appropriate.
 Monitor temperature of extremities, color, capillary refill, presence of edema, quality
of pulses, and motor, function and sensation.
 Monitor input and output chart. Assess need for diuretic therapy in collaboration with
surgeon.
 Monitor chest tube drainage every I5 minutes for initial 1-2 hours, then every 1 to 2
hour until removed. During
 first 2 to 24 postoperative hours, drainage should decrease to less than 30 cc/hour.
Chest tube may be removed on postoperative day 1 when chest tube output less than
80 cc for 8- 12 hours.
 Check wounds, pacemaker wires and dressings every 2 hours.
 Assess bowel sounds every 4 hours.
 Assess heart sounds, note any additional sounds or new murmurs. Assess more
frequently if the patient develops untoward changes in vital signs or significant
changes in chest tube output.
 Report the following immediately to the surgeon:
 Chest tube drainage > 100 cc/hr
 Sudden change in ECG rhythm
 Cardiac output (outside of the parameters)
 Systolic blood pressure < 90 or > 140 mm Hg
 MAP < 60 mm Hg
 Extreme shivering
 Loss of swan or arterial line
 Extreme agitation despite medication
 Any sudden or dramatic change in neurological status
 Pour ABG's or drop in Oz saturation from baseline
 Dehiscence of wounds
 Decreased urine output < 30 Cc/hour
 Temperature more than 102°F.

Ongoing Patient Care

Respiratory
 Continually monitor SaO2 saturation via probe
 Obtain ABG‘s analysis values
 Wean from ventilator as per protocol
 Turn, cough and deep breathe every 2 hours
 Post extubation, initiate respiratory care protocol
 Incentive spirometer every 1-2 hours while awake
 Assist patient in use of pillows to splint incision while coughing
 Administer oxygen as per order after extubation.

Cardiovascular
 Maintain pacemaker wires insulated and grounded
 Obtain 12-lead ECG and chest X-ray. Nutrition
 Remove NG tube post-extubation unless gastroepiploic graft
 Maintain NPO until extubated
 When extubated, progress diet as per order. Neurology Provide sedation/pain medication
as appropriate.

Fluid/Electrolytes
 Administer fluid and electrolytes as per order
 Obtain serum electrolytes values
 Weigh the patient daily.

Pain Management
 Assess patient every 1-2 hours concerning presence of discomfort and characteristics.
 Duration of pain
 Quality
 Location Radiation
 Aggravating/alleviating factors
 Quantity
 Compare and Contrast previous angina characteristics versus incisional pains, if available.
 Utilize Positioning and support techniques to promote patient comfort, e.g. splinting,
pillows, etc.
 Administer pain medications as per order.

Wound Care
 Keep dressing clean and dry, and aseptically redress wound After 24 hours open to air if
there is no drainage.
 Assess for signs and symptoms of wound infection
 Spreading erythema
 Superficial drainage
 Sternal instability (grating or clicking)
 Excessive incisional pain
 Fresh dehiscence
 Spiking fever
 Purulent drainage
 Positive blood cultures
 Marked leucocytosis
 Signs of systemic sepsis.
 NURSING DIAGNOSIS
1. Acute pain related to disruption of skin, tissue, and muscle integrity as evidenced
by alteration in muscle tone; facial mask of pain.
2. Impaired skin integrity related to altered circulation, effects of medication;
accumulation of drainage; altered metabolic state as evidenced by disruption of
skin surface/layers and tissues
3. Disturbed Sensory Perception related to chemical alteration: use of
pharmaceutical agents as evidenced by disorientation to person, place, time and
change in usual response to stimuli.
4. Risk for infection related to broken skin, traumatized tissues, stasis of body fluids
5. Risk for injury related to disorientation; sensory/perceptual disturbances due to
anaesthesia.

INTERVENTIONS WITH RATIONALE

1. Acute pain related to disruption of skin, tissue, and muscle integrity as evidenced by
alteration in muscle tone; facial mask of pain.
 Evaluate pain regularly (every 2 hrs noting  To obtain baseline data and plan further
characteristics, location, and intensity (0–10 interventions.
scale).
 Review intraoperative or recovery room  Presence of narcotics and droperidol in
record for type of anesthesia and medications system potentiates narcotic analgesia,
previously administered. whereas patients anesthetized with
Fluothane and Ethrane have no residual
analgesic effects.
 Reposition as indicated: semi-Fowler‘s;  May relieve pain and enhance circulation.
lateral Sims‘. Semi-Fowler‘s position relieves abdominal
muscle tension and arthritic back muscle
tension, whereas lateral Sims‘ will relieve
dorsal pressures.
 Provide additional comfort measures:  Improves circulation, reduces muscle
backrub, heat or cold applications. tension and anxiety associated with pain.
Enhances sense of well-being.

 Encourage use of relaxation techniques:  Relieves muscle and emotional tension;

deep-breathing exercises, guided imagery,
visualization, music.
 Provide regular oral care, occasional ice chips
or sips of fluids as tolerated.
 Document effectiveness and side and/or
adverse effects of analgesia.
enhances sense of control and may improve
coping abilities
 Reduces discomfort associated with dry
mucous membranes due to anesthetic
agents, oral restrictions.
 Respirations may decrease on
administration of narcotic, and synergistic
effects with anesthetic agents may occur.

 Administer medications as indicated:  Analgesics given IV reach the pain centers

Analgesics IV immediately, providing more effective
relief with small doses of medication.
 2. Impaired skin integrity related to altered circulation, effects of medication;
accumulation of drainage; altered metabolic state as evidenced by disruption of skin
surface/layers and tissues.
 Reinforce initial dressing and change as
indicated. Use strict aseptic techniques.
 Gently remove tape (in direction of hair
growth) and dressings when changing.
 Apply skin sealants or barriers before tape if
needed. Use hypoallergenic tape or
Montgomery straps or elastic netting for
dressings requiring frequent changing.
 Check tension of dressings. Apply tape at
center of incision to outer margin of
dressing. Avoid wrapping tape around
extremity.
 Maintain patency of drainage tubes; apply
collection bag over drains and incisions in
presence of copious or caustic drainage.
 Elevate operative area as appropriate.
 Splint abdominal and chest incisions or area
with pillow or pad during coughing or
movement.
 Apply ice if appropriate.
 Protects wound from mechanical injury and
contamination. Prevents accumulation of
fluids that may cause excoriation.
 Reduces risk of skin trauma and disruption
of wound.
 Reduces potential for skin trauma and/or
abrasions and provides additional protection
for delicate skin or tissues.
 Can impair or occlude circulation to wound
and to distal portion of extremity.
 Facilitates approximation of wound edges;
reduces risk of infection and chemical injury
to skin and tissues.
 Promotes venous return and limits edema
formation. Note: Elevation in presence of
venous insufficiency may be detrimental.
 Equalizes pressure on the wound,
minimizing risk of dehiscence or rupture.
 Reduces edema formation that may cause
undue pressure on incision during initial
postoperative period.
 POSTOPERATIVE COMPLICATIONS
Cardiac Complications
 Low cardiac output
 Cardiac tamponade
 Hypertension
 Coronary spasm
 Heart failure
 Decreased myocardial contractility.
Renal Complications
 Bleeding
 Renal failure
 Hypothermia
 Hyperkalemia
 Dysrhythmias
 Hypercalcemia
 Cardiac arrest
 Hypomagnesemia
 Dressler's syndrome
 Hypokalemia
Pulmonary Complications  Hypocalcemia
 Alelectasis  Hypermagnesemia
 Pneumothorax
Neurological Complications
 Acute lung injury
 Stroke
 Pulmonary edema
 Seizures
 Pleural Effusion
 Anxiety and depression
 Acute respiratory distress syndrome
 Phrenic nerve neuropathy
 Pneumonia
 Laryngeal nerve injury.
 Pulmonary embolism
 Encephalopathy and delirium
Gastrointestinal Complications  Cognitive decline
 Abdominal distention  Brachial plexus injury
 hock-liver syndrome  Recurrent laryngeal nerve neuropathy
 Gastroduodenal bleeding
 Diarrhea
 THORACIC SURGERIES
ANATOMY AND PHYSIOLOGY OF LUNG
 The lungs are the essential organs of respiration; they are two in number, placed one on
either side within the thorax, and separated from each other by the heart and other
contents of the mediastinum.
 The right lung usually weighs about 625gm, the left 567gm, but much variation is met
with according to the amount of blood or serous fluid they may contain.
 The lung is a cortical is shaped organ and has an apex, base, three borders (anterior,
posterior, and inferior) and three surfaces (costal, mediastinal, diaphragmatic).
 The lungs extend from the diaphragm to just slightly superior to the clavicles and lie
against the ribs anteriorly and posteriorly.
 The broad inferior portion of the lung is called as base it is concave in shape and fits over
the convex area of the diaphragm.
 The narrow superior portion of the lung is called apex.
 The lung is enclosed and protected by a double-layered serous membrane called the
pleural membrane.
 The outer layer, called the parietal pleura, lines the wall of the thoracic cavity; the inner,
the visceral pleura, lines the lungs. Between the visceral and parietal pleurae is a small
space, the pleural cavity which contains a small amount of lubricating fluid secreted by
the membranes.
 This pleural fluid reduces friction between the membranes, allowing them to slide easily
over one another during breathing.

Anatomy of lung
 Mechanism of Respiration
 Ventilation is the term for the movement of air to and from the alveoli.
 The two aspects of ventilation are inhalation and exhalation, which are brought about by
the nervous system and the respiratory muscles.
 The respiratory centers are located in the medulla and pons.
 These muscles are the diaphragm and the external and internal intercostal muscles.
 The diaphragm is a dome- shaped muscle below the lungs; when it contracts, the
diaphragm flattens and moves downward.
 The intercostal muscles are found between the ribs.
 The external intercostal muscles pull the ribs upward and outward, and the internal
intercostal muscles pull the ribs downward and inward.
 Ventilation is the result of the respiratory muscles producing changes in the pressure
within the alveoli and bronchial tree.
 With respect to breathing, three types of pressure are important:
1. Atmospheric pressure—the pressure of the air around us. At sea level, atmospheric
pressure is 760 mm Hg.
2. Intrapleural pressure or intrathoracic pressure the pressure within the potential pleural
space between the parietal pleura and visceral pleura. This is a potential rather than a real
space. A thin layer of serous fluid causes the two pleural membranes to adhere to one
another. Intrapleural pressure is always slightly below atmospheric pressure (about 756
mmHg), and is called a negative pressure. The elastic lungs are always tending to collapse
and pull the visceral pleura away from the parietal pleura. The serous fluid, however,
prevents actual separation of the pleural membranes.
3. Intrapulmonary pressure or Intraalveolar pressure the pressure within the bronchial tree
and alveoli. This pressure fluctuates below and above the atmospheric pressure during
each cycle of respiration.
 COMMON DISORDERS REQUIRING THORACIC SURGERY
TRAUMATIC INJURIES
 Penetrating chest trauma
 Blunt chest trauma
 Thoraco-abdominal trauma

INFECTIOUS DISORDERS
 tuberculosis
 Fungus Infections.

INFLAMMATORY DISORDERS
 Bronchiectasis
 Giant Emphysematous Blebs Or Bullae
 Cystic fibrosis
 Interstitial lung disease
 Pleural effusion
 Pulmonary embolism
 atelectasis

CANCER
 Bronchogenic Carcinoma
 Benign Minors
 Metastatic Malignant Tumours
 COMMON THORACIC SURGERIES

THORACIC INCISIONS
 Postero-lateral Thoracotomy
 Axillary Thoracotomy
 Anterior Thoracotomy
 Thoraco-abdominal Incision
 Median Sternotomy Incision
 Transverse Thoraco-sternotomy (Chamshell)
 Thoraco-sternotomy (Hemi-clamshell)

PULMONARY RESECTIONS
 Pneumonectomy
 Lobectomy
 Segmentectomy
 Wedge resection
 Sleeve lobectomy
 Bullectomy
 Lung volume reduction surgery
 Lung transplantation

ADVANCED SURGERIES
 Video assisted thoracic surgery
 Robotic thoracic surgery
 PREOPERATIVE CARE

History
 A critical component of the preoperative evaluation is the assessment of a patient‘s
functional status.
 Functional status is an important component of the decision algorithm for both the
pulmonary and cardiac elements of the preoperative evaluation.
 A variety of approaches have been taken to determine functional capacity.
 These include questionnaires; tests such as the 6- minute walk or stair climbing; and
cardiopulmonary exercise testing.
 One convenient approach to use is the Duke Activity Status Index (DASI), a
questionnaire that can be administered during an interview or can be self-administered.
 There is a rough correlation between the score on the DASI, which ranges from 0 to 58.2,
and maximal oxygen uptake.
 In addition, the answers to this questionnaire can be used to estimate the functional
capacity of the patient in metabolic equivalents (METs).

Important Components of History in Preoperative Evaluation

 Presenting symptoms and circumstances of diagnosis
 Prior diagnosis of pulmonary or cardiac disease
 Comorbid conditions: diabetes mellitus, liver disease, renal disease
 Prior experiences with general anesthesia and surgery
 Cigarette smoking: never, current ex-smoker
 Inventory of functional capacity of patient (e.g. Duke Activity Status Index)
 Medications and allergies
 Alcohol use, including prior history of withdrawal syndromes.

Physical Examination
 The examination of the patient includes an assessment of general overall appearance,
including signs of wasting.
 Respiratory rate and the use of accessory muscles of respiration are noted.
 Examination of the head and neck includes assessment of adenopathy and focal
neurologic deficits or signs, particularly Homer's syndrome in patients with a lung mass.
 The pulmonary examination includes an assessment of diaphragmatic motion (by
percussion) and notes arty paradoxical respiratory pattern in the recumbent position.
 The relative duration of exhalation as well as the presence or absence of wheezing should
be noted.
 The presence of tales should raise the possibility of pneumonia, heart failure, or
pulmonary fibrosis.
 The cardiac examination includes assessment of a third heart sound to suggest left
ventricular failure, murmurs to suggest valvular lesions, and an accentuated pulmonic
component of the second heart sound suggestive of pulmonary hypertension.
 The heart rhythm and the absence or presence of any irregular heartbeats is noted.
 The abdominal examination notes liver size, presence or absence of palpable masses or
adenopathy and any tenderness.
 The examination of extremities notes any edema, cyanosis, or clubbing.
 Clubbing should not be attributed to chronic obstructive pulmonary disease (COPD) and
raises the possibilities of intrathoracic malignant disease or congenital heart disease.
 The patient's gait should be observed, both as an assessment of neurologic function and to
confirm the patient's ability to participate in postoperative mobilization.

Laboratory Studies
It is reasonable practice to check electrolyte values, renal function, and cloning
parameters and to obtain ci complete blood count as pan of the preoperative assessment in
patients with known or suspected malignant disease, liver function and serum calcium
concentration should also be checked.

Imaging Studies
For patients undergoing pulmonary parenchymal resection, review of images is
essential to estimate the amount of lung that will be removed in surgery in this setting,
patients usually have a computed tomographic (CT) scan of the chest in addition to the
pathologic process for which the patient has been referred, the scan should be received for
signs of emphysema or pulmonary fibrosis m general, review of images is an important
component of surgical planning and determination of the extent of resection, which in turn
influences the process of evaluation of the patient.

Pulmonary Function Testing

The utility of preoperative pulmonary function testing in part depends on the type of
operative procedure being planned. For patients undergoing mediastinoscopy, drainage of
pleural effusions, or pleural biopsy or esophageal surgery and who have no prior history of
lung disease or unexplained dyspnea preoperative pulmonary function testing is unlikely to
contribute to the preoperative evaluation.
For patients being considered for pulmonary parenchymal resection, preoperative
pulmonary function testing should be performed. Although a variety of pulmonary function
tests have been examined in this setting, the two that have are the forced expiratory volume in
1 second (FEVI) measured during spirometrv and the diffusing capacity for carbon
monoxide. Both of these values can be used to provide a rough estimate of the risk of
operative morbidity and mortality.

Arterial Blood Gas Measurements

Commonly measured preoperatively, arterial blood gases have been used to attempt to
stratify risk of perioperative complications. Reports on the utility of arterial oxygen saturation
in preoperative evaluation are contradictory; some suggest that testing hypoxemia or
exertional desaturation identifies patients at higher risk but others fail to confirm this
association. This has led to the recommendation that patients with resting SaoO2, below 90%
have further physiologic evaluation. Common clinical dogma is that patients with a resting
pCO2, above 45 mmHg are at increased risk. Several studies, however, have demonstrated
that resection may be safely undertaken in patients with resting hypercarbia in the absence of
other contraindications to surgery.
 NURSING DIAGNOSIS

1. Ineffective airway clearance related to tracheal and bronchial obstruction as evidenced

by abnormal breath sounds and use of accessory muscles.
2. Ineffective breathing pattern related to decreased lung expansion as evidenced by
decreased breath sounds over affected lung areas.
3. Impaired gas exchange related to inflammation of airways and alveoli as evidenced by
pale, dusky skin colour.
4. Activity intolerance related to imbalance between oxygen supply and demand as
evidenced by exertional dyspnoea and tachypnoea.
5. Risk for infection related to stasis of respiratory secretions.

INTERVENTIONS WITH RATIONALE:

1. Ineffective airway clearance related to tracheal and bronchial obstruction as evidenced

by abnormal breath sounds and use of accessory muscles.

1. 1Assess the rate, rhythm, and depth of respiration,
chest movement, and use of accessory muscles.
Assess cough effectiveness and productivity.
2. Elevate the head of the bed and change position
frequently.
 To obtain baseline data and plan further
interventions.
 Doing so would lower the diaphragm and
promote chest expansion, aeration of lung
segments, mobilization, and
expectoration of secretions.

3. Teach and assist the patient with proper deep-
breathing exercises. Demonstrate proper splinting
of the chest and effective coughing while in an
upright position. Encourage the patient to do so
often.
4. Suction as indicated: frequent coughing,
adventitious breath sounds, desaturation related to
airway secretions.
 Deep breathing exercises facilitate the
maximum expansion of the lungs and
smaller airways and improve the
productivity of cough.
 Coughing is a reflex and a natural self-
cleaning mechanism that assists the cilia
in maintaining patent airways. It is the
most helpful way to remove most
secretions.
 Splinting reduces chest discomfort and an
upright position favours deeper and more
forceful cough effort making it more
effective.
 Stimulates cough or mechanically clears
airway in a patient who cannot do so
because of ineffective cough or decreased
level of consciousness.

5. Maintain adequate hydration by forcing fluids to
at least 3000 mL/day unless contraindicated
(e.g., heart failure). Offer warm, rather than cold,
fluids.
 Fluids, especially warm liquids, aid in the
mobilization and expectoration of
secretions. Fluids help maintain hydration
and increase ciliary action to remove
secretions and reduce viscosity. Thinner

6. Assist and monitor effects of nebulizer treatment
and other respiratory physiotherapy: incentive
spirometer, IPPB, percussion, postural
drainage. Perform treatments between meals and
limit fluids when appropriate.
7. Encourage ambulation.
8. Administer medications, as indicated:
secretions are easier to cough out.
 Nebulizers humidify the airway to thin
secretions and facilitate liquefaction and
expectoration of secretions.
 Postural drainage may not be as effective
in interstitial pneumonias or those
causing alveolar exudate or destruction.
 Incentive spirometry serves to improve
deep breathing and helps prevent
atelectasis.
 Chest percussion helps loosen and
mobilize secretions in smaller airways
that cannot be removed by coughing or
suctioning.
 Helps mobilize secretions and reduces
atelectasis.
 Mucolytics increase or liquefy respiratory
secretions.
 Expectorants increase productive cough
to clear the airways by liquefying lower
respiratory tract secretions and reducing
their viscosity.
 Bronchodilators are medications used to
facilitate respiration by dilating the
airways.
 Analgesics are given to improve cough
effort by reducing discomfort but should
be used cautiously because they can
decrease cough effort and depress
respirations.
 2. Ineffective breathing pattern related to decreased lung expansion as evidenced by
decreased breath sounds over affected lung areas.
1. Assess and record respiratory rate and depth
at least every 4 hours. Auscultate breath
sounds at least every four (4) hours.
Assess for the use of accessory muscle.
2. Place patient with proper body alignment for
maximum breathing pattern.
3. Encourage sustained deep breaths by:
Using demonstration: highlighting slow
inhalation, holding end inspiration for a few
seconds, and passive exhalation.
Utilizing incentive spirometer.
Requiring the patient to yawn.
4. Encourage diaphragmatic breathing for
patients with chronic disease.
5. Maintain a clear airway by encouraging the
patient to mobilize their own secretions with
successful coughing.
6. Encourage frequent rest periods and teach the
patient to pace activity.
7. Teach patient about the following:
pursed-lip breathing
abdominal breathing
performing relaxation techniques
taking prescribed medications (ensuring
accuracy of dose and frequency and
monitoring adverse effects)
scheduling activities to avoid fatigue and
provide for rest periods
 To obtain baseline data and plan further
interventions.
 A sitting position permits maximum lung
excursion and chest expansion.
 These techniques promote deep inspiration,
which increases oxygenation and prevents
atelectasis. Controlled breathing methods may
also aid slow respirations in tachypneic
patients. Prolonged expiration prevents air
trapping.
 This method relaxes muscles and increases
the patient‘s oxygen level.
 This facilitates adequate clearance of
secretions.
 Extra activity can worsen shortness of breath.
Ensure the patient rests between strenuous
activities.
 These measures allow the patient to
participate in maintaining health status and
improve ventilation.
 INTRAOPERATIVE CARE

Ventilation
 Single-lung ventilation during thoracotomy or thoracoscopy is accomplished by placing a
double-lumen tube, bronchial blocker, univent tube, or, as a last resort, a single-lumen
tube down the desired main-stem bronchus.
 Use of lower intraoperative tidal volumes during singlelung ventilation has been shown to
decrease the incidence of respiratory failure in pneumonectomy patients.
 Increased peak inspiratory pressure, decreased oxygen saturation, and increased end-tidal
CO2 during the procedure without a known etiology from the surgical field lead to a
differential diagnosis of retained secretions or blood, dislodgement of the endotracheal
tube or blocker, or contralateral pneumothotax.
 Stabilization may require reinflation of the operative-side lung if increased fraction of
inspired O2 (FiO2) administration and oxygen flow and gentle bagging by the
anesthesiologist do not improve the situation.
 Investigations and treatments include suctioning of obstructing blood or mucus,
bronchoscopy and repositioning of single-lung ventilation equipment or decompression of
the contralateral pleural space of air.

Monitoring
 Different operations require different levels of monitoring.
 ECG monitoring and continuous pulse oximetry are necessary in all cases.
 An arterial line is placed if there is a need for multiple blood samples.
 Continuous arterial pressure monitoring is useful during procedures involving mediastinal
dissection, such as transhiatal esophagectomy (THE), to gauge cardiac or great vessel
compression.
 Temperature monitoring by bladder temperature probe or esophageal temperature probe is
necessary for major procedures.
 Intravenous access should be appropriate for the invasiveness and potential blood loss of
the procedure.
 Anticipated blood loss is rarely enough to justify the need for large-bore central lines.
 However, adequate access is necessary before the procedure starts, because the arms,
chest, and groin are often inaccessible for line placement during an operation done in the
decubitus or prone position in emergency situations, a large-bore line can be placed in the
operative field via the subclavian vein, superior vena cava, inferior vena cava, or azygous
vein.

Body Temperature
 Mild hypothermia has been shown to increase events including ventricular tachycardia,
cardiac arrest, anti-myocardial infarction.
 Heat loss through thoracotomy, sternotomy, and laparotomy incisions can be lessened by
keeping the room temperature greater than 21 C. using airway heating and humidification
devices, covering portions of the patient not in the operative held and using forced-air
warming blankets.
 Warm saline lavage intrapleurally and intraperitoneally can also be performed. Rarely
intravenous fluid warmers are needed.
Positioning
 Careful positioning of the patient is of utmost importance in the operating room.
 The surgeon needs to ensure adequate access for the planned operation as well as any
potential counter incisions or chest wall resection.
 Use of muscle flaps often requires planning ahead to protect the vascular supply and leave
adequate skin coverage.
 Padding to prevent neuropathy includes the use of an axillary roll for the decubitus
position and padding of both arms.
 Stability of the patient during the operation can be achieved using a deflatable beanbag,
sand bags, laminectomy rolls and security straps or tapes.

Fluid Administration
 Fluid administration during pulmonary resection is kept to a minimum.
 If pneumonectomy is planned administration of 1L of fluid during the intraoperative
course has been advocated.
 During esophagectomy, more fluid administration may be needed because of increased
blood loss and third spacing.
 Clear communication between surgeon and anesthesiologist regarding blood loss,
hemodynamic trends, and pressor and fluid administration during the operation is crucial.
 THORACIC INCISIONS
Indications
 Penetrating chest trauma
 Blunt chest trauma
 Thoraco-abdominal trauma

Types
Posterolateral Thoracotomy
 The posterolateral thoracotomy incision is made with the patient in the lateral decubitus
position with the arms in a "praying" position.
 The skin incision is placed to provide access to the appropriate intercostal space.
 Occasionally it is helpful to outline the proposed incision with a felt-tipped marking pen.
 Most pulmonary operations are best performed through a fifth intercostal space incision.
 A similar skin incision can be used for access to the fourth through sixth intercostal
spaces.
 The extent of incision can be varied according to the procedure to be performed and
required exposure.
 The classic incision starts in front of the anterior axillary line, curves two fingerbreadths
under the tip of the scapula, and extends vertically on a line halfway between the
posterior midline over the vertebral column and the medial edge of the scapula.

Posterolateral thoracotomy

Axillary Thoracotomy
 The classic description of this incision has the patient placed in a lateral decubitus
position with the arm abducted at 90 degrees and positioned on an armrest.
 Abduction or posterior rotation beyond 90 degrees should be avoided to prevent brachial
plexus injury. The antecubital fossa over the armrest is padded.
 We have found that abduction of the arm for a fourth intercostal space or lower incision is
generally not necessary.
 Upper lobe lesions are best approached through the fourth intercostal space. Middle and
lower lobe lesions are easily handled through the fifth intercostal space.
Anterior Thoracotomy
 The anterior thoracotomy has the distinct advantage of allowing the patient to remain
supine, with a resultant improvement in cardiopulmonary function.
 It has been used with decreasing frequency because of improvement of anesthetic
techniques and development of video-assisted thoracic surgery (VATS) for lung biopsy.
 It remains the incision of choice of some surgeons for open-lung biopsy.
 It is occasionally used in the Ivor Lewis procedure for carcinoma of the esophagus to
eliminate the need for repositioning the patient after the intra-abdominal portion of the
operation.
 Its main disadvantage is the limited exposure it provides.
 A limited anterior thoracotomy should receive strong consideration when open-lung
biopsy is needed in the critically ill-patient.
 In such a patient, the traditional VATS type of lung biopsy might be inappropriate, as it
would require a double-lumen endotracheal tube and single lung ventilation for a time.

Anterior Thoracotomy

Thoracoabdominal Incision
 The thoracoabdominal incision provides extended exposure, particularly for operations in
the lower thorax and upper abdomen.
 It can be particularly useful for difficult operations involving the lower esophagus and
gastroesophageal junction and is used for open thoracoabdominal aortic operations.
 The patient is placed in the lateral decubitus position and the hips are allowed to rotate
posteriorly, imparting a twist to the torso.
 A seventh- or eighth-intercostal space incision is extended on the same oblique line into
the upper quadrant toward the midline.
 The costal margin is cut with a knife.
 The incision can be extended interiorly on the abdomen in either a median or paramedian
fashion.
 A curvilinear or radial incision can be made in the diaphragm to facilitate ex-posure.

Median Sternotomy Incision

 Median sternotomy is the most common thoracic incision, as it is used in the vast
majority of cardiac operations.
 It is also the incision of choice for many anterior mediastinal lesions and bilateral
procedures, such as the resection of multiple pulmonary lesions.
 Median sternotomy is occasionally useful for anterior transpericardial repair of
postpneumonectomy bronchopleural fistula.
 A partial upper median sternotomy can be useful for exposure of the lower cervical and
upper thoracic esophagus and for thymectomy.

Transverse Thoracosternotomy (Chamshell)

 The transverse thoracostemotomy is often referred to as the clamshell or crossbow
incision.
 Its primary role in recent years has been for bilateral lungtran splantation.
 However, it is an altemative to median sternotomy for bilateral general thoracic surgical
procedures such as me resection of bilateral metastatic lesions to the lungs and large
anterior mediastinal masses.
 The incision is made over the fourth or fifth intercostal space, and the sternum is
transected with an oscillating saw.
 Both internal mammary vascular bundles are identified and ligated.
 Closure is accomplished with pericostal sutures of heavy polyglycolic acid, with a figure-
of-eight maneuver about the sternum.

Transverse Thoracosternotomy (Chamshell)

Thoracosternotomy (Hemi-clamshell)
 The hemi-clamshell incision provides outstanding exposure to the apex of the chest and
the anterosuperior mediastinum.
 Large or apical tumors and trauma to the subclavian or innominate vessels are the most
common indications.
 The incision includes a partial sternotomy and anterior thoracotomy and may include a
cervical extension.
 A second-intercostal space (instead of a fourth) thoractomy may be used in the resection
of apical tumors and anterior spine exposures.

Thoracosternotomy (Hemi-clamshell)
 PULMONARY RESECTIONS

Pneumonectomy
 A surgical procedure in which an entire lung is removed.

Indications
 Carcinoma
 Bronchiectasis
 tuberculosis

Procedure
 A pneumonectomy is most often done for cancer of the lung that cannot be treated by
removal of a smaller portion of the lung.
 The removal of an entire lung (pneumonectomy) is performed chiefly for cancer when the
lesion cannot be removed by a less extensive procedure.
 It also may be performed for lung abscesses, bronchiectasis, or extensive unilateral
tuberculosis.
 The removal of the right lung is more dangerous than the removal of the left, because the
right lung has a larger vascular bed and its removal imposes a greater physiologic burden.
 A posterolateral or anterolateral thoracotomy incision is made, sometimes with resection
of a rib.
 The pulmonary artery and the pulmonary veins are ligated and severed. The main
bronchus is divided and the lung removed.
 The bronchial stump is stapled, and usually no drains are used because the accumulation
of fluid in the empty hemithorax prevents mediastinal shift.
Lobectomy
When the pathology is limited to one area of a lung, a lobectomy (removal of a lobe of
a lung) is performed. Removal of two lobes is called bilobectomy.

Indications
 Bronchogenic Carcinoma
 Giant Emphysematous Blebs Or Bullae
 Benign Minors
 Metastatic Malignant Tumours
 Bronchiectasis
 Fungus Infections.

Lobectomy
Segmentectomy
 Some lesions are located in only one segment of the lung.
 Bronchopulmonary segments are subdivisions of the lung that function as individual
units.
 They are held together by delicate connective tissue.
 Disease processes may be limited to a single segment.
 Removal of this single segment is called segmentectomy.
 Care is taken to preserve as much healthy and functional lung tissue as possible,
especially in patient who already have limited cardiopulmonary reserve.

Segmentectomy
Wedge Resection
 A wedge resection is a surgical procedure during which the surgeon removes a small,
wedge- shaped portion of the lung containing the cancerous cells along with healthy
tissue that surrounds the area.
 The surgery is performed to remove a small tumor or to diagnose lung cancer.
 A wedge resection is performed instead of a lobectomy (removing a complete lung lobe)
when there is a danger of decreased lung function if too much of the lung is removed.
 A wedge resection can be performed by minimally-invasive video-assisted thoracoscopic
surgery (VATS) or a thoracotomy (open chest surgery).

Wedge resection
Sleeve Lobectomy
 A surgical procedure that removes a cancerous lobe of the lung along with part of the
bronchus (air passage) that attaches to it.
 The remaining lobe(s) is then reconnected to the remaining segment of the bronchus.
 This procedure preserves part of a lung, and is an alternative to removing the lung as a
whole (pneumonectomy).

Sleeve Lobectomy

Bullectomy
 Bullectomy is the surgical removal of a bulla, which is an air pocket in the lung that is
greater than one centimeter in diameter (across).
 Bullae tend to occur as a result of lung tissue destruction and diseases such as cancer and
emphysema.
 Their presence in the lung takes up space, causes pressure and blocks the breathing.

Bullectomy
Lung Volume Reduction Surgery
 Lung volume reduction surgery involves the removal of a portion of the diseased lung
parenchyma (20 to 30%), through a midsternal incision or video thoracoscopy.
 The diseased lung tissue is identified on a lung perfusion scan.
 Lung volume reduction surgery allows the functional tissue to expand, resulting in
improved elastic recoil of the lung and improved chest wall and diaphragmatic
mechanics.
 This type of surgery does not cure the disease, hut it may decrease dyspnea, improve lung
function, and improve the patient‘s overall quality of life.
 Careful selection of patients for this procedure is essential to decrease the morbidity and
mortality.

Lung volume reduction surgery

 VIDEO-ASSISTED THORACIC SURGERY (VATS)
 It involves insertion of a long, thin tube (called a thoracoscope) through a small incisions,
or port.
 This procedure involves three or four 1-inch incisions made on the chest that allow the
thoracoscope and instruments to be inserted and manipulated.
 Video-assisted thoracoscopy improves visualization because the surgeon can view the
thoracic cavity on the video monitor.
 The thoracoscope is equipped with a camera that magnifies the image on the monitor.
 For more extensive operations, such as lung resection for cancer, an extra incision
measuring about 5 cm is made for the removal of the lung tissue.
 There are many benefits of VATS when compared with a conventional thoracotomy
procedure.
 These include less adhesion formation, minimal blood loss, less time under anesthesia,
shorter hospitalization, faster recovery, less pain, and less need for postoperative
rehabilitation therapy because of minimal disruption of thoracic structures.

Indications
 Lung biopsy
 Lobectomy
 Resection of nodules
 Repair of fistulas.

VATS
 ROBOTIC THORACIC SURGERY
 It is performed using the da Vinci Surgical System.
 This sophisticated robotic approach, like VATS, gives the surgeon access inside the chest
cavity through tiny incisions.
 The surgeon controls the robots movements from a nearby console in the operating room.
 The robotic system provides improved visualization (using three dimensional
technology), better access to mediastinal tissues, and improved ability to remove lymph
nodes as part of a cancer operation.

Robotic Thoracic Surgery

 POST-OPERATIVE CARE
MEDICAL MANAGEMENT
Fluid Management
 Fluid administration for lung resection patients must be determined on an individual
basis.
 Vasodilation secondary to use of local anesthetic in epidural catheters, and the use of
antihypertensive medications justify careful administration of fluid to maintain blood
pressure and adequate end-organ perfusion.
 The guidelines regarding postoperative fluid management:
(1) at maximum of 20 mL/kg fluid to be given intravenously for the first 24
postoperative hours.
(2) acceptance of average urine output of 0.5 mL/kg/hr the first 24 hours, and
(3) use of vasopressors if tissue perfusion is inadequate and the 20 mL/kg maximum of
fluid has already been administered.
 Other manipulations such as lowering the dose of the epidural infusion or removing the
local anesthetic component of the epidural infusion and leaving only narcotic may
decrease sympathetic blockade and vascular vasodilation.

Blood Administration
 No hemoglobin level or hematocrit has been documented as being a threshold for
recommending transfusion.
 In critically ill patients with cardiovascular disease, a hemoglobin level of 7.0 to 9.0 g/dL
is well tolerated.
 Although intuition argues that a higher hemoglobin level provides better oxygen delivery,
the increased oxygen extraction by most organs and tissues when stressed negates the
need for a higher hemoglobin level.
 This is not true for the heart, which extracts most of the oxygen delivered under
nonstressed physiologic conditions and requires increases in blood flow to increase
oxygen delivery with physiologic stress.
 For critically ill-patients with acute cardiac ischemia, increased mortality was found with
a restrictive transfusion protocol.

Medications
 Each patient's preoperative medications should he reviewed before restarting them
postoperatively.
 Often, antihypertensive medications need to be held for several doses until fluid shifting
and equilibrium are attained to prevent continued hypotension.
 We recommend restarting beta-blocker therapy as soon as possible after the operation to
prevent rebound tachycardia. This also decreases the occurrence of atrial fibrillation and
of rapid ventricular response should postoperative atrial fibrillation occur.
 Administration of postoperative antibiotics for more than 48 hours has not been
definitively proven to decrease the amount of pneumonia or wound infection in thoracic
surgical patients.
 Many patients suffer from nausea after general anesthesia or postoperative pain
medications.
 Antiemetics such as metoclopramide, ondansetron, promethazine, trimethobenzamide,
and prochlorperazine can help.
 Stress ulcer prophylaxis is now recommended for high-risk surgical patients only.
 H2-receptor blockers or proton pump inhibitors should be continued in patients who
demonstrate reflux on barium swallow tests postoperatively, have symptoms of heartburn,
or have a history of Barrett's disease.
 Vagotomized patients may benefit from the prokinetic effects of erythromycin or
metoclopramide.
 However, erythromycin may cause gastrointestinal upset and metoclopramide can
produce extrapyramidal symptoms.
 Use of low-molecular-weight heparin, low-dose unfractionated heparin, or sequential
compression devices continues until the patient is reliably walking at least four times a
day for patients with a low risk for deep venous thrombosis.

NURSING MANAGEMENT
Nutrition
 Adequate nutrition is of paramount importance in the postoperative period.
 Most lung resection patients can be started on clear liquids or a regular diet in the evening
of surgery.
 A more cautious approach may be necessary if there is concern about a difficult airway or
a higher risk of respiratory failure.
 Nausea and vomiting are fairly common after general anesthesia, and narcotic
medications may magnify the problem.
 If liquids are tolerated, the patient's diet can be advanced starting the day after surgery.
 These patients need to be counseled preoperatively and postoperatively about taking most
of their fluid between meals, eating smaller portions more frequently during the day, and
avoiding foods such as dry bread, raw vegetables, large chunks of meat, and foods and
fluids that increase gas reduction in the immediate postoperative period.
 Providing patients at discharge with a list of eating tips and foods to avoid is
recommended.

Respiratory Therapy
 The most common complications after thoracic surgery are related to the pulmonary
system.
 Vigilant postoperative pulmonary care decreases the incidence of complications.
Incentive spirometry and chest physiotherapy, including clapping, postural drainage, and
vibratory therapy, aid in mobilizing mucous secretions and allowing patients to clear their
own secretions.
 Cough can be stimulated and secretions suctioned by placing a soft suction catheter
through the nose and into the trachea Ambulation is an excellent method of decreasing
atelectasis.
 Nebulized albuterol is very helpful in curtailing or preventing bronchospastic episodes.
 If a patient has had multiple manipulations of the upper airway and there is concern about
edema and stridor, intravenous and aerosolized steroids and aerosolized racemic
epinephrine are effective in reducing edema.

Wound Care
 Incision care is usually routine if the skin is closed.
 Open wounds historically are packed with gauze moistened with saline, dilute antibiotic
solution, sodium hypochlorite (Dakin's) solution, acetic acid solution, or dilute Betadine
solution.
 Newer dressings, including siliconeimpregnated dressings, thin polyurethane films,
hydrocolloids, alginates, polyurethane foams, and hydrogels, are available, although there
are no strong data to recommend the use of one over the other or gauze.
 Vacuum dressings can be placed in clean wounds and can speed the healing process.
 Open chests for bronchopleural fistula are packed with gauze soaked in antibiotic solution
until a decision is made about definitive closure.
 If muscle or skin flaps are raised and there is the potential for seroma formation, drains
may be left and binders or ace bandages can be considered.
 Depending on the muscle rotation used and the tautness of the closure, restriction of range
of motion may be required for several days to prevent tension and dislodgement or
compromise of flap vascular supply.

Management of Drainage Tubes

 Placement and removal of chest tubes should be standardized by protocol after lung
resection.
 Tubes are left in as long as any air leak remains, but recent studies indicate that earlier
transition from water suction to water seal is not harmful and promotes quicker resolution
of parenchymal air leakage.
 Fluid drainage of 300 to 400 mL or less per 24 hours is acceptable for chest tube removal
after lung resection.
 Chest tube removal after pleurodesis for malignant pleural effusion has a stricter volume
requirement, as these patients are known to have problems absorbing pleural fluid
normally.
 Chest tube removal after drainage of chylothorax or empyema must be tailored to the
particular patient‘s course.
 When there is any concern about anastomotic leak in the chest or mediastinum after
esophageal resection or tracheal reconstruction, tubes should be left until resolution of the
leakage.
 Mediastinal tubes are left after median sternotomy is performed for removal of bilateral
lung tumors, lung reduction surgery, or mediastinal mass resection.

Physical Therapy
 Exercise therapy after lung resection benefits patients by decreasing pulmonary
complications, restoring mobility and independence, and decreasing the potential for deep
venous thrombosis.
 Pulmonary rehabilitation is designed specifically to help patients clear secretions,
strengthen respiratory muscles, and provide cardiopulmonary exercise, a patient who
requires continuous chest tube suction can exercise on a stationary bicycle in the hospital
room.
 NURSING DIAGNOSIS
1. Ineffective breathing pattern related to decreased lung expansion as evidenced by
reduced vital capacity.
2. Acute pain related to disruption of skin, tissue and muscle integrity as evidenced by
pin scale score 8/10.
3. Disturbed sensory perception related to use od pharmaceutical agent as evidenced by
disorientation to time, place and person.
4. Anxiety related to change in health status as evidenced by decreased self-assurance.
5. Deficient knowledge related to lack of exposure as evidenced by statement of
misconception.

INTERVENTION WITH RATIONALE

 Disturbed sensory perception related to use od pharmaceutical agent as evidenced by
disorientation to time, place and person.

1. Reorient patient continuously when emerging
from anaesthesia; confirm that surgery is
completed.
2. Speak in normal, clear voice without
shouting, being aware of what you are saying.
Minimize discussion of negatives within
patient‘s hearing. Explain procedures, even if
patient does not seem aware.
 As patient regains consciousness, support and
assurance will help alleviate anxiety.
 The nurse cannot tell when patient is aware,
but it is thought that the sense of hearing
returns before patient appears fully awake, so
it is important not to say things that may be
misinterpreted. Providing information helps
patient preserve dignity and prepare for
activity.

3. Evaluate sensation and/or movement of  Return of function following local or spinal

extremities and trunk as appropriate. nerve blocks depends on type or amount of
agent used and duration of procedure.

4. Use bedrail padding, restraints as necessary.  Provides for patient safety during emergence
state. Prevents injury to head and extremities
if patient becomes combative while
disoriented.

5. Secure parenteral lines, ET tube, catheters, if  Disoriented patient may pull on lines and
present, and check for patency. drainage systems, disconnecting or kinking
them.

6. Maintain quiet, calm environment.  External stimuli, such as noise, lights, touch,
may cause psychic aberrations when
dissociative anaesthetics (ketamine) have
been administered.

7. Reassess sensory or motor function and  Ambulatory surgical patient must be able to
cognition thoroughly before discharge, as care for self with the help of SO (if available)
indicated. to prevent personal injury after discharge.
  Anxiety related to change in health status as evidenced by decreased self-assurance.
1. Provide preoperative education, including
visit with OR personnel before surgery when
possible. Discuss anticipated things that may
concern patient: masks, lights, IVs, BP cuff,
electrodes, bovie pad, feel of oxygen cannula
or mask on nose or face, autoclave and
suction noises, child crying.
2. Introduce staff at time of transfer to operating
suite.
3. Prevent unnecessary body exposure during
transfer and in OR suite.
4. Give simple, concise directions and
explanations to sedated patient. Review
environmental concerns as needed.
5. Control external stimuli.
6. Discuss postponement or cancellation of
surgery with physician, anesthesiologist,
patient, and family as appropriate.
 Can provide reassurance and alleviate
patient‘s anxiety, as well as provide
information for formulating intraoperative
care. Acknowledges that foreign environment
may be frightening, alleviates associated
fears.
 Establishes rapport and psychological
comfort.
 Patients are concerned about loss of dignity
and inability to exercise control.
 Impairment of thought processes makes it
difficult for patient to understand lengthy
instructions.
 Extraneous noises and commotion may
accelerate anxiety.
 May be necessary if overwhelming fears are
not reduced or resolved.
 POST-OPERATIVE COMPLICATIONS

Early Complications
 Respiratory failure
 Pulmonary edema
 Atelectasis/ pneumonia
 Acute respiratory distress syndrome

Late Complications
 Bronchopleural fistula
 Wound Infection and empyema
 Post-thoracotomy pain
 Bronchovascular fistula
 LATEST RESEARCH 1
Title:
Correlating oxygen delivery on cardiopulmonary bypass with Society of Thoracic Surgeons
outcomes following cardiac surgery

Research done by:

Trend Magruder, Stuart Wisses, Et. Al

Background
The relationship between low oxygen delivery (DO2) on cardiopulmonary bypass and
morbidity and mortality following cardiac surgery remains unexamined.

Methods
 They reviewed patients undergoing Society of Thoracic Surgeons index procedures from
March 2019 to July 2020, coincident with implementation of a new electronic perfusion
record that provides for continuous recording of DO2 and flow parameters.
 Continuous perfusion variables were analyzed using area-over-the-curve (AOC)
calculations below predefined thresholds (DO2 <280 mL O2/min/m2, cardiac index
<2.2 L/min, hemoglobin < baseline, and mean arterial pressure <65 mm Hg) to quantify
depth and duration of potentially harmful exposures.
 Multivariable logistic regression adjusted by Society of Thoracic Surgeons predicted-risk
scores were used to assess for relationship of perfusion variables with the primary
composite outcome of any Society of Thoracic Surgeons index procedure, as well as
individual Society of Thoracic Surgeons secondary outcomes (eg, mortality, renal failure,
prolonged ventilation >24 hours, stroke, sternal wound infection, and reoperation).

Results
 Eight hundred thirty-four patients were included; 42.7% (356) underwent
isolated coronary artery bypass grafting (CABG), whereas 57.3% underwent nonisolated
CABG (eg, valvular or combined CABG/valvular operations).
 DO2 <280-AOC trended toward association with the primary outcome across all cases
(P = .07), and was significantly associated for all nonisolated CABG cases (P = .02)—
more strongly than for cardiac index <2.2-AOC (P = .04), hemoglobin <7-AOC (P = .51),
or mean arterial pressure <65-AOC (P = .11).
 Considering all procedures, DO2 <280-AOC was independently associated prolonged
ventilation >24 hours (P = .04), an effect again most pronounced in nonisolated-CABG
cases (P = .002), as well as acute kidney injury <72 hours (P = .04).
 Patients with glomerular filtration rate <65 mL/min and baseline hemoglobin <12.5 g/dL
appeared especially vulnerable.

Conclusion
 Low DO2 on bypass may be associated with morbidity/mortality following cardiac
surgery, particularly in patients undergoing nonisolated CABG. These results underscore
the importance of goal-directed perfusion strategies.
 LATEST RESEARCH 2
Title:
Surgical Outcomes in a Large, Clinical, Low-Dose Computed Tomographic Lung Cancer
Screening Program

Research done by:

Bryan Walker, Christiana Williamson, Et. Al

Background
Lung cancer screening with low-dose computed tomography is proven to reduce lung cancer
mortality among high-risk patients.
However, critics raise concern over the potential for unnecessary surgical procedures
performed for benign disease as a result of screening.
They reviewed our outcomes in a large clinical lung cancer screening program to assess the
number of surgical procedures done for benign disease, as we believe this is an important
quality metric.

Methods
They retrospectively reviewed our surgical outcomes of consecutive patients who underwent
low-dose computed tomography lung cancer screening from January 2012 through June 2014
using a prospectively collected database.
All patients met the National Comprehensive Cancer Network lung cancer screening
guidelines high-risk criteria.

Results
 There were 1,654 screened patients during the study interval with clinical follow-up at
Lahey Hospital & Medical Center.
 Twenty-five of the 1,654 (1.5%) had surgery.
 Five of 25 had non-lung cancer diagnoses: 2 hamartomas, 2 necrotizing granulomas,
and 1 breast cancer metastasis.
 The incidence of surgery for non-lung cancer diagnosis was 0.30% (5 of 1,654), and the
incidence of surgery for benign disease was 0.24% (4 of 1,654).
 Twenty of 25 had lung cancer, 18 early stage and 2 late stage.
 There were no surgery-related deaths, and there was 1 major surgical complication (4%)
at 30 days.

Conclusions
The incidence of surgical intervention for non-lung cancer diagnosis was low (0.30%) and is
comparable to the rate reported in the National Lung Screening Trial (0.62%). Surgical
intervention for benign disease was rare (0.24%) in our experience.
 SUMMARY
The most common surgical procedure encountered is the Aorto-Coronary Bypass Graft
(ACBG) for various indications such as left main coronary artery stenosis, severe triple-
vessel disease, angina refractory to medical therapy, or recurrent CHF due to ischemia. Other
surgical procedures, concomitantly with ACBG or alone, include valve repair or
replacements, repair of congenital or acquired defects (ASD, VSD, etc.), and repair or
replacement of the aortic root. Less common are removal of intracardiac tumors and LV
aneurysmectomy.
To perform the surgery, the patient is usually put on "pump" or cardiopulmonary
bypass (CPB). This involves cannulation of the right atrium and aorta (and later cross-
clamping of the aorta), allowing the entire cardiac output to bypass the patient's heart and
lungs. Blood flow is maintained using a pump and the blood is oxygenated via a membrane
oxygenator incorporated into the circuit. Several myocardial preservation techniques are used
to protect the heart from ischemic damage during this period. Cardioplegic arrest is induced
using a hyperkalemic solution to induce asystole and thus decrease myocardial metabolism
and oxygen consumption. The heart is usually cooled. The patient is also usually systemically
cooled to < 32 C to minimize peripheral oxygen consumption.
While "on pump", the patient's BP and cardiac output are controlled by by the
perfusionist and also the anesthesiologist by means of vasoactive medications and inotropes.
During this time, the patient must by systemically anticoagulated with heparin to an ACT
>400 to prevent clotting in the bypass circuit. Long pump times are associated with increased
post-operative complications such as bleeding, myocardial stunning, and multi-system organ
failure. CPB also seems to be associated with the induction of a systemic inflammatory
response syndrome (SIRS). It is sometimes difficult to liberate the patient from CPB or "get
him off pump." That is, to restart the heart contracting normally. Pressors or inotropes are
often used in order to aid "coming off pump." A variety of dysrhythmias also may occur
during this period including bradycardias requiring pacing. Most often, these dysrhythmias
are transient and resolve.
In the past few years, more cases are being done with "beating heart" or "off pump".
The advantages of Off-pump Coronary Artery Bypass (OPCAB) are that the patient is not
exposed to the possible deleterious effects of CPB. In some operations involving the aortic
root, cross- clamping and cannulation of the aorta are not feasible. In these situations the
technique of Deep Hypothermic Circulatory Arrest (DHCA) may be used. The patient is
systemically cooled as much as possible (usually below 28 C) and a large dose of barbiturates
are given as a neuro- protective agent. The circulation is then completely arrested for a brief
period of time to allow completion of the surgical anastomosis.
 REFERENCES
BOOK REFERENCE
1. PR Ashalata ―Textbook of anatomy and physiology for nurses‖, 4 th edition
2015, Jaypee publication, Page no.: 424 – 427
2. P Hariprasath ―Textbook of Cardiovascular and thoracic nursing‖, 1 st
edition 2016, Jaypee publication, Page no.: 3 - 300, 379 – 487
3. Lewis Sharanmantik, Heitkemper Margaret Mclean, Shannon Ruff Dirksen,
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nursing: Assessment and management of clinical problems, 6th edition
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4. Joyce M Black and Jane Hawks, ―Medical-surgical nursing: Clinical
management for positive outcomes‖, 8 th edition, Elsevier; page no:. 1342-
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ONLINE REFERENCES
1. www.abdominalkey.com/cardiopulmonary-bypass/
2. http://www.cardiothoracicsurgeryservices.com/
3. www.nursingcenter.com
4. www.mayoclinic.org/departmentscenters/cardiovascularsurgery/sections/ov
ervie