Surgery
The story of a broken heart
From day 1 to discharge
THE TERMINOLOGY
LIMA/
RIMA- left or right internal mammary artery
EVH- Endovascular vein harvest
OHS- open heart surgery
POD- Post op day
LAAL- Left atrial appendage
Ligation
PVI- Pulmonary Vein Isolation
CABG- Coronary Artery Bypass
Graft
COMMON
PRE-OP
ORDERS
**SEE BINDER IN UNIT FOR PAPER ORDERS OR
FOLLOW THIS LINK TO VIEW ALL http:// phsintranet.pinnaclehealth.org/collectionCat egorized2.aspx?id=20737418239 PRE-OP
InpatientAka- IN THE HOSPITAL
•
• May be scheduled, urgent, or emergent
• From cath lab
• From ER
• From MD office
• From another facility
• *Waiting in the facility because they are too unstable to go home and wait •
•
Outpatient
Aka- FROM HOME
• After a large MI
• After scheduled cath or other positive diagnostic test • Symptoms are mostly controlled • * Stable enough to go home and wait
• *may need significant time to recover before surgery is safe if post MI
PRE-OP TEACHING
- Give them the pre-op booklet
- May watch “preparing for heart surgery” video
- ISB teaching
- Pain scale and importance of pain medication - Importance and expectation of early & frequent ambulation and use of bipap
- Teach heart pillow for splinting
- Give them “the tentative plan”
- Average post op length of stay is 3-5 days
- Be sure there are no skin conditions or rashes - Must remove all jewelry pre-op
U/A
PRE-OP
TESTING
C&S
MRSA SWAB
CBC, CMP, PT/INR, PTT
**Open heart screen = 2 pink tubes for type and cross, timed for different times. Place 4 units on hold.
Hemoglobin A1C
EKG
CXR
Pulmonary function tests
Carotids
Echo
TEE if severe valve disease
BGM on call to OR
PRE-OP PAPERWORK
***Consent
(PAs fill out, RN can
get signed)
Blood consent
Anesthesia checklist
Online pre-procedure checklist – follow instructions for printed materials MEDS TO GIVE
Antibiotic
MEDS TO HOLD
sent to OR with
patient
CABG only- amiodarone 2 days before surgery
Beta blocker within 24 hours of surgery
Aspirin 81mg
Heparin gtt- turn off on call to
OR (when they come to get the patient you turn it off)
Possible nitro gtt for active chest pain or nitro paste otherwise Lovenox
24 hrs before
surgery
ACEs/ ARBs at least
48-72 hours before surgery Plavix, Effient,
Coumadin, Xarelto,
Eliquis at least 5-7 days preop
MEDICATIONS
This is why we hold ACE inhibitors- they will cause vasodilation that is difficult to combat post-op OTHER IMPORTANT INFO PRE-OP
Hibiclens
bath- night before and morning of surgery
Clipping of excess hair all over before last hibiclens bath
BGM on call to OR
NPO after midnight- morning meds with a sip of water
Endocrine consult pre-op if uncontrolled/ undiagnosed diabetic
PCCMA consult pre-op if COPD/ poor PFT component Hibiclens Bath
Evening
before and morning of surgery
PTs must be assisted with this.
Use new basin for each bath.
Use fresh washcloth and half the bottle
Wash the chest first, scrub in vigorous circular motions Get all folds, crevices, even feet!
Wash groin last
Repeat a second time with the second half of the bottle and a fresh washcloth
Place new disposable leads on the patient after the bath
Surgeries
CABG
https://www.youtube.com/watch? v=bYbNmbR-fCY Valve
https://www.youtube.com/watch? v=AkymZ_eQN5w LAAL
https://www.youtube.com/watch? v=6GQXcnSfu5o PVI
Cox
Maze
https://www.youtube.com/watch? v=q4iCEbww3Bk CABG
VALVES
LAAL / PVI
COX- MAZE –
Afib treatment of choice
The surgical technique “maze” is performed by making cuts and seams in the atria.
ARTERY
LIMA/
VEIN
RIMA
RADIAL
EVH
HARVESTS
BYPASS MECHANICS
BY
PA
SS
EF
FE
C
TS
O
N
B
O
D
Y
LUNGS
DECREASED BLOOD FLOW
POSSIBLE ATELECTASIS
DECREASED GAS
EXCHANGE
INCREASE IN PULMONARY
VASCULAR RESISTANCE
-
-
BRAIN
DECREASED CEREBRAL
PERFUSION
RISK FOR EMBOLI
ENDOCRINE
INCREASED
CATECHOLAMINES
INCREASED STRESS
HORMONES
HYPERGLYCEMIA
-
-
-
-
KIDNEY
DECREASED BLOOD
FLOW