BY

RAMYA SAJU

Post Basic BSC Nursing

Kasaragod1

Introduction

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Definition

“Procedure in which occluded coronary

arteries are bypassed with the patient’s

own venous or arterial blood vessels or own venous or arterial blood vessels or

synthetic grafts” (Ignatavicius &

Workman, 2010).

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Review of Coronary Arteries

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�The major vessels of the coronary circulation are the left main coronary that divides into left anterior descending and circumflex branches, and the right main coronary artery.

�The left and right coronary arteries originate at the base of the aorta from openings called the coronary ostia located behind the aortic valve leaflets.

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�The left and right coronary arteries and their

branches lie on the surface of the heart, and

therefore are sometimes referred to as the

epicardial coronary vessels.

�These vessels distribute blood flow to

different regions of the heart muscle.

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Purposes

� Restore blood flow to the heart

�Relieves chest pain and ischemia

�Improves the patient's quality of life

�Enable the patient to resume a normal lifestyle

�Lower the risk of a heart attack

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Indications for CABG

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Contraindications for CABG

�Aneurysms

�Valvular diseases

�Congenital diseases

�Diseases of blood

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Types of Coronary Artery Bypass

Grafting

1. On pump Coronary Artery Bypass Grafting

2. Off-Pump Coronary Artery Bypass Grafting

3. Minimally Invasive Direct Coronary Artery

Bypass Grafting

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Traditional Coronary Artery Bypass

Grafting

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Off-Pump Coronary Artery Bypass Grafting

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Minimally Invasive Direct Coronary Artery

Bypass Grafting

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• Robotic-assisted coronary artery bypass grafting

is a minimally invasive procedure.

• The surgeon makes several small incisions

between the ribs, and then inserts a small

camera and small robotic arms through the camera and small robotic arms through the

incisions.

• During the procedure, the surgeon sits at a

console and controls the robotic instruments.

• The camera that was inserted provides images

of the heart at a high magnification.15

Common source grafts

Arterial Conduits.

Left Internal Thoracic (Mammary) Artery

(LIMA).

The ITA arise from subclavian artery just above The ITA arise from subclavian artery just above

and behind the sternal end of the clavicle

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Radial Artery

�The second artery that can be used as

arterial conduit for coronary graft is Radial

Artery (RA).

� The RA arises from the bifurcation of the � The RA arises from the bifurcation of the

brachial artery in the cubital fossa and

terminates by forming the deep palmar arch

in the hand.

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Ulnar Artery

• when surgeons do not have other choice

they use Ulnar Artery as arterial conduit.

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Gastroepiploic artery

The Gastroepiploic artery is sometimes used as

an arterial graft when the IMA cannot reach the

posterior surface of the heart or when other

conduits are not availableconduits are not available

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Greater Saphenous Vein (GSV)

• The Greater Saphenous Vein (GSV) of the

lower extremity is the best choice.

GSV is harvested in two different ways:

�Directly through multiple incisions �Directly through multiple incisions

tunnelling over the vein along the medial

thigh and leg

�Endoscopic vein harvest two small

incisions are made, one above the knee, and

the second upper thigh for this type of

harvest. 22

Multiple incisions and tunneling

Endoscopic vein harvest

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Procedure

• An endotracheal tube is inserted and secured by

the anaesthetist and mechanical ventilation is

started. General anaesthesia is maintained by a

continuous very slow injection of Propofol.continuous very slow injection of Propofol.

• The chest is opened via a median sternotomy

and the heart is examined by the surgeon

involves creating a 6 to 8 inch incision in the

chest (a thoractomy) .

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Sternotomy

Posterior Thoracotomy

Anterior Thoracotomy

Sternotomy with

Subxiphoid Laparotomy Distal Sternotomy

Transverse Curved Laparotomy

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• The bypass grafts are harvested – frequent

conduits are the internal thoracic arteries, radial

arteries and saphenous veins.arteries and saphenous veins.

• When harvesting is done, the patient is given

heparin to prevent the blood from clotting.

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• "on-pump", the surgeon sutures cannulae into

the heart and instructs the perfusionist to start

cardiopulmonary bypass (CPB).

• Once CPB is established, the surgeon places

the aortic cross-clamp across the aorta and

instructs the perfusionist to deliver

cardioplegia to stop the heart and slow its

metabolism

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Final view of the anastomosis

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when there is concern about multiple anastomoses on aorta,

surgeon can construct two or more distal anastomoses with a

single vein graft.

Sequential Distal Vein Graft Anastomoses

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• Chest tubes are placed in the mediastinal and

pleural space to drain blood from around the heart

and lungs.

• The sternum is wired together and the incisions

are sutured closed.

• The patient is moved to the intensive care unit

(ICU) to recover.

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• Nurses in the ICU focus on recovering the patient by

monitoring blood pressure, urine output and

respiratory status as the patient is monitored for

bleeding through the chest tubes.bleeding through the chest tubes.

• If there is chest tube clogging, Thus nurses closely

monitor the chest tubes and under take methods to

prevent clogging so bleeding can be monitored and

complications can be prevented.32

Complications of CABG

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Nursing Management

• Pre operative Phase • Pre operative Phase

• Intra operative Phase

• Post operative Phase

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Patient History

• Patient history of major illness, previous

surgery, medications, and usage of drugs and

smoking and drug history

• A systematic assessment of all systems

performed ,with emphasis on cardiovascular

functioning

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Physical Examination

�Functional status of the cardiovascular system

determined by reviewing the patient symptoms,

including past and present experience

�Chest pain, hypertension, palpation, cyanosis,

breathing difficulty, leg pain that occur with breathing difficulty, leg pain that occur with

walking, Orthopnea, peripheral edema.

�Because alteration in cardiac function (cardiac out

put can affect renal, respiratory, gastrointestinal ,

integumentary, hematological, and neurological

functioning ).

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Physical Examination continued…..

�General appearance and behavior.

�Vital signs

�Nutritional and fluid status ,weight, height.

�Inspection and palpation of the heart, noting the �Inspection and palpation of the heart, noting the

point of maximal impulses ,abnormal pulsation.

�Auscultation of the heart ,noting pulse rate, rhythm

and quality S4 and S3 , murmur, and friction rib

�Jugular venous pressure

�Peripheral pulses

�Peripheral edema 37

Psychosocial Assessment

�Meaning of the surgery to the patient and family

�Coping mechanisms that are being used

�Measures used in the past to deal with stress

�Anticipated changes in life style

�Support system in effect

�Fears regarding the present and future

�Knowledge and understanding of the surgical

procedure.

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Nursing Diagnoses

•  Acute pain

•  Decrease cardiac output

•  Risk for infection

•  Risk for alteration in fluid volume & electrolyte

imbalance imbalance

•  Risk for impaired gas exchange

•  Risk impaired renal perfusion

•  Impaired skin integrity

•  Anxiety

•  Fear

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Discharge Planning & Teaching

� What to expect at home

� Pain in your chest around the incision area

� Swelling in the leg at harvest site

�Itchiness or tingling feeling at incision site

�Weakness

� Cardiac rehabilitation

�Lifestyle & diet modification

�Smoking cessation

�Cardiac diet (Low salt, low cholesterol, low fat)

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Discharge Planning & Teaching continued…

� Activity

�No driving for at least 4 to 6 weeks

�Walking / climbing stairs are good exercise

�Light household chores (folding clothes, setting tables

�Self care�Self care

� Shower & wash incision gently with soap and water

� Do not use hot tubs until incision is completely healed

�Adhere to all medication regimen

�Have someone stay with you in your home for at least

first 1-2 weeks

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summary

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Reference

1. Brunner & Suddarth's Textbook of Medical-Surgical

Nursing, Thirteenth edition, 2013, Elsevier publications.

2. www.ncbi.nlm.nih.gov/pubmed/23859277

3. Mark Shikhman, Coronary Artery Bypass Grafting

(CABG) (Part 1) lecture constructed based on (CABG) (Part 1) lecture constructed based on

publications by leading cardiothoracic American

surgeons.

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BY

RAMYA SAJURAMYA SAJU

Post Basic BSC Nursing

Kasaragod

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