Page 75 - Critical Care Notes

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Management
■ Postoperative care: Monitor vital signs and intake and output.
■ Monitor central venous pressures.
■ Check femoral sites, dressings for drainage, hematoma, erythema.
■ Assess bilateral lower extremities for warmth, color, sensation, and movement
every 15 min for first hour, then hourly × 4 hr (or per hospital protocol).
■ Keep affected limb straight for 8 hr.
■ Head of bed should be elevated no more than 30°.
■ Maintain bedrest for 12–24 hr post procedure; then the patient must ambulate.
■ Assess neurological status frequently.
■ Medicate for pain as needed.
■ Administer IV fluids as ordered for 24 hr postop.
■ Monitor CBC and BMP labs.
■ Provide continuous ECG monitoring.
■ Administer clopidogrel (Plavix).
Endoscopic (Minimally Invasive) Coronary Artery
Bypass Graft
■ This less invasive cardiac surgical technique employs smaller incisions and
totally “robotic” surgery using a computer-enhanced telemanipulation sys-
tem. Saphenous vein harvesting can also be accomplished through small
incisions using video-based surgical techniques, decreasing the morbidity
associated with leg incision (pain, infection) and permitting more rapid
recovery.
■ The term minimally invasive CABG is applied to procedures that use alter-
natives to standard median sternotomy and off-pump CABG or on-pump
CABG when a sternotomy is utilized. Two alternative techniques are used:
beating heart CABG surgery and MID CABG off pump.
■ Less invasive minimal access CABG surgeries emphasize the use of a limit-
ed thoracotomy incision as an alternative to a sternotomy, with either direct
thoracoscopic or robotic-assisted left and right internal mammary artery
harvesting and direct LIMA to coronary artery anastomotic techniques for
myocardial stabilization.
■ Beating heart CABG surgery is performed with specialized platforms that
enable myocardial surface stabilization and limit myocardial motion and by
use of temporary endovascular shunts to limit ischemia.
■ MID CABG off pump: The pericardium is opened, and cardiac motion is
limited by the creation of accurate technical anastomosis and designed
to minimize disruption of the adjacent beating heart. Cardiac motion can
further be limited by use of pharmacological interventions that temporarily
decrease the heart rate or cause transient cardiac asystole for several
seconds. Refer to CABG surgery for the detailed description of the actual
bypass procedure.
CV