Page 325 - ACCCN's Critical Care Nursing

302 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

Assessment and Management of Regardless of low mortality rates, the possibility of death
Postoperative Pain and painful wounds can concern patients. Consequently,
As much an art as a science, pain control in the cardiac patients undergoing cardiac surgery often experience
surgical patient remains a major challenge and continues anxiety and depression, which can be distressing for
37–39
to provide uncertainty and opportunities for nursing cli- patient and family. Women appear to be more vulner-
nicians and researchers. Principles are similar to those able to these emotions in relation to cardiac surgery than
40
outlined in Chapter 7. Surgical pain, often complicated men. Although it is normal and potentially protective
by pericardial inflammation, results in differing pain to experience anxiety, higher levels of these emotions can
types, requiring different approaches. These different be destructive. Anxiety and depression are predictive of
34
approaches to pain management must be balanced worse postoperative outcomes, including poorer psycho-
against the promotion of spontaneous breathing, chest social adjustment and quality of life, more cardiac symp-
41
physiotherapy, mobilisation, and participation in educa- toms and readmissions. Therefore, it is essential to
tion and lifestyle modification programs. consider and address anxiety and depression when pro-
viding care for cardiac surgical patients.
Analgesic options include intravenous, oral or rectal anal- Preoperative preparation provided by nurses usually
gesics, antiinflammatories and, less commonly, epidural incorporates information and support, so that patients
therapies and nerve blocks. Intravenous opiates and and their families are familiar with procedures and can
codeine/paracetamol preparations provide the mainstay cooperate during recovery. However, seeing a patient
42
of postoperative analgesia. When insufficient, or when who is successfully recovering from surgery may instil
clinical and electrocardiographic features suggest pericar- more confidence. Patients who have had their surgery
ditis, antiinflammatory agents such as rectal indometha- postponed or who have been operated on in an emer-
cin are appropriate. The place of IV COX-2 inhibitors gency setting may need additional support. For many
such as parecoxib appear uncertain, as analgesic efficacy patients, fast-track procedures, including admission on
now must be weighed against emerging data suggesting day of surgery, early extubation and early discharge pro-
increased thrombotic complications. 35
cesses, decrease the discomfort associated with being
Fluid and Electrolyte Management away from home and surgical costs. For other patients
there is too little time to be informed and understand
Fluid therapy in the postoperative period is aimed at postoperative and post-discharge care. Also, critical path-
maintaining blood volume, replacing recorded and ways for cardiac surgery do not include assessing the
insensible losses, and providing adequate preload to patient’s psychological state, so nurses must take care to
sustain haemodynamic status. Isotonic dextrose solu- consider this aspect. Consequently, family members
tions (5%) or dextrose 4% + saline 0.18% are commonly assume an important role in supporting patients and
used at approximately 1.5 L/day as maintenance fluids. 14
helping them understand recovery requirements. It is
Potassium replenishment is generally necessary accord- vital that family members understand and anticipate a
ing to measured serum potassium. Polyuria is usually certain amount of anxiety and depression, particularly in
evident in the early postoperative period due to deliber- the first week post-discharge. Family members may also
ate haemodilution while on cardiopulmonary bypass. be distressed by seeing their loved one ill and the unfa-
With polyuria comes potassium losses, which must be miliar ICU environment and equipment, so the addi-
treated to avert atrial or ventricular ectopy and tachyar- tional requirement for them to assess and support the
rhythmias. Because of these predictable potassium losses, patient may be onerous. Printed information regarding
protocols for potassium replacement may be instituted, the surgery, recovery and emotions will be useful for the
with standing orders for potassium replacement (e.g. patient and family.
10 mmol over 1 hour if the serum potassium is
<4.5 mmol/L, or 20 mmol over 2 hours if <4.0 mmol/L). INTRA-AORTIC BALLOON PUMPING
Main line hydration infusions may also have added
potassium to avoid hypokalaemia. Hypomagnesaemia Intra-aortic balloon pumping (IABP) is a widely-used cir-
may also develop due to polyuria, and is likewise proar- culatory assist therapy that has become straightforward
rhythmic. Supplementation (magnesium chloride) is in application and relatively free of complications. 43,44
often used for arrhythmia management postoperatively, The primary aim of IABP is to assist restoring an existing
but its effectiveness has been questioned in many trials. 36 imbalance between myocardial oxygen supply and
demand. The main indications are for cardiogenic shock,
Hyperkalaemia occurs less often but is seen particularly myocardial infarction or ischaemia and weaning from
when there is impaired renal function. Additional con- cardiopulmonary bypass. The combined effects of increas-
tributors to a rising potassium level include acidosis, ing cardiac output and mean arterial pressure (increasing
administration of stored blood, haemolysis, inotrope use, oxygen supply) and decreasing myocardial workload
and any postoperative use of depolarising muscle relax- (reducing oxygen demand) make IABP therapy ideal for
ants such as suxamethonium.
the management of infarct-related cardiogenic shock,
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Emotional Responses and Family Support for which IABP should be regarded as a standard
The experience of being diagnosed with a cardiac disor- management.
der, waiting for surgery, the surgical experience and recov- IABP therapy involves placement of a balloon catheter in
ery is an emotional journey for patients and their families. the descending thoracic aorta. This catheter is most