Cardiovascular Surgery and Nursing

NURSING

Nursing: Cardiovascular Surgery

After going through sections of the given book and watching a video of cardiovascular surgery, the indications and risk factors for bypass graft, aortic replacement, and valve replacement surgery include age, previous heart surgery, serum creatinine level, peripheral or cerebral vascular disease, left main artery coronary artery stenosis, and left ventricular ejection fraction, etc. (Gardner et al., 2004).

The most common diagnoses observed in patients who have undergone cardiovascular surgery are:

· Coronary artery disease: This disease is triggered by plaque formed around the walls of the arteries responsible for pumping blood to the heart and other body parts (Centers for Disease Control and Prevention, 2021).

· Non-ST elevation myocardial infarction (NSTEMI): It is a type of heart attack but less harmful than the actual one since the damage caused to the heart is lower than a real heart attack (Baptist Health, n.a.). It is most commonly caused by tobacco products, hypertension, low involvement in physical activities, the possible presence of diabetes, family history for the illness or genetics, being overweight, and the presence of certain medical conditions.

· S.T. elevation myocardial infarction (STEMI) is caused by transmural myocardial ischemia that leads to myocardial injury or necrosis (Akbar et al., 2021). The EKG changes, chest pain, and myocardial ischemia are still confirmed for inclusion in this injury with abnormal cardiac biomarkers.

· Aortic aneurysm: The large artery carrying blood from the heart towards the chest is the aorta in which a balloon-like bulging is called, referred to as aortic aneurysm (Centers for Disease Control and Prevention, 2021). When the blood is forced through this bulge, it causes the splitting of the artery, resulting in blood leaks and bursts, called dissection and ruptures, respectively, being the most common causes of death.

· Aortic stenosis (AS): When the heart’s aortic valve contracts and does not allow the blood flow to fully reach the main artery to the body coming from the heart, the blood flow is reduced, causing this particular condition (Mayo Clinic, 2021).

· Mitral valve disease: When the working condition of the mitral valve, lying between the left atrium and left ventricle, is disturbed, such as not closing accurately that might result in backward flow or leakage of the blood backward in the left atrium, then the said condition prevails (Mayo Clinic, 2020).

· Diabetes type 2 is the malfunctioning of the blood regulation when it uses sugar (glucose) as fuel, and excessive circulation of sugar in the blood causes a chronic condition in patients (Mayo Clinic, 2021).

· Chronic kidney disease is the condition in which gradual loss of kidney functioning is experienced that constantly damages the kidney over time (Mayo Clinic, 2021). The wastes in the body become difficult to get rid of, and healthy body functioning is troubled.

· Hyperlipidemia is a condition wherein the blood in the body has too many fats or lipids (Cleveland Clinic, 2021). It leads to causing of blockage in the blood vessels and high cholesterol, leading to heart attacks.

· Obesity: The excessive formation of fat and its accumulation in the body causes obesity, creating a high risk of certain unsafe body conditions (World Health Organization, n.a.). A body mass index (BMI) of over 25 is considered dangerous for this condition.

· Hypertension: The prevalence of high blood pressure that includes increased pressure levels in the blood vessels is called hypertension (World Health Organization, n.a.). The force with which the blood has to be pumped against the walls of the blood vessels is risky for the heart, making it weak gradually.

The concepts for the diagnoses as mentioned earlier are:

· Coronary artery disease: Tissue integrity, infection, perfusion

· Non-ST elevation myocardial infarction (NSTEMI): Functional ability

· ST-elevation myocardial infarction (STEMI): Functional ability

· Aortic aneurysm: Inflammation, perfusion

· Aortic stenosis (AS): Functional ability, perfusion

· Mitral valve disease: Functional ability

· Diabetes type 2: Cellular regulation

· Chronic kidney disease: Immunity, patient-centered care, system-based practice

· Hyperlipidemia: Metabolism, immunity, clotting

· Obesity: Nutrition, metabolism, immunity, mobility

· Hypertension: Nutrition, metabolism, immunity

The concept map of the above diagnoses is as below:

Obesity

Hyperlipidemia

Type 2 diabetes

Hypertension

Chronic kidney disease

Mitral valve disease

Aortic stenosis

Aortic aneurysm

STEMI

NSTEMI

Coronary artery disease

The indications, actions, and side effects of the following medications specifically related to cardiovascular surgery are:

· Adenosine: For patients who have undergone cardiac operations, a study revealed that giving them a safe amount of Adenosine, which is a 5-minute infusion of 140 µg that was followed by ten minutes of washing out before cardioplegic arrest, can lead to protein kinase C (PKC)-mediated signaling pathway (Belhomme et al., 2000). The actions could be observed in the preconditioned situation; however, reducing cell necrosis after coronary artery surgery is still not evident. There are no visible adverse effects related to this medication for this specific purpose.

· Lidocaine: It has been studied that the use of Lidocaine during coronary artery bypass surgery reduces the likelihood of myocardial injury in patients undergoing the procedure (Lee et al., 2011). 2% of the medication is inserted in the anesthesia for effective results. The action could be seen in the form of lower concentrations 24 hours after the surgery. The possible side effects could include twitching, shakes or trembles, seizures, low heart rate, muscle stiffness or pain, weakened or shallower breathing, etc. (Frankel Cardiovascular Center, n.a.).

· Ketamine is used as an anesthetic drug that causes lesser respiratory and cardiovascular depression for patients undergoing cardiac surgery (Mazzeffi, Johnson & Paciullo, 2015). It is indicated to be used after making a solution in water or sometimes prepared for oral consumption depending upon the metabolism. The side effects include tachycardia in patients with cardiovascular artery disease and unpleasant psychotropic effects resulting from extensive use as a sedative (Mazzeffi, Johnson & Paciullo, 2015).

· Propofol: A study revealed that continuous infusion of this anesthetic drug at a rate of 2 mg/kg/h with the solution in 50 cc 0.9% sodium chloride solution, pumped into the patient at a rate of 0.4 µg/kg/hr creates low blood pressure, lower levels of myocardial enzymes in patients undergoing cardiac surgery (Elgebaly et al., 2020). The side effects include preload, which is suggested to be managed by giving fluid sensibly or by uplifting legs to improve venous return.

· Etomidate: It is indicated that it should be injected via intravenous route, and the amount should be 0.2 to 0.3 mg/kg for 30 to 60 seconds (Williams, Boyd & Fitzgerald, 2021). The side effects include adrenal insufficiency that results in poor outcomes for high-risk cardiac surgery (Wagner et al., 2014).

· Epinephrine: The standard dose of this medication is believed to be 1.0 mg depending on the body weight (“Part 6: advanced cardiovascular life support”, 2000). It has been witnessed that it acts positively for coronary perfusion pressure and brings improvements in ROSC. For patients suffering from heart problems or arrest, a high dose has proved beneficial. No adverse effects have been observed if the dosage has been increased, specifically in CPR circumstances (“Part 6: advanced cardiovascular life support”, 2000).

· Heparin: The indications for its dosage were mentioned in one of the researches, which was 150U/kg of porcine heparin being injected into patient’s central venous line after determining the baseline activated clotting time (ACT) with blood sampling (Chun et al., 2011). The side effects include 1 to 5% of the patients having post-surgery bleeding and when the blood platelets count is perceived to be low, usually referred to as thrombocytopenia (Klingele et al., 2020)

· Isuprel: The normal dosage of this medication is through injection by intravenous infusion or intravenous bolus injection (Rx List, 2021). It could be seen when cardiac arrests occur, or possibilities of adverse cardiac functioning are predicted in Adam-Stokes attacks. The side effects include hypertension, ventricular arrhythmias, pulmonary edema, angina, etc. (Rx List, 2021).

· Lincomycin: It is now known as Vancomycin, which is indicated to be used 15mg/kg before cardiac surgery instead of its usual dosage of 1g (Movahed, Kasravi & Bryan, 2004). The side effects have been studied to include unpredictable risk of hypotension, particularly in cardiac surgery (Valero et al., 1991).

· Cefazolin: The indications for its dosage include 1 or 2g depending on the patient’s body weight who is undergoing cardiac surgery, recommended 60 minutes before incision (Calic et al., 2018). Its actions include the effectiveness in removal of infection before cardiac surgeries. There are no major adverse effects of this medication, except those who are hypersensitive to certain medications.

· Milrinone: The indications for its dosage include 25 to 50 mcg/kg in a low amount infused through intravenous administration (Ayres & Maani, 2021). The actions have been seen in the prevention of hypertension and cardiac failure for cardiac surgery patients. The side effects of this medication signify an increase in all-cause mortality in comparison with the use of dobutamine (Nielsen et al., 2018). Also, high peak plasma levels are observed, decrease in systemic vascular struggle and venous return that results in hypotension has been noted as side effects (Levy, Bailey & Deeb, 2002).

· Phenylephrine: The dosage recommended for this medication is 0.25 mcg/kg/min to 1.0 mcg/kg/min (Clinical Trials.gov, 2020). The actions are seen in the form of reduced hypotension and treatment of low blood pressure during surgery (Mayo Clinic, 2021). The side effects occur when low blood pressure is not managed effectively, aggravating systolic and diastolic blood pressure levels (Stavert et al., 2015).

· Nitroprusside: The dosage indicated for this medication is 0.3 mcg/kg/min for infusion that may go to a maximum of 10 mcg/kg/min and 5 minutes before monitoring the blood pressure (Drugs.com, 2021). The actions could reduce inflammatory responses occurring during the surgery (Gibson, Davis & Bradford, 2017). Post-operative hypertension could be one of the side effects of this medication, for which it is suggested that other agents should be considered as well (Gibson, Davis & Bradford, 2017).

· Nitroglycerine: The indications include normal blood pressure and infusion with a dose of 80 +/- 4.7 mug/min (Kapla, Dunbar & Jones, 1976). The actions were seen in the form of decreased myocardial oxygen demand and relief in myocardial ischemia. No adverse effects have been reported explicitly for the drug until now.

· Papaverine: Its actions could be seen in LIMA spam easing for dissection in cardiac operations since the dosage of 0.8 mg/mL to 1.5 mg/mL is among the most suitable ones (Girard et al., 2004). This drug is considered safe and effective to be used for cardiac surgeries, especially for increasing mean blood flow of the left internal thoracic (mammary) artery (LITA or LIMA) (Siddiqeh, 2018).

· Sodium bicarbonate: The indications for its dosage are suggested to be 0.5 mmol/kg according to body weight for over one hour after anesthesia. Its actions are observed in the prevention of kidney damage during cardiac surgeries. The side effects could be witnessed in reducing kidney toxins, thus resulting in precise functioning of the kidneys post-operation (Haase et al., 2013).

The nurses should include certain tests and examinations immediately in the first 24 hours’ time period after cardiovascular surgery, such as patient’s history, physical examination, lab tests, body warming, checking for any possible bleeding, hemodynamic management procedures, tamponade, and use of necessary medical assisting devices (Melanson, 2001).

Three self-care measures the nurse will teach the post cardiovascular surgery patient entails caring for wounds, managing parent’s weight by himself, and taking medicines on time (C.S. Mott Children’s Hospital, 2020). Along with this, there are other crucial steps, such as making healthy lifestyle changes, taking a balanced diet, and regularly attending cardiac rehabilitation for long-term improvement in heart and lung health.

The video related to cardiovascular surgery showed some important steps taken for the patient undergoing surgery (Nucleus Medical Media, 2009). The video is informative for a patient undergoing the said surgery since the patient would know what to expect from the operations. For example, it has steps that the patient should take before and after the surgery. The patient must be aware of the process that would be attempted so that he does not remain fearful of the surgery as information about a major operation would release him if his fears related. This video is the best way to let the patient know about the surgical procedure and what would happen after surgery. Making the patient aware of the procedure beforehand creates high chances for the surgery’s success as it would help answer most of the concerns from the patient’s side and give him medical support.

References

Akbar, H., Foth, C., Kahloon, R.A., & Mountfort, S. (2021, August 9). Acute S.T. elevation myocardial infarction. In StatPearls [Internet]: StatPearls Publishing. Available at https://www.ncbi.nlm.nih.gov/books/NBK532281/

Ayres, J. K. & Maani, C.V. (2021, August 6). Milrinone. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532943/

Baptist Health. (n.a.). What is an NSTEMI? https://www.baptisthealth.com/services/heart-care/conditions/non-st-elevation-myocardial-infarction

Belhomme, D., Peynet, J., Florens, E., Tobourtine, O., Kitakaze, M. & Menasche, P. (2000). Is adenosine preconditioning truly cardioprotective in coronary artery bypass surgery? The Annals of Thoracic Surgery, 70(2), 590-594.  https://doi.org/10.1016/S0003-4975(00)01502-2

Calic, D., Ariano, R.E., Arora, R.C., Grocott, H.P., Lakowski, T.M., Lillico, R. & Zelenitsky, S.A. (2018). Evaluation of cefazolin antimicrobial prophylaxis during cardiac surgery with cardiopulmonary bypass. Journal of Antomicrobial Chemotherapy, 73(3), 768-771. https://doi.org/10.1093/jac/dkx439

Centers for Disease Control and Prevention. (2021, September 27). What is aortic aneurysm? https://www.cdc.gov/heartdisease/aortic_aneurysm.htm

Centers for Disease Control and Prevention. (2021, July 19). What is coronary artery disease? https://www.cdc.gov/heartdisease/coronary_ad.htm#:~:text=Related%20Pages,This%20process%20is%20called%20atherosclerosis.

Clinical Trials.gov. (2020, October 26). Low dose vasopressin vs. phenylephrine in cardiac surgery. https://clinicaltrials.gov/ct2/show/NCT04602767

Chun, D., Baik, S., Kim, S.Y., Shim, J.K., Kim, J.C. & Kwak, Y.L. (2011). Heparin responsiveness during off-pump coronary artery bypass graft surgery: Predictors and clinical implications. Acta Pharmacologica Sinica, 32. https://doi.org/10.1038/aps.2010.180

Cleveland Clinic. (2021, September 8). Hyperlipidemia. https://my.clevelandclinic.org/health/diseases/21656-hyperlipidemia

C.S. Mott Children’s Hospital. (2020, August 31). Coronary artery bypass graft surgery: Self-care for recovery. https://www.mottchildren.org/health-library/ue4714abc

Drugs.com. (2021, July 15). Nitroprusside dosage. https://www.drugs.com/dosage/nitroprusside.html

Elgebaly, A.S., Fathy, S.M., Sallam, A.A. & Elbarbary, Y. (2020). Cardioprotective effects of propofol-dexmedetomidine in open-heart surgery: A prospective, double-blind study. Annals of Cardiac Anesthesia, 23(3), 134-141. https://doi.org/10.4103/aca.ACA_168_18

Frankel Cardiovascular Center. (n.a.). Lidocaine injection. https://www.umcvc.org/health-library/d00059v1

Gardner, S.C., Grunwald, G.K., Rumsfeld, Cleveland, J.C., Schooley, L.M., Gao, D., J.S., Grover, F.L., McDonald, G.O. & Shroyer, A.L. (2004). Comparison of short-term mortality risk factors for valve replacement versus coronary artery bypass graft surgery. The Annals of Thoracic Surgery, 77(2), 549-556. https://doi.org/10.1016/S0003-4975(03)01585-6

Gibson, C. M., Davis, S., & Bradford, D. (2017). Examining the use of sodium nitroprusside in coronary artery bypass grafting: Is the benefit worth the cost? Hospital Pharmacy, 52(7), 502–507. https://doi.org/10.1177/0018578717722538

Girard, D.S., Sutton, J.P., Williams, T.H., Crumbley, A.J., Zellner, J.L., Kratz, J.M. & Crawford, F.A. (2004). Papaverine delivery to the internal mammary artery pedicle effectively treats spams. The Annals of Thoracic Surgery, 78, 1295-1298. https://doi.org/10.1016/j.athoracsur.2004.01.061