NURSING
 
TITLE: Bypass, Cardiopulmonary: Post-Operative Care (Initial 24 Hours) (Adult Patient)
 
PURPOSE: To outline the nursing management of the adult patient who has undergone surgery requiring cardiopulmonary bypass.
 
LEVEL: Interdependent (*requires MD order)
 
SUPPORTIVE DATA: Many patients experiencing cardiac and thoracic surgery require cardiopulmonary bypass (CPB). CPB is used to facilitate tissue oxygenation during surgical procedures, such as coronary artery bypass grafting, cardiac valve replacement or repair, thoracic aortic aneurysm repair, and heart or heart/lung transplantation. CPB and its concomitant therapies of hemodilution, hypothermia, anticoagulation, and cardioplegia can result in dramatic fluid and electrolyte imbalances, catecholamine storm, and hemorrhage. Immediate postoperative nursing care focuses on recovering the patient from the effects of CPB and anesthesia.

ASSESSMENT:

1. Assess upon arrival to the CT-ICU:
•blood pressure
•heart rate and rhythm
•O2 saturation by pulse oximeter (SpO2)
•temperature
•pulses in all 4 extremities
•respiratory rate
•pain level
•CVP, PA pressures, CO, CI, SVR
•SvO2 (if oximetric PA catheter used) or ScO2 (if continuous cardiac output catheter used)
•vasoactive/inotropic drip concentrations
•urine output
•chest tube output
• JP output
•epicardial pacing wires/generator settings
NOTE: Provide care according to Nursing Protocol Pacing, Epicardial: Wires & Pacemaker (Post-op) [Adult] Protocol.
•surgical dressings

2. Assess on post-op admission, every 15 minutes x 4, every 30 minutes x 2, then every 1 hour and prn while titrating vasoactive and inotropic medications:
•blood pressure
•heart rate
•heart rhythm
•respiratory rate
•oxygen saturation

3. Assess every hour while titrating vasoactive and inotropic medication, then every 4 hours and p.r.n.:
•CVP, PA pressures, CO/CI, SVR
•SvO2 (if oximetric PA catheter used), or ScO2 (if continuous cardiac output catheter used)

4. Assess every hour, then change to every 2 hours and prn when patient is without pharmacological or mechanical ventilatory support:
•respiratory rate
•heart rate and rhythm
•blood pressure
•temperature
•O2 saturation by pulse oximeter
•urine output
ASSESSMENT: •chest tube drainage
•mediastinal tube drainage
•JP drainage
• Pain score (either verbal or NAPS)

*5. Draw mixed venous gas on admission, every 24 hrs, and p.r.n. for calibration if oximetric PA catheter in place.
LABS/DIAGNOSTIC
STUDIES:

*6. Obtain within 30 minutes of admission:
•ABG with ionized calcium
•SvO2 (measured by Blood Gas Lab), oximetric PA catheter only
•Na, K, Cl, BUN, Cr, CO2, glucose, magnesium, phosporus
•CBC
•PT/PTT/INR for chest tube output >200mL/hr
•chest X-ray
•12 lead ECG

*7. Obtain 6 hours after admission:
• Na, K, Cl, BUN, Cr, CO2, glucose, magnesium, phosporus
•CBC

*8. Obtain on post-op Day 1:
•Na, K, Cl, BUN, Cr, CO2, glucose
•CBC
•PT, INR, PTT if patient had valve replacement
•chest x-ray every morning until chest tubes are removed

REPORTABLE CONDITIONS/ NOTIFY M.D.:

9. Notify M.D. of the following hemodynamic parameters:
•cardiac index <2 L/min/m2
•MAP <60 or >90 mmHg.
•SBP >140 mmHg of < 90mmHg.
•SvO2 <60%

10. Notify M.D. of:
•cardiac dysrhythmias
•changes in sensorium
•temperature =35° or >38.5° C
•urine output <30mL/hr x 2 hours (since last void or foley removed)
•chest tube & JP drainage >100 mL/hr. x 2 hours

11. Notify M.D. of laboratory values when:
•hematocrit <28%
•PaO2 <70 mmHg
•SaO2 = 90%
•PaCO2 <30 or >50 mmHg.
•pH <7.35 or >7.5
•ionized Ca++ <4.5 mEq/L

REPORTABLE CONDITIONS/ NOTIFY M.D.

12. Notify M.D. STAT of signs of cardiac tamponade as evidenced by:
•cardiac index <2 L/min/m2
•heart rate >130 bpm
•muffled/distant heart tones
•pulsus paradoxus >15mm Hg during inspiration
•elevated PAD >20 mmHg, CVP >20 mmHg.
•narrowing pulse pressure--systolic blood pressure <90mm Hg with diastolic blood pressure >70 mmHg
•distended neck veins
•SvO2 < 60 % or changed by 10%

CARE:

13. Receive report from OR Anesthesiology staff to include:
•vital signs including most recent temperature
•location of lines and drains
•PA pressures
•history (to include all abnormal physical findings)
•allergies
•surgical procedures
•duration of cardiopulmonary bypass and aortic cross clamp
•hemodynamic profile in OR, current vasoactive/inotropic drips
•crystalloid/colloid infusion totals
•urine output in OR
•most recent potassium, magnesium and glucose
•most recent hemoglobin
•anesthetic agents/ volume administrated
•pre-op baseline data
•last antibiotic dose

*14. Institute ventilator weaning protocol when patient is awake and initiating
own breaths.

*15. Apply warming blanket for core temperature <36°C.
NOTE: Provide care according to UNC Hospitals Nursing Procedure Warming Blanket: Warm Touch® or Warming Blanket: Bair Hugger® and remove blanket when patient’s temperature reaches 36.5° C.

16. Observe airstrips for drainage every shift.

17. Turn every 2 hours. Head of bed 30-40 degrees unless medically contraindicated.

EMERGENCY MEASURES:

18. CARDIAC TAMPONADE, HEMORRHAGE (MEDIASTINAL DRAINAGE > 200mL/HR x 1 hrs)
•STAT page M.D.
•prepare for emergency sternotomy/ return to O.R.

19. SYMPTOMATIC DYSRHYTHMIAS:
•STAT page M.D.
•Provide care according to Guidelines for Handling Specific Emergency Situations located in Critical Care Policy manual online.

PATIENT/CAREGIVER

TEACHING:

20. Orient to purpose of monitoring and supportive equipment and devices.

21. Review visitation policies and unit routine for patient/ caregiver.

22. Evaluate family/caregiver’s knowledge and level of understanding of instructions.

DOCUMENTATION:

23. Document on Progress Notes, Patient Care Record/flowsheet, Patient Education Index or electronic record:
•implementation of Post-Operative Care (Initial 24 hours) of the Adult Patient Requiring Cardiopulmonary Bypass protocol
•implementation of Oral Care for Ventilated and Cardiac Surgery Patients (Adult) protocol.
•implementation of Epicardial Pacing protocol (if pacing wires in place).
•assessment findings
•interventions and patient responses/outcomes
•reported conditions
•patient/caregiver teaching and level of understanding

REFERENCES: Bojar RM. (1999). Manual of perioperative care in cardiac surgery. Malden, Massachusetts: Blackwell Publishing.
Finkelmeier BA. (2000). Cardiothoracic surgical nursing. Philadelphia, Pennsylvannia: Lippincott Company.
Margereson, C. & Riley, J. (2003). Cardiothoracic surgical nursing: Current trends in adult care. Malden, Massachusetts: Blackwell Publishing.
APPROVAL: Standards Committee DATE: 08/06/91
REVISED: DATE: 12/12/94
02/17/98
02/20/01
04/13/04
04/09/07
Distribution: Critical Care Service