The following description reflects the daily practice of the management of the cardiac surgery patient as practiced in the intensive care of the Erasme Hospital associated with a reminder of the hemodynamic functions. The normal expected evolution, as well as the evolution related to complications, will be discussed. The monitoring of the cardiac surgery patient will be reviewed on a point-by-point basis following the definition of the types of cardiac interventions as well as the use of cardiopulmonary bypass (CPB) and post-operative medical treatments.
The management of the cardiac surgery patient can be carried out according to a conventional approach by invasive sternotomy (open heart surgery) or less invasive by mini-thoracotomy or without CPB (“off-pump“ surgery, also called “beating heart surgery,” takes place while the heart is still beating, and does not use CPB).
Cardiac surgery procedures include coronary artery bypass graft (CABG), valve replacement or plasty, Bentall, ventricular aneurysm resection, placement of internal defibrillator and/or internal pacemaker, and finally, heart transplant.
Conventional, invasive surgery requires the use of CPB to stop and cool the heart. The use of a heart-lung machine can lead to postoperative complications, which have led to the development of less invasive techniques.
On admission to the ICU, the patient is in a pharmacological coma state and is mechanically ventilated. The cardiac surgery patient can be characterized by two main aspects: the surgical procedure and hemodynamic (HD) monitoring.
Once installed, patient management includes:
- Hemodynamic monitoring by means of various catheters (Art KT, Swan-Ganz, etc.)
- Blood gas monitoring
- Monitoring of post-operative losses: via surgical drains (hemorrhagic signs)
Management includes basic nursing care:
- Maintaining skin integrity
- Catheter fixation and tracheal tube
- Surveillance of the surgical site
- Chest drainage
The normal expected evolution of the patient consists of mechanical ventilation weaning and extubation on day 0 and a switch from intravenous to oral treatment. The patient usually returns to his room on day 1.
The nurse’s role is to:
- Provide ongoing monitoring
- Detect early signs of tampering
- Proactive role in passing on information to the physician and anticipating complications
Complications that may occur are either cardiac or extra cardiac:
- Low cardiac output, arrhythmias, conduction disorders
- Pulmonary
- Hemorrhagic
- Ischemic, heart attack
- Digestive
- Neurological
The management of the ICU cardiac surgery patient implies knowledge of both pathological and surgical processes and their implications in postoperative evolution. The nurse’s continued presence with the patient allows her to screen for abnormalities and refer them to the physician. The ability of the nurse to detect early signs of impairment is optimal in the management of the patient. The technical assistance inherent in patient monitoring should not take precedence over the importance of clinical observation. The whole management of the ICU cardiac surgery patient combines knowledge and experience.