care of clients with beating heart surgery

IDC International Journal Feb - April 2017

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CARE OF CLIENTS WITH BEATING HEART SURGERY Mary Kalyani Amarthaluri* | Rajina Rani**

*Research Scholar, Himalayan University, Itanagar, Arunachal Pradesh, India

**Principal, Rass Academy College of Nursing, Poovanthi, Sivagangai, Tamil Nadu, India

ABSTRACT The prevalence of heart disease is increasing rapidly in the developing countries of the world owing to demographic transitions and changing life styles among people. Coronary artery disease (CAD) is the most common type of heart disease and accounts for the majority deaths. “Beating Heart Surgery is a way to perform surgery without stopping the heart”. In Beating Heart Surgery, surgeons use a special device called “Star Fish” and “Urchin Heart Positioners” to hold the heart to give the Surgeon easy access to the blocked vessel requiring the bypass graft, and “Octopus tissue stabilizer” minimizes and limits the motion of a small area of the heart while the rest of heart continues to beat and circulate blood to heart muscle during the operation”. It helps in Better preservation of heart function, Better survival rate, especially among high risk patients, reduced hospital stay and Quick recovery. Nurses should be aware regarding the care of clients who are undergoing beating heart surgery. Key words: CAD, Urchin Heart Positioners, Octopus Tissue Stabiliser ABOUT AUTHORS

Author Ms. Mary Kalyani is Research Scholar in Himalayan University, Itanagar, Arunachal Pradesh, India.

Author Dr. Rajina Rani is active researcher with many publications in her name. She has attended and organised various National and International conferences and given extension lectures. At present she is Principal, Rass Academy College of Nursing, Poovanthi, Sivagangai, Tamil Nadu, India.


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INTRODUCTION Health is real wealth of man. A healthy body and a healthy soul is the secret of happy life. Heart is one of the vital

organs of human body. The prevalence of heart disease is increasing rapidly in developing countries of the world owing

to demographic transitions and changing life styles among people. Coronary artery disease (CAD) is the most common

type of heart disease and accounts for the majority deaths.

The heart is a roughly a cone-shaped hallow muscular organ. It is about 10 cms (4 inches) long and is about the size of

the owner’s fist. It weighs about 255 gms in women and is heavier in men. It is situated in the thoracic cavity in the

middle mediastinum between the lungs, a little more to the left than the right, and presents a base above and an apex

below. The right atrium receives deoxygenated blood from the body. The blood moves to the right ventricle, which

pumps it to the lungs. The left atrium receives oxygenated blood from the lungs.

RISK FACTORS

Risk factors can be categorised as non-modifiable and modifiable.

Non- Modifiable major risk factors ― Heredity, including race, age and gender

Modifiable major risk factors ― Cigarette smoking

― Hypertension

― Diabetes Mellitus

― Hyperlipidemia

― Physical inactivity

― Obesity

Contributing risk factors ― Stress

― Homocysteine level

Chest pain ― Radiating to jaw and left hand, substernal pain

Cyanosis, Fatigue, Haemoptysis,

Abnormal heart rhythm- Palpitation

Dizziness, Vomiting, Dyspnoea

Dependent oedema, Weight gain

CABG DONE ON BEATING HEART (OR) BEATING HEART SURGERY

Definition:

“Beating Heart Surgery is a way to perform surgery without stopping the heart”.

In Beating Heart Surgery, surgeons use a special device called “Star Fish” and “Urchin Heart Positioners” to hold the

heart to give the Surgeon easy access to the blocked vessel requiring the bypass graft, and “Octopus tissue stabiliser”

minimises and limits the motion of a small area of the heart while the rest of heart continues to beat and circulate

blood to heart muscle during the operation”.

“Surgery on a beating heart helps reduce the risk for complications associated with temporarily stopping the heart

during surgery.”

“Surgery on a stopped heart is common, and some heart procedures can only be performed on a motionless heart.

Physicians use a special solution called Cardioplegia solution to stop the heart. If the heart is stopped for surgery, the

surgeon must restart it and reintroduce blood into the tissue. This is called “Reperfusion”.

Reperfusion can cause impairment of heart function. Sometimes, heart muscle tissue can be damaged at cellular level

during reperfusion, a phenomenon known as reperfusion injury. In some people, reperfusion injury can lead to

complications such as arrhythmias and heart attacks. Reperfusion injury is especially a concern in high-risk patients,


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such as the elderly, people who have had several heart surgeries, patients with severe blockages, and those with

complex heart problems. Reperfusion injury can be avoided if the heart is kept beating during surgery.

Indications for Beating Heart CABG Surgery:

The indications for Beating Heart CABG Surgery include:

Patients with isolated single-vessel LAD (Left anterior descending) or RCA (Right coronary artery) disease or both,

in patients in whom angioplasty, or stenting is not advisable due to complex stenosis or complete blockage.

Patients with multivessel disease requiring revascularisation.

Patients with contra-indications or at increased risk for cardiopulmonary bypass, such as ―

Severe myocardial dysfunction,

Immunosuppression

History of transient Ischemia attacks or cerebrovascular accidents,

Heavily calcified aortas,

Aortic disease with increased risk of dissection, rupture or embolisation,

Impaired renal function,

A history of previous cardiac surgery.

Patients who are Jehovah’s witnesses who refuse transfusion of blood products.

Other high risk patients such as those with advanced age, respiratory problem or other systemic disease.

Contra- indications of Beating Heart Surgery:

Small Left Anterior Descending (LAD) with a diameter less than 1.5 mm.

Calcified Left Anterior Descending (LAD) or Right Coronary Arteries (RCA).

Intra myocardial LAD.

Previous use of internal mammary artery (IMA) or an inadequate IMA.

Patients in whom a media sternotomy or parasternal incision is contraindicated.

Obese patients.

Rightward displacement of the LAD.

Severe pulmonary hypertension with a large left ventricle, as graft occlusion is more likely to occur.

Advantages of Beating Heart Surgery:

Better preservation of heart function.

Better survival rate, especially among high risk patients.

Reduced hospital stay.

Quick recovery.

Less chance for heart rhythm, kidney or liver complications.

Reduced risk for Neurological injury, including stroke and memory complications.

Fewer traumas due to the elimination of the heart lung machine.

Reduction in need for blood transfusion.

Disadvantages of Beating Heart Surgery:

Technical challenges of operating on a beating heart.

Absence of circulatory support.

Increased risk of incomplete revascularisation


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Types of Surgeries performed on a Beating Heart:

In modern days 90 percent of coronary artery bypass surgeries are performed on a beating heart. While not all

procedures can be performed on a beating heart, surgeons have developed many techniques that make beating heart

surgery an option for even complex procedures on the inside of the heart – including valve repair. ‘The University of

Chicago Medicine’ were among the first in the world to perform beating heart Mitral valve surgery Some of the

procedures performed on a beating heart include ―

Coronary artery bypass graft surgery.

Surgery for atrial fibrillation.

Treatment of some congenital heart defects, such as closure of atrial septal defect.

Valve repair (mitral, pulmonary, or tricuspid).

Valve replacement (mitral or tricuspid).

Ventricular reconstruction.

Beating Heart Surgery is technically demanding that require specialised skills and training. In beating heart surgery

there is no need of heart lung machine and the patient’s heart and lungs will continue to perform during surgery.

“Beating Heart Bypass Surgery” is also called “Off Pump Coronary Artery Bypass Surgery (OPCAB).

NURSES ROLE IN PRE-OPERATIVE PERIOD

Early Pre-Operative Care:

Admission of the patient to ward.

Assessment of patient, including – History Collection, Physical Examination – emphasis on cardio respiratory

system, Height and Weight, records of previous illnesses, treatment.

Reports of diagnostic procedures.

Evaluation of patients and family members’ emotional status, coping strategies.

Regular Medication.

Pre-operative Teachings ―

Anatomy-Physiology of Cardio respiratory system.

Disease and operation to be done.

About Operation Theatre.

Intensive Care Unit, various tubing and machines used and their purposes and duration of use

Waiting room and communication facilities.

Demonstrating and return demonstration of all the breathing exercises, pursed lip breathing, abdominal

breathing, huffing and coughing, supporting of sternum during exercises, range of motion exercises, gradual

ambulation and how to take steam inhalation.

Spirometry which helps in lung expansion.

Written informed consent from the patient or significant others.

Previous Day of Operation:

Remove all the jewellery, nail polish, cut nails.

Skin preparation and Savlon bath.

Sterile hospital dress to wear and Sterile bed sheets.

Sensitivity test for antibiotics and results to be recorded.

Any investigations such as chest x-ray, CBC, blood sugar, urea, electrolyte, ECG etc. is done and reports collected.

Instruct the patient not to take anything orally after 10 PM. (NBM post mid-night).


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Administer anti-anxiety drugs for a good sleep as prescribed by the anaesthetics.

Check and keep the case sheet with all records and reports and informed consent form.

Preparation on the morning of surgery:

Morning care.

Record vital signs.

Administer morning dose of antibiotics.

Facilitate to meet the spiritual needs of the patient.

Pre-medication to be given.

Patient to be handed over to O.T Nurse with proper endorsement and hand over the case sheet with all reports

and records.

Reassure the patient and significant others.

Preparation of ICU:

Cardiac surgical ICU is generally connected to the operation theatre.

Patients unit, bed and equipments are cleaned and carbolated thoroughly.

Prepare the bed with sterile sheets.

Keep all equipments at hand in working condition. Cardiac monitor with all cables, ventilator, central suction, chest

drainage system, arterial flush system with transducers set, central oxygen supply, I/V poles, syringes, needles,

emergency drugs, emergency cart with sterile pack sets to meet any emergency, defibrillator, Pace maker.

Flow chart for complete records of activities and events in ICU.

Intra operative care:

As with other cardiac surgical procedures, the Scrub Nurse and Circulating Nurse play important roles in the

patients Beating Heart Surgical journey.

Equipment:

Some extra equipment is needed in cardiac OT - cardio pulmonary bypass machine and the perfusionist are usually

kept standby to be readily available. So a circulating nurse has to keep all equipment available in OT for necessary

traditional CABG.

A Co2 tank and pressure bag of sodium chloride (NaCl) for blow minster. It is attached to stabiliser arm and

essentially “blows” the walls of the artery open, and maintains a blood- free operative field.

‘Starfish’ to give position to Heart, and Octopus to stabilise the movement of a small part of heart.

Two scrub assistants are usually required for these procedures. The first scrub assistant is the person who passes

the instruments to the surgeon during the operation, and the assistant will have all the items that will be needed

for the scheduled procedure, she will be in line setup in the emergency event that bypass is required.

During off-pump procedure the surgeon determines that the patient is not tolerating the procedures well or

becomes too unstable to continue, the scrub assistants must be ready to assist with the possibility of cardio

pulmonary bypass. The instrumentation needed to go On-pump, should always be opened on the sterile field and

ready to go.

Off-pump coronary artery bypass graft is technically more demanding than ‘On-pump’ CABG as the surgeon has to

accurately anastomise a two millimetre graft to a two millimetre coronary artery on a beating heart. In addition,

positioning of the heart to expose target coronary arteries on the lateral and posterior surface of the heart can

lead to a gradual fall in blood pressure and cardiac arrest, so the surgery has to be performed quickly. This limited

time makes it necessary for the main scrub nurse to be alert at all times and thoroughly be familiar with the steps

of surgery and the surgical instruments, so that she can anticipate the needs of the surgeon and provide assistance

without causing additional delays.


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The perioperative nurse play a critical role in providing expertise and insight in the use and evaluation of products

used in surgical patient care.

POST- OPERATIVE CARE

Immediate care

The patient is accompanied to the ICU by a surgeon, anaesthetist and the nurse who assisted for the surgery with

portable ventilator and ECG monitor.

The patient is shifted to the bed.

The ECG leads are connected to the cardiac monitor and watched for dysrhythmia

The CVP (central venous pressure) and arterial blood pressure lines are connected to the flush system via the

transducer and then to the monitor.

E.T tube connected to Ventilator and parameters are set.

Chest drainage is connected to the central suction and observed. If drainage is more than 70ml/ hr from each tube,

is bright red and free flowing, haemorrhage is suspected.

Urinary bag is attached to the bed and hourly measurement of urine output to be recorded.

Ryle’s tube is unclamped.

Temperature probe, pulse oxymetry leads are connected.

I/V fluids connected and drip adjusted.

Blood gases monitored hourly and corrective action taken.

Observe hourly endotracheal suction with strict asepsis.

Blood for sodium and potassium is tested every 2 hourly for 12 hours and then 4 hrs to 6 hrs. Hypokalemia and

Hyperkalemia both can cause dysrhythmia.

Keep defibrillators ready to use at the bed side.

Strict intake and output chart to be maintained.

Post operative care after 2 hrs to 72 hrs:

ABG every hourly for 12 hrs then 2 hourly.

ET suction hourly, chest physiotherapy, changing of position to promote ventilation and perfusion of the lungs.

Fourth hourly chest X-ray.

If breathing is effective and ABG normal patient is weaned off from ventilator gradually.

First, patient is connected to ‘T’ piece for 2 hours and ABG monitored.

Through bronchial toileting done, cuff is released, encourage the patient to take deep breath and while exhaling,

the ETT is pulled out.

Proper mouth wash is given.

Humidified oxygen inhalation using a venting mask, monitor ABG 4 hourly, cupping, clapping, vibrating and turning

position as the cardiac status permits, continued hourly.

As respiratory status shows satisfactory levels, patient is weaned off from oxygen.

Steam inhalation to assist in bringing out the secretions.

When chest drainage is less than 50ml/ 24hrs, the chest tubes are removed. The wound is properly sealed with

adhesive and the patient is made comfortable.

Prevention of infection by following strict asepsis practice.

Provide psychological support. Help the patient to get oriented to time and date and let family members visit

patient once with precautions.


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Transferring the patient from ICU to ward:

The patient is made to ambulate in ICU before shifting to ward. Vitals are stabilised. The ward nurse is explained

about the patient’s operation done, recovery made and further instructions to be followed in the ward before the

patient is transferred. The unit is prepared and the patient is received.

The patient is encouraged to ―

Ambulate more and more.

Continue breathing and other physiotherapy exercises.

Perform activities of daily living and appreciate whatever the patient is able to do.

Involve family members in helping the patient and to encourage and appreciate the activities of the patient.

Start on normal diet in small quantity and more frequently. If salt restriction is there, use lime to improve the

taste.

By the 6th

or 7th

day the stitches are taken out, the I/V cannula for medication is removed, the pacing wire is

removed. Keep the patient in supine position for two hours after the removal of epicardial pacing wire,

observe his pulse for bleeding from the site, after two hours a 12 lead ECG and chest x-ray is done to see

whether there is no bleeding and no dysrhythmia

Discharge Health Teaching:

Special care is needed:

In a patient with coronary artery bypass graft, the patient has additional dressing depending upon the place of

graft removal. The graft may be from ―

o Internal Mammary artery - No additional dressing will be there. Preventing infection to the sternal wound

is very important as the supply of blood to sternal area is reduced as the blood is diverted to the coronary

artery.

o Radial artery - Dressing over the forehand which could be removed by the 5th

or 6th

day. Movement of the

affected hands is encouraged. A slight swelling may be there which will get subsided as healing takes

place and movement of hand takes place. Instruct patient not to keep hand hanging for a long time and to

do the finger and wrist movements.

o Saphenous veins - In some cases, the saphenous veins from both the legs are used for grafting. Both legs

may have long incisions and dressing. The dressings are removed by the 5th

or 6th

day. Swelling may

develop on the feet due to gravity pull in the circulation. There are special elastic stockings of appropriate

sizes, which when work gives a counter pressure and reduce swelling. Teach the care of the legs.

Daily wash the leg with soap and water after the stitches are removed (only clean the area other than stitch line).

When stitches are there, wipe the stitches with antiseptic lotion and dry, apply powder and then slip the stocking

on to the leg. Wash the stockings once in 24-48hrs in light detergent, dry and reuse. Explain to the patient that the

stocking are needed only for three months.

During the time:

Keep his feet raised on a pillow while resting in bed.

Not to keep his feet dangling or downward more than one hour at a time, use of a stool to raise the feet.

Not to sit in one position continuously for more than one hour.

Not to sit cross-legged while sitting.

Continue doing the simple exercises for the legs- range of movements as taught.

Progressive physical activity should be balanced with a period of rest in between the activity. The heart should

not be overworked.

Practice meditation for 20-30 minutes daily to manage stress.

Consume a low calorie diet.


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Stop smoking.

REFERENCES

BOOKS

1. BT Basavanthappa, MN, PhD, 2nd

edition, Nursing Research, Jaypee Brothers, New Delhi, India.

2. Chintamani MR, FRCS, Mrinalin Mani, MBPS, FIMSA, Lewis Medical and Surgical Nursing, Elsevier, Noida, U.P.,

India, Pg 750- 762.

3. Jacob Jose V,MD, FIAE, (2007) 1st

edition, Manual of Cardiology, Jaypee Publications, New Delhi, India, Pg 96- 110.

4. James Moroney, MB, 15th

edition, Surgery for Nurses, English Language, Book Society, Churchill, Pg 18- 20.

5. Joyce .M. Black, PhD, RN, Jane Hokanson Hawks, DNSC, RN, 8th

edition, Medical and Surgical nursing, Elsevier,

Noida, U.P., India, Pg 1421- 1430.

6. Kathleen T. Wilson, PhD, 5th

edition, Foundation of Anatomy and Physiology, ELBS- Churchill Liverston, Pg 55- 80.

7. Sister Nancy, (2008), 3rd

edition, Coronary Care Nursing, Kumar Publishers, Delhi, India, Pg 137- 145.

8. Stephen J. Mc Phee, MD, William F. Ganong, MD, 5th

edition, Pathophysiology of Disease, Large Medical Books,

New York, Pg 259- 300.

9. Wilma J. Phipps, RN, PhD, Barbara C. Long, 7th

edition, Shaffer’s Medical and Surgical Nursing, B.I. Publications,

Delhi, India, Pg 427- 435.

JOURNALS

1. Baljinder Kaur, The Nursing Journal of India, Role of Nurse in Beating Heart Bypass Surgery, (Nov 2007), Vol. XCVIII,

Aravali Printers, New Delhi, India, Pg 251- 252.

2. Nirmal Kaur, M.Sc.(N), Cardiopulmonary Resuscitation, Nurses of India, (2007) Vol. 8, Brilliant Printers, Bangalore,

India, Pg 4- 6.

3. PP Saramma, AK Aswathi, The Nursing Journal of India, Assessing the Patients’ Recall regarding Pain and its Relief

after Open Heart Surgery, (Dec 2011), Vol. CII, Paramount Publishing, New Delhi, Pg 282-284.

4. Vasantha, M.Sc.(N), Myocardial Infarction, Nurses of India, (2007) Vol. 8, Brilliant Printers, Bangalore, India, Pg 8-

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care of clients with beating heart surgery

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