Cardiac-Vascular Surgery RPN 2023 PDF

MOUDLE 17: Cardiac Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 25 Tighe (2015) Instrumentation for the Operating Room Chapter 85, 87, 90...

MOUDLE 17: Cardiac Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 25 Tighe (2015) Instrumentation for the Operating Room Chapter 85, 87, 90 ORNAC Standards 2023 Learning Outcomes Describe the anatomy of the heart. Explain basic procedural considerations for cardiac surgery. Describe the cardiopulmonary bypass machine, the purpose and location of the three main units and their corresponding cannulas. Cardiac Anatomy The heart is a muscle that is composed of four chambers, which includes right atrium, right ventricle, left atrium, and left ventricle. There are four valves within the heart, which includes tricuspid valve, pulmonary valve, mitral valve, and aortic valve. The cardiac wall is made of three layers: the epicardium, mypocardium, and endocardium. The left ventricle has the thickest muscle layer in comparison to the other four chambers. The heart is covered by the pericardial sac, which is positioned within the mediastinum, in between the lungs. The heart is anterior to the esophagus and vertebrae. Module 17: Cardiovascular The heart acts as a pump that boosts the deoxygenated blood into the pulmonary circulation via the right atrium, tricuspid valve, right ventricle, pulmonary valve, and pulmonary artery. The lungs oxygenate the blood, which then travels back to the heart via the pulmonary vein, left atrium, mitral valve, left ventricle, aortic valve, and aorta. The heart propels oxygenated blood into the systemic circulation. The heart is supplied with oxygen and nutrients through the coronary circulation. Just behind the aortic valve, there are left and right sinuses that supply the left and right coronary arteries. Perioperative Nursing Considerations Nursing Assessment In this text, there will be a focus on aortoconary bypass (ACB) and valve repair/replacements. ACBs are also known as coronary artery bypass graft (CABG). The nursing considerations related to thoracic and vascular surgery are similar to cardiac surgery. Review the patient’s cardiac catheterization report, which will identify how coronary arteries are have stenosis and require bypass grafts. The number of diseased coronary arteries will give you an idea of the number of Surgipro/Prolene sutures that are needed and the time duration of the surgery. The report may also give you an indication of the patient’s left ventricular function. Anaesthesia Patients undergoing ACB or valve replacement/repair surgeries will require general anaesthesia with ETT. The period of induction is one of the most critical elements during the procedure, which require close monitoring, especially for patients with ventricular ischemia. It is critical that the whole surgical team is present during anaesthesia induction. Blood Replacement - Some patients may require extensive tissue dissection in highly vascular areas, resulting in the need for blood transfusion. Orders and availability of blood products must be confirmed pre-, intra-, and post-operatively. The RPN should be prepared in the scrub role with hemostatic agents, such as hemoclips, sutures, ties, sponges, Gelfoam, surgicel, etc to anticipate any critical surgical needs. If autologous transfusion is required, ensure that the blood collection and reinfusion systems are in place and the institutional policies and procedures are followed. Patient Positioning The cardiac surgeon conducts a median sternotomy for patients who undergo valve replacement/repairs or ACBs. Patients are positioned supine to provide optimal exposure. Refer to the ORNAC Standards and the positioning performance checklist for appropriate practices. Module 17: Cardiovascular Instrumentation and Counting Common cardiac instruments: - Potts scissors - Castroviejo needle holders and scissors - Ryder needle holders - Debakey or cooley forceps - Vascular forceps - Sternal retractors - Tubing clamps - Femoral debakey clamps - Statinsky clamps - Surgipro or Prolene sutures (synthetic, non-absorbable, monofilament, polypropylene) are used for anastamosis or repair of vessels. Ticron sutures (synthetic, non-absorbable, braided, polyester) are commonly used for valve repair/replacements. #11 and #15 blades are commonly used. In ACBs, grafts are used to bypass occluded coronary arteries. Saphenous vein graft is commonly used. Minimally invasive techniques may be used to harvest the saphenous vein. Endoscopic instruments: - Telescope, camera, light cord - Endoscopic Scissors A major count is required for cardiac surgeries. Initial Count (major) → Closing Count (major) → Final Count (minor) Cardiopulmonary Bypass CPB is a temporary substitution of the heart and lungs by diverting blood away from the heart and lungs. A perfusionist is the operator of the bypass machine, who works together with the surgeon and anaesthetist. The surgeon stops the heart to perform surgery on the heart. The CPB provides a dry and motionless surgical field while allowing the surgeon to manipulate the heart without inducing ventricular fibrillation or reduced cardiac output. Before the surgeon performs ACB or valve repair/replacement, venous and arterial cannulae and cardioplegia catheter are inserted into the heart. Venous cannula is inserted into the right atrium and drains from the IVC. This cannula diverts deoxygenated blood away from the heart. Arterial cannula is inserted into the aorta to return oxygenated blood back into the systemic circulation. Cardioplegia catheter is inserted into the aorta to administer cardioplegia, which contains potassium and buffering agents, to counteract ischemic acidosis intraoperatively. An aortic crossclamp, such as a femoral debakey clamp, is applied between arterial and cardioplegia Module 17: Cardiovascular catheter. These cannulae and catheter are connected to the cardiopulmonary bypass circuit, which is made up of venous reservoir, oxygenator, heat exchanger, cardioplegia pump, and centrifugal pump. The venous reservoir is the chamber where venous blood is collected. The oxygenator removes carbon dioxide and adds oxygen to the blood. The heat exchanger warms or cools the blood as needed. After completion of the repair, the patient is rewarmed systemically by using the oxygenator’s heat exchanger. Clamps, cannulae, and catheter are removed and the patient’s chest is closed. Chest Drainage - Chest tubes are inserted before closure of the chest and are inserted into the patient’s pericardial cavity and mediastinum to monitor and evacuate blood postoperatively. Surgical Interventions Aortocoronary Bypass (Also termed Coronary Artery Bypass Grafts) with Arterial and Venous Conduits This procedure is for the treatment of Coronary Artery Disease (CAD) and is the gold standard for patients with left main or three-vessel CAD. The goal is to revascularize the ischemic myocardium using the right or left thoracic IMA, greater saphenous vein, radial artery, and other autogenous arterial and venous conduits. CABG procedure alleviates angina pectoris. The most common grafts used are: 1. Internal Mammary Artery (IMA) - has excellent long-term patency. 2. Saphenous Vein - ideal for when multiple grafts are required. This vein is usually harvested endoscopically. 3. Radial Artery Mammary arteries are already attached to the main artery (the aorta). When grafting, this means that only its one end must be disconnected and grafted onto the diseased coronary artery. LIMA (Left Internal Mammary Artery) → Grafting the Left Anterior Descending Coronary Artery RIMA (Right Internal Mammary Artery) →Grafting the Right Coronary Artery Because these grafts are arteries, the LIMA and RIMA are more accustomed to a forceful blood flow than a saphenous vein. Veins carry deoxygenated blood from the body back to the heart and aren't under as much pressure. Therefore, these grafts may prove to be more durable long term. Module 17: Cardiovascular Procedural Considerations: - Median sternotomy - Cardiopulmonary Bypass (CPB) - Conduit selection – i.e. IMA or Saphenous Vein - Conduit harvest - Coronary anastomoses using the saphenous vein, free arterial grafts, and in situ arterial grafts (IMA) - Additional anastomoses are completed. - Distal anastomosis of the IMA to the coronary artery - Proximal aortic anastomoses - CPB ends and sternum is closed Valve (Tricuspid, Pulmonary, Mitral, Aortic) Repair or Replacement Valve repair or replacement is required for stenosis, the narrowing of the valve which prevents forward blood flow, or regurgitation, when the valve leaflets do not close and blood flows back into the ventricle. Procedural Considerations: - The perioperative nurse must confirm the type of valve the surgeon will use to replace the diseased valve. - Mechanical or Bioprosthesis Valve - Depending on which valve is repaired or replaced will depend on the ventricles and chambers of the heart affected and the procedural steps. - If the patient receives a mechanical valve, they will be placed on long-term anticoagulation therapy postoperatively. Module 17: Cardiovascular  Vascular Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 24 Tighe (2015) Instrumentation for the Operating Room Chapter 94 ORNAC Standards 2023 Learning Outcomes Describe the anatomy of the vascular system. Explain basic procedural considerations for vascular surgery. Anatomy – Artery and Vein Arteries and veins are composed of three layers: tunica media (innermost layer), tunica media (muscular middle layer), and tunica adventitia (fibrous outer layer). The structure and function of arteries differ from veins. Artery Vein Thicker muscle layer Thinner wall More elastic fiber Less elastic Capable to contract and constrict to stop More fragile and difficult to control venous hemorrhage bleeding Carries blood away from the heart Valves to prevent blood backflow Fewer nerve fibers than arteries Carrier blood towards the heart Patients who are admitted for vascular surgery may be diagnosed with one or more of the following arterial diseases: Aneurysmal Disease (e.g. abdominal aortic aneurysm), acute or chronic arterial insufficiency (e.g. atherosclerosis). Patients may also be diagnosed with one or more of the following venous diseases: acute or chronic venous insufficiency. This vascular surgery module will focus on bypass and vascular reconstruction surgery on aneurysms and acute arterial insufficiency, and chronic arterial insufficiency. Module 17: Cardiovascular  Perioperative Nursing Considerations Nursing Assessment Patients with vascular disease may display symptoms related to cerebrovascular disease or peripheral ischemia (e.g. aortic aneurysms). Medications and Solutions In vascular surgery, there may be several medications and solutions on the sterile table. The scrub nurse may have heparinized saline, papavarine, contrast dye, or normal saline. 1. Heparinized saline is used during vascular surgery for irrigation, especially during the cross clamping of the involved vessel. 2. Papavarine is used as a vasodilator, as well as an antispasmodic on the smooth muscle of the vessel wall. 3. Contrast dye may be used during endoscopic vascular procedures, such as EVAAR, to visualize the vessels under fluoroscopy. There are differences in surgical preferences regarding which medications to use and their concentrations. Topical hemostatic agents, such as absorbable gelatin sponge, may be used to promote adhesion of platelets. The scrub nurse must follow ORNAC Standards and label all medications and solutions on the sterile field. Instrumentation and Counting Instruments that are used in cardiac and vascular surgery are the same (see Cardiac Surgery Module). In vascular surgery, the length and size of the clamps and retractors will vary depending on the size of the vessels to be repaired. These include: - Cascular bulldog clamps - Bipolar cautery - Microforceps - Microdissectors Shunts may also be used in vascular surgery. In carotid surgery the surgeon may use carotid shunt clamps for removing plaque from carotid artery, while perfusion to the internal carotid artery is maintained. A major count is required for vascular surgeries. Initial Count (major) → Closing Count (major) → Final Count (minor) Module 17: Cardiovascular Vascular Prosthesis Vascular grafting materials and techniques are used for bypass procedures and reconstruction. The patient’s own vein (autogenous) or a prosthetic graft (allograft) may be used to circumvent the stenosed artery and re-establish arterial circulation. Autogenously vein grafting may use in situ method or reversed vein graft. The in-situ method uses the patient’s own vein, commonly the saphenous vein, which is kept in its natural place inside the patient’s body. Prosthetic grafts may be used by surgeons to improve the arterial stenosis. Prosthetic grafts come in different sizes and configurations and must be biocompatible, hypoallergenic, and last a lifetime. They must be easy to handle and permit blood flow without infection and clotting. Some vascular reconstructive surgery may require the use of vascular patches. For example, bovine pericardial patch is commonly used in carotid endarterectomy to repair the vascular wall that is resected intraoperatively. There are vascular patches that are biologic tissues (bovine or porcine origin). Surgical Interventions Abdominal Aortic Aneurysm Resection and Repair Surgical resection of an aortic aneurysm, which may or may not involve of the iliac arteries, with insertion of synthetic prosthesis to re-establish distal perfusion. Procedural Considerations: - Perioperative nurse must be alert to the aortic crossclamp application and removal. Patient may experience “declamping shock” or severe hypotension upon removal of the distal clamp. Endovascular Abdominal Aortic Aneurysm Repair The endoscopic repair of abdominal aneurysm. The surgeon uses a prosthetic endograft or stent- graft that is introduced through the surgically exposed femoral artery. Guided by fluoroscopy, the graft is tunneled through the femoral artery and deployed inside the aneurysm. The stents are self- expanding or balloon-expanding. Sutures are not needed to secure these stents inside the aneurysm. Procedural Considerations: - Intraoperative measurements of blood loss are necessary! - Risk of converting to an open procedure and the scrub and circulating nurse must be prepared with instrumentation and supplies as this will happen quickly! Module 17: Cardiovascular Emergency Aneurysm Repair: The main goal is to clamp the ruptured aneurysm as soon as possible. Counts may not be completed. The anaesthetist may insert monitoring lines and you may need to prep and drape while the patient is still awake. Make sure you have the following items ready on your sterile table: 20 blade loaded, aortic cross clamps, sponges, and suction. Femoral Popliteal Bypass An extra-anatomic bypass performed to re-establish blood flow to one leg. This is performed if a major aortic bypass procedure is not desired. Procedural Considerations: - For this procedure, the surgeon exposes the femoral and popliteal arteries. The surgeon may use the patient’s own vein (commonly saphenous vein) or a straight prosthetic graft to circumvent the arterial stenosis. - If the surgeon uses the patient’s saphenous vein as a graft, it will be removed it from its natural location. They will reverse the vein graft and sew the distal and proximal ends. - If a prosthetic graft is used, the circulating and scrub nurses must confirm graft type, size, expiry date, and reconstitution/preparation requirements before implantation. The implant must be documented in the patient’s chart. In a different procedure, called femoralpopliteal bypass in situ, the surgeon may use the patient’s saphenous vein in its natural location to circumvent the arterial stenosis. In this in situ procedure, the saphenous vein is not removed from its natural location, but the valves are removed using a valvulatome. The proximal and distal ends of the saphenous vein is anastamosed to the involved artery. Permanent Pacemaker Insertion Insertion of one or two electrodes (i.e. atrial and/or ventricular leads) through the subclavian vein, which is tunneled through the SVC and into the heart chamber (Right atrium and/or right ventricle). The pulse generator is attached to the lead/s and placed in the subcutaneous pocket under the clavicle. The pulse generator senses bradydysrhythmias and initiates atrial or ventricular contraction. Procedural Considerations: - Strict aseptic technique is followed to prevent infection of pulse generator and leads. - Patient is commonly awake during this surgery. The perioperative nurse places signs throughout the OR suite to alert colleagues that patient is awake. Minimize noise in the suite. - This procedure usually takes only an hour to complete. - Atrial lead, ventricular lead, and pulse generator are considered implants. Confirm the implant type, size, expiry date, and reconstitution/preparation requirements before implantation. The implant must be documented in the patient’s chart. Module 17: Cardiovascular Implantable Cardioverter Defibrillator (ICD) Insertion Insertion of an electronic device that monitors cardiac electrical activity and delivers defibrillator shocks, as needed, to treat ventricular tachycardia or fibrillator. ICDs are capable of pacing and defibrillating. Although ICD and permanent pacemaker insertions have similar procedural steps, their purposes are different. Procedural Considerations: - Strict aseptic technique is followed to prevent infection of ICD and leads. - Patient is commonly awake during this surgery. The perioperative nurse places signs throughout the OR suite to alert colleagues that patient is awake. Minimize noise in the suite. - This procedure usually takes only an hour to complete. - In some situations, ICDs may be tested in the OR after incision closure. Patient is induced into a V-fib dysrhythmia then shocked by the ICD. There are safety measures that are taken to ensure patient safety. For example, defibrillator pads or paddles with compatible external defibrillator should be available in the room. - Atrial lead, ventricular lead, and ICD are considered implants. Confirm the implant type, size, expiry date, and reconstitution/preparation requirements before implantation. The implant must be documented in the patient’s chart. Module 17: Cardiovascular