The First Few Hours: Initial Recovery The first few hours of recovery after cardiac surgery are critical and require skilled nursing care and attention. Patients are usually transferred to the intensive care unit (ICU) immediately after surgery for recovery from anesthesia and hemodynamic stabilization. The goals for this period are to stabilize the patient’s hemodynamic status, maintain oxygenation, and normalize body temperature. Attaining these goals requires careful assessment and hemodynamic monitoring to quickly recognize and treat potential complications. The nurse at the bedside has the responsibility to see the whole picture and work with the physician and other members of the health care team to optimize hemodynamic parameters. Managing medications and titrating vasoactive drips are critical steps to ensure cardiac output is maintained at an adequate level. The cardiac surgery nurse should know the actions of each ordered medication and when to use each. The nurse also must realize when treatments are not effective and notify the physician for further interventions. Objectives In this chapter, you will learn: 1. What assessments to perform during the initial post-op period 2. How to optimize cardiac output in the post-op cardiac surgery patient 3. How to assess for and manage potential complications of anesthesia PATIENT TRANSFER FROM OPERATING ROOM TO INTENSIVE CARE UNIT Transferring the patient from the operating room to the ICU requires collaboration and communication among members of the health care team. The goal is to transfer the patient safely with all pertinent information communicated effectively. Hand-Off Communication As a patient is being transferred from the operating room to the ICU, critical information must be relayed from the anesthesia provider to the receiving nurse. (See Table 9.1 for a list of information that should be relayed on transfer.) In addition, most patients would have had a pre-op assessment that can give information about the risk of post-op complications. For example, a patient with preexisting pulmonary disease may have difficulty with weaning from the ventilator. Reviewing this pre-op assessment allows the nurse to anticipate and observe for potential complications in a patient-specific manner. TABLE 9.1 Critical Information on Transfer From Operating Room to ICU Pre-Op Information Intra-Op Information Post-Op Information Patient medical and surgical history Pre-op status Surgical procedure Length of surgery Position on the operating room table Anesthetics and reversal agents used Intra-op complications Cardiopulmonary bypass time Estimated blood loss Type and amount of blood products and fluids given Anticoagulation given and reversal of anticoagulation Any assistive devices used Intake and output during surgery Hemodynamic status Ventilatory status Current laboratory data Location and type of intravenous lines and catheters Type and rate of any vasopressors or inotropes Presence and location of pacing wires and chest tubes Presence and location of drains and dressings Knowledge of a patient’s pre-op status, the surgical procedure performed, and any intraoperative complications assists the nurse in anticipating problems in the immediate post-op period. Initial Physical Assessment Potential complications may be related to preexisting conditions and comorbidities of the patient, effects of anesthesia, or the surgical procedure itself. The initial physical assessment must be detailed and must include observation for potential complications. Specific complications commonly seen in the immediate post-op period will be discussed in Chapter 10. The following items should be a part of the initial physical assessment performed by the cardiac surgery nurse. Vital Signs and Hemodynamics The patient’s heart rate and rhythm, blood pressure, temperature, and pulse oximetry should be evaluated. Hemodynamic parameters should be measured, including pulmonary artery pressure, pulmonary artery occlusion pressure (PAOP; wedge pressure), central venous pressure (CVP), cardiac output, cardiac index (CI), and systemic vascular resistance (SVR). For some patients a mixed venous saturation is warranted. If so, this would be ordered by the physician and sent to the lab or performed on a bedside blood gas analyzer. Normal hemodynamic values for a post-op cardiac surgery patient are listed in Table 9.2; however, different values may be stated by the surgeon as acceptable for particular patients depending on their disease process and underlying comorbidities. Cardiac Assessment A post-op baseline 12-lead electrocardiogram (ECG) should be performed to evaluate for ischemia and any conduction problems. If the patient has epicardial pacing wires, atrial wires exit the chest wall on the patient’s right and ventricular wires exit the chest wall on the patient’s left. These pacing wires should be checked for functioning in case they are needed emergently. If the patient is being paced on arrival to the ICU, pacer settings should be evaluated and documented (Table 9.3). TABLE 9.2 Normal Values of Hemodynamic Measurements for Post-Op Cardiac Surgery Patients Measurement Normal Values Systolic blood pressure (SBP) 100–130 mmHg Diastolic blood pressure (DBP) 60–90 mmHg Mean arterial pressure (MAP) 70–105 mmHg Pulmonary artery pressure (PAP) (systolic/diastolic) 15–30/6–12 mmHg Pulmonary artery occlusion pressure (PAOP) (wedge pressure) 4–12 mmHg Right atrial pressure/central venous pressure (RA/CVP) 0–8 mmHg Cardiac output (CO) 4–8 L/min Cardiac index (CI) 2.5–4.2 L/min/m2 Systemic vascular resistance (SVR) 770–1,500 dyne/sec/cm-5 FAST FACTS in a NUTSHELL To check to see if epicardial pacer wires are still functioning, connect a temporary pacemaker generator to the lead wires. Set the pacemaker in the DDD mode at a rate higher than the patient’s own intrinsic heart rate. Increase milliamps until pacing spikes followed by paced beats are seen on the monitor. This indicates that the epicardial pacing wires are functioning. Neurological Assessment A neuro assessment should be completed, including level of consciousness, pupil size and reaction, and ability to move extremities. Patients who are intubated or sedated should have as complete a neuro assessment as is possible. Assessing pain is an important part of this assessment. Either patients should self-report their pain, which is the most reliable pain assessment, or a validated behavioral pain scale should be used. Several behavioral pain scales have been validated in critical care patients. These include the Checklist of Nonverbal Pain Indicators (CNPI), the Behavioral Pain Scale (BPS), and the Critical Care Pain Observation Tool (CPOT). TABLE 9.3 Pacemaker Settings First Letter Chamber Paced Second Letter Chamber Sensed Third Letter Response After Sensing A—atrium A—atrium I—pacing inhibited V—ventricle V—ventricle T—pacing triggered D—dual (atrium and ventricle) D—dual (atrium and ventricle) D—dual (both inhibited and triggered) O—none O—none Respiratory Assessment Initial assessment should include respiratory rate, symmetry of chest expansion, and breath sounds. Patients who are still intubated should have the placement of the endotracheal tube verified using the marking on the tube. Ventilator settings should also be verified. A baseline chest x-ray should be performed as ordered by the physician to evaluate placement of the endotracheal tube and other devices such as catheters, pacing wires, and chest tubes. A chest x-ray will also show the presence and extent of post-op atelectasis and pneumothorax. Patients frequently have chest tubes on arrival to the ICU. The type and number of tubes vary based on the surgical procedure performed. One or more chest tubes may be placed in the mediastinal cavity (within the pericardial sac next to the heart) or in the pleural cavity (within the pleural space next to the lungs). Each chest tube should be clearly marked and documented so it is apparent how much drainage is coming from which tube. This is critical when evaluating bleeding. Chest tubes should be attached to −20 cm H2O wall suction. The type, color, and amount of drainage should be monitored and documented. Patency of these chest tubes must be maintained at all times. Fluid and Electrolyte Status Intake and output from the operating room and during the initial post-op period should be recorded and evaluated to determine the patient’s fluid status. Electrolytes should be monitored frequently and kept within a normal range. It is important that the cardiac surgery nurse anticipate third spacing of fluids, which is an increase in edema due to fluid leaving the vascular space and entering the tissues. CLINICAL ALERT! Frequent assessments should be made to ensure dressings, bandages, or sequential compression devices do not become excessively tight during these fluid shifts. These devices can cause severe damage to skin and tissues. FAST FACTS in a NUTSHELL 
FAST FACTS in a NUTSHELL
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