Critical Care Management in Coronary Bypass Surgery

Introduction

In healthcare, critical care is referred to the medical support required by the people who are under the life-threatening condition with their usual care performed in the intensive care unit (ICU). The critical care is important because it focuses on resuscitating patients with unstable health condition to allow them recover from the effect of hindered health issues and respond to therapies made for their improved health outcome to prevent them from death. The critical care is provided under emergency support to the patients who are in immediate requirement of care for the sudden deteriorated critical health problem (Lee et al., 2020).

In this assignment, the critical care of patient M is to be discussed who is supported to undergo coronary bypass surgery due to extreme narrowing of two out of the four major arteries supply blood to the heart creating risk for heart attack. The care requirement of M with complex anaesthetic, surgical and post-anaesthetic process is to be identified. Thereafter, assessment and planning of care is to be made for M to ensure his enhanced health along with explanation of pharmacology followed for M is to be made. In explaining critical care, the role of surgical first assistant (SFA) is to be explained. The Data Protection Act 1998 mentions that personal data of the individuals stored in computer or paper filling system are to be effectively protected so that the confidentiality and privacy of the individual are maintained (legislation.gov.uk 1998). Thus, the pseudonym M is used to indicate the patient and verbal consent is taken from him to discuss his care process so that his personal identity is kept confidential and his privacy is ensured.

Case Study

M who is 62 years old was admitted to the hospital under emergency conditions due to extreme pain in the chest with progressing shortness of breath, highly elevated heart palpitations, extreme sweating and weakness. He was immediately transferred to the cardiac ward and the clinicians performed initial investigation which led to diagnose that his right marginal coronary artery and posterior descending coronary artery are extremely narrowed. M was suffering from coronary heart disease for the past 4 years and have mentioned to irregularly follow medications and diet. Thus, the initial investigation included performing an echocardiogram (ECG), which presented an irregular heart performance of the patient. The physician of detecting the probability of presence of blockage of the arteries performed coronary CT angiogram which presented the image of the heart and blood vessels of M indicating two out of four major coronary arteries of the heart is extremely narrowed which is running risk for heart attack. On determination of initial blockage of the arteries, through further analysis, the physician mentioned M to undergo coronary bypass surgery by the end of the week for which he was asked to be prepared.

M also had been suffering from type-2 diabetes for the past 10 years for which he uses Metformin as the regular medication. The BMI rate of M is 35.7 which indicates that he also suffers from obesity. M is mentioned to live a sedentary life after his retirement from the law firm where he used to work as the senior consulting manager, which was mainly a desk job. He lives with his wife who is 60 years old and is suffering from arthritis instead of which she managed to take M to the hospital for emergency admission. M’s only son lives abroad for work purpose and remains in contact with the family over phone each day. The initial medical history of M mentions he actively smoked 40 cigarettes a day and in the past 10 years has reduced it to 12 cigarettes a day. He still actively drinks beers each day in the evening and drinks whiskey with his retired friends on the weekend. At home, M prefer having fast food irrespective of cooked food being served by his wife.

Pathophysiology of critical condition of patient

The pathophysiology of coronary artery disease mentions that it is mainly developed due to build-up of plaque in the arterial walls which causes the arteries to be narrowed with time leading to reduced supply of blood to the heart (Collet et al., 2018). In the study by Poss et al. (2020), it is mentioned that increased cholesterol in the blood leads to accumulation on the arterial wall. It eventually leads to plaque formation on the arterial walls leading to narrow them or block them in supplying blood to the heart. The developed plaques may burst open and cause formation of blood clot which may travel to the heart to cause stroke. According to Kondo et al. (2019), smoking leads to the deposition of plaque in the arteries. This is because the harmful chemicals present in cigarette smoke promotes the hardening of the arteries known as atherosclerosis leading to gradual blockage in the transmission of blood to the heart. In case of M, it is seen that he is already an active smoker which may have contributed towards his condition of coronary artery blockage leading him in critical health condition of narrowed arteries which may eventually cause him to develop heart attack that is fatal.

In contrast, the study by Kulik et al. (2019) mentions that blockage of the arteries does not occur immediately but required increased amount of time. The continuous deposition of plaque occurs as a result of increased alcohol consumption. This is because it leads to raise the overall level of cholesterol in the body which is responsible for initial plaque formation. As mentioned by Liu et al. (2019), alcohol on entering the body gets broken into smaller particles which later rebuild itself into triglycerides and cholesterol in the blood. The developed cholesterol and triglycerides on transportation in the blood raise the low-density lipoprotein (LDL) level of the body. The LDL is mentioned is mentioned as bad cholesterol because it leads to fat deposition on the inner walls of the arteries which leads to plaque formation which worsen the coronary heart condition leading to blockage and gradual progression to heart attack. In case of M, he is found to a regular drinker with heavy drinking on the weekends which indicates his alcohol habits has increased contribution towards his current worsened coronary blockage making him critical for the condition and increased risk of facing heart attack out of full blockage of the arteries.

Care Requirement of the Patient

In order to identify the care required by patient M, the ABCDE assessment is to be used. This is because it helps in holistic analysis of the health condition of the patient which assists in understanding the individuals needs of the patients to be cared in the perioperative stage to ensure smooth surgical intervention (Smith and Bowden, 2017). The ABCDE assessment stands for airway, breathing, circulation, disability and exposure assessment in patients (resus.org.uk, 2022). The airway assessment in coronary heart disease (CAD) is important because airway obstruction in the patient could instigate the development of hypoxia which create an adverse effect on the supply of oxygen to the different parts of the body including the heart causing failure of their effective functioning (Javaheri et al., 2020). The signs of airway blockage include paradoxical chest as well as abdominal movement (resus.org.uk, 2022). In case of M, he was able to talk but with difficulty and expressed increased chest and abdominal movement indicating some sign of airway malfunctioning.

The breathing assessment in CAD is significant because CAD causes reduced supply of nutrients and oxygen to the heart which lowers its effective functioning leads to create difficulty in pumping out of blood to the lungs. It creates pressure on the heart and pushes the fluid into the air sacs of the lungs causing breathlessness (Mirabelli et al., 2018). In case of M, his breathing per minute recorded in the preoperative stage is 24 breaths/min. The normal breathing rate in adults is 12-20 breaths/min and above 25 breaths/min indicate the patient’s health is deteriorating (resus.org.uk, 2022). This indicates that M was facing slight breathlessness as the issue due to CAD. The circulation assessment is important in patients with CAD because it helps in determining the impact of the disease on heart performance and blood circulation in the body (Georgakis et al., 2021). Thus, initially a stress test is executed to determine the amount of blood flow to the heart through the blocked coronary arteries. In this process, a tracer is added to determine the exact coronary arteries that are narrowed or blocked which is leading to the development of CAD in patients (Gheisari et al., 2020). The nuclear stress test revealed M’s right marginal coronary artery and posterior descending coronary artery are extremely narrowed.

The cardiac CT scan and angiogram is further performed along with angiogram to develop the image of the coronary arteries leading to the heart and identify the extent of blockage present in them (Dilsizian et al., 2021). The CT scan and angiogram images are used for M at the initiation of the surgery to determine the location in which the surgery is to be performed. The blood group assessment is executed to detect blood group of the patient so that same group of blood can be arranged which is required in supplementing the lost blood during the surgical process in the body (Stowell and Stowell, 2019). M’s blood group was detected as O+ according to which additional blood is arranged of the same blood group to be used during the surgery.

The disability assessment is important for surgery of CAD patients because it helps in identifying the additional health disorder present in the patient which may interfere during the surgical process to create life risk for the individual (resus.org.uk, 2022). M is mentioned to be suffering from type-2 diabetes and is taking Metformin to control his blood sugar. The fasting blood glucose test is performed to determine M’s glucose level which was recorded to be 6.5 mmol/l. In type-2 diabetes patients, the blood glucose level is needed to be controlled within 5.6-6.9 mmol/l in fasting state (Kogan et al., 2018). This indicates that M’s blood sugar is under control with using metformin. However, the study by Umeda et al., (2018) mentions that metformin use is to be restricted for use before and after 48 hours of the surgery to avoid the risk of lactic acidosis. Thus, the metformin was avoided to be taken by M prior to 2 days before the coronary bypass surgery.

The exposure assessment prior to bypass surgery for CAD is performed to determine any external damage of the body which may interfere with the surgical process and create life risk for the patient (resus.org.uk, 2022). In M’s case, no additional bruises or damages on the skin was present. The body temperature of the patient undergoing coronary bypass surgery is lowered as cooling of the body assist in lowering the oxygen needed in the body that helps surgeons to work effectively for 2-4 hours without causing any damage to the cardiac tissues (Linassi et al., 2022). Therefore, the nurses are provided with the task to cool M’s body before the surgery and continuously monitor his body temperature through electronic thermometer during the surgery so that any sudden drop in temperature can be determined which may cause life risk of patients.

Surgical Planning and Patient Needs

The surgical planning is referred to the preoperative method of prior visualisation of any surgical intervention to predefine the surgical stages to be followed and actions to be taken prior to the surgery (Sadeghi et al., 2020). The coronary bypass surgery is to be performed on M for which the surgical planning is to be made. The initial stage of the plan includes arranging detailed presence of all diagnostics results and health vital reports of the patient on whom the surgery is to be executed. Thereafter, the anaesthesia procedure is to be initiated with patient positioning for the surgery. M’s health vitals before anaesthesia are checked which indicated all the vitals including blood sugar under normal levels. In preparing M for anaesthesia, it is ensured that all forms of blood thinners are avoided week before surgery. This is because blood thinner provided to CAD individual in smoothening the blood flow causes thinning of the blood which create prevention in clotting creating opportunity of severe bleeding during surgery (Win et al., 2019). In planning effective surgery, it is to be ensured that the patient provides informed consent regarding the action. This is because it makes the patient aware of the consequence of the treatment and take decisions accordingly to avail the intervention by determining its benefits and risks towards their care (Pearse et al., 2019). Thus, informed consent was taken from M by explaining the benefit and risk of coronary bypass surgery.

In preparing the patient for anaesthesia before surgery, it is to be ensured that he maintain fasting for six hours with only clear liquid to drink until two hours before surgery. This is to avoid contents from the stomach to enter the lungs as after anaesthesia the reflexes of the body are stopped temporarily (Jiao et al., 2019). The further step includes positioning the patient in the supine position to administer the anaesthetic to gradually sedate the individual to prepare them for surgery. The anaesthetic medication is to be administered to the patient through intravenous line in the arm (Kunst et al., 2020). In case of M, similar action is to be performed where he is to be administered anaesthetic through intravenous line to make him prepared for the surgery.

During the induction and intubation of the trachea in anaesthesia, the presence of steady blood pressure and heart rate is essential in patients. Therefore, patients like M are to be preoxygenated to ensure their steady heart rate and blood pressure (Yang et al., 2020). The study by Bilgi et al. (2020) mentions that tracheal intubation is to be executed orally as nasal intubation may lead to significant bleeding after administration of heparin. Moreover, a double-lumen endotracheal tube is needed in coronary bypass surgery in case it is being performed through left thoracotomy. This is because it would help to physiologically and anatomically makes the lung isolated from the body to ensure no respiratory issue is developed during the surgery. In case of M, the coronary bypass surgery is performed through right thoracotomy due to the arrangement is not required. In the study by (Nagendran et al., 2018), it is mentioned that in a standard sternotomy, the anterior thorax of the individual remains exposed in a supine position in patients undergoing coronary bypass surgery. A roll is located in the intracapsular region for enhancing the access to the sternum by extension of the neck and elevation of the sternal notch. In usual condition, the sterile field extends from the chin to toes for including sternotomy incision as well as enhance access to saphenous veins to harvest as a conduit (Gaudino et al., 2019). Similar positioning is maintained for M to execute the surgery.

The surgery to be performed on M is coronary bypass surgery which is the surgical procedure for redirecting the blood to the heart via attached blood vessels around a section of the partially blocked entirely blocked artery in the heart. In this process, the healthy blood vessels are taken from either the arm, leg or chest to be connected below and above the damaged artery in the heart for diverting the blood flow to smoothly reach the heart (Kinnaird et al., 2018). In case of M, the surgery is to be performed because it is seen that two of his arteries delivering blood to the heart are highly narrowed which has created risk for heart attack in him. Therefore, the surgery is essential to improve the blood flow to the heart and avoid the risk of heart attack. The surgery is usually avoided to be performed in patients above 65 years of age due to life risk and the procedure is similarly followed in all patients of any age group (Kinnaird et al., 2018). For preoperative consideration regarding M, the checklist includes mentioning the information of intervention, patient details, allergies (if present), medication taken and the information of the team (anaesthetic, nurses, surgeons and others) to be involved in the surgery. This is important to ensure safe surgery as the checklist allows assessment of all the information and ensure availability of individuals required for the surgery (Jullia et al., 2017).

Intraoperative Consideration for Patient

The intraoperative period initiates from the patient being transferred to the operating room till the end of the transfer of the individual in the Post Anaesthesia care Unit (PACU). In this phase, various considerations are made for the patients so that their safety and privacy can be maintained along with their health and well-being could be promoted (Taggart et al., 2020). A checklist is maintained in the intraoperative condition which requires to include information regarding anaesthesia technique, induction pathway, airway management, in and out fluids (urine output, blood, IV fluids), equipment to be made available, required injection, haemodynamic stability, respiratory stability and remaining time of surgery (Jullia et al., 2017). The anaesthesia technique to be used for M in performing coronary bypass surgery is general anaesthesia. This is because it would make the patient entirely unaware of the surgical action and assist the patients undergoing bypass surgery to preserve their myocardial functioning, maintain stable hemodynamic and prevent ischemia (Labus et al., 2021). According to the checklist, the technique is to be effectively analysed to determine M receives proper anaesthesia to allow surgeons to initiate the surgery.

According to the checklist, one of the intraoperative considerations is blood loss monitoring during the surgery. In the study by Nelson et al., (2018), it is mentioned that 500ml of blood loss occurs in 89% of the surgical operations in patients. Thus, the extent of blood loss is to be detected in M during the intraoperative phase so that the amount of blood and haemoglobin level do not become extremely reduced that may cause cardiac attack. During blood loss monitoring, the nurses could use the cell savers for M undergoing coronary bypass surgery. This is because the cell savers help to avoid allogeneic blood transfusion and enhance the outcome for the patients through removal of debris from the blood shed during the surgery, which assist in avoiding risk of neurocognitive dysfunction or stroke after the surgery (Nelson et al., 2018).

The nurses under care of the patient have the interoperative consideration of ensuring all the health documentations of the patient is present in the environment to be referred during the surgery by the surgeon to execute the actions smoothly (Stone et al., 2021). The other consideration includes maintaining steady body temperature to ensure the patient remain warm and do not suffer from hypothermia. This is because hypothermia leads to hindered functioning of the organs leading to create risk of death in patients out of respiratory or heart failure (Alqalyoobi et al., 2019). In coronary bypass surgery, the common equipment used are Heart Lung machine, Defibrillator with internal paddles, heater cooler, sternum saw, extractors and others (Merkle et al., 2019; Azarrafiy and Carrillo, 2018). Thus, according to the checklist, it is to be ensured that all the equipment is available during M’s surgery by the surgical first assistant and ensure the individual can provide them to the surgeon during the surgery without delay.

The urinary catherization is required for M as well as for any individual of any age undergoing cardiac surgery to help the patients drain the urine freely from the bladder for collection. The patients after the cardiac surgery have limited movement due to which they are unable to use the bathroom for releasing the urine for which the catherization is important (Shaw et al., 2018). At the end of the surgery, wounds are to be stitched and dressed to avoid any blood release from the wounds and ensure their steady healing (Alqalyoobi et al., 2019). In coronary bypass surgery, a chest brain is fitted in the chest area of the patient to help the fluids and the air to be drained from the chest cavity. This is because without its release, the patient could not get resolved from cardiac complication and experience issues with respiration after the surgery (Stone et al., 2021). Therefore, chest drain is to be fitted to the chest of M which is to be removed 48-72 hours after the bypass surgery unless there is more damage, or the surgeon determines other reason for keeping the tubes (Hussain and Harky, 2019).

Patient Transition to Intensive care after surgery

The SBAR communication tool is to be used in framing interaction between the healthcare team and the surgical team for enhanced transferring of M from the operating theatre to the intensive care unit (ICU). The SBAR stands for situation, background, assessment and recommendation (Rehm et al., 2021). The situation includes providing concise description of the patient’s problem and the background include imparting pertinent knowledge about the present condition of the patient (Kiesle and Hooten, 2018). This indicates that during the transfer of M to ICU, brief and concise statement of M’s health problem is to be shared with the nurse in-charge of his care. Moreover, the nurse is to be informed regarding the present health situation after the surgery of M and present the health report with current vitals of M during the transfer. This is to make the nurse understand in what condition the patients are transferred and develop idea regarding the needs to be fulfilled to ensure the patient’s effective care after surgery.

The assessment includes analysis and consideration of the care options for the patients after the surgery during transfer to the postoperative unit (Rehm et al., 2021). In this regard, nurse in-charge for M is to monitor and assess M’s health condition and develop communication with the surgeon or the physician caring for M to inform the assessment fort assisting them in effective analysis of the condition of the patient. It is important to help them recommend the further care to be followed for M by the nurse to ensure his good and steady recovery after surgery in the ICU. The recommendation includes informing the additional treatment and medication to be administered to the patient based on their existing health condition (Kiesle and Hooten, 2018). In this regard, the physician analysing M’s health is to inform the nurse in-charge of the medications and additional treatment to be made available for him to ensure his good health in the ICU. During handover of the patient from the OT to ICU, the patient’s family members are to be communicated regarding the way they are to interact with the individual during visitation so that no stress is created on the patient (Marshall et al., 2019). Thus, M’s wife was informed regarding the importance of controlling her emotion and need of her to make minimum interaction with M in the ICU for his better health.

Evaluation of Care

In caring for the patient, many staffs and professionals are available who have advanced and non-medical roles to be performed for the patient. In evaluating M’s care, the role to be focussed is that of surgical first assistant. The surgical first assistant (SFA) are individuals who work closely with the surgeons, anaesthesiologists, nurses and other staff of the healthcare team to ensure safe surgical process for the patient (Hoffman et al., 2021). The role of SFA is that they have the role to act in best interest of the patient and respect their self-determination and autonomy (afpp.org.uk, 2021). This is significant to ensure positive health consequences for the patients and make them feel valued in care which intends them to show increased compliance (Nissen et al., 2021). In case of M’s care, SFA has effectively played his role of acting in best interest of M by informing the surgeon about the patient’s details through the chart to avoid any lack of information that may create delay or error in performing the surgery on him. The role of SFA also includes maintaining privacy and confidentiality of all information of the patients only to be revealed under the permission of the patient (Bachar and Manna, 2018). The SFA caring for M ensured his confidentiality and privacy of health information under all conditions by allowing it to be shared between physicians caring for him.

The role of the surgical first assistant (SFA) is to manage the pre-operative and post-operative settings where they are responsible in primarily assisting the surgeons in the operation theatre like handing and arranging surgical tools, dressing surgical wounds, holding open incisions and others (rcseng.ac.uk, 2021). In case of M, it was seen that SFA played similar role where he effectively supported the main surgeon in-charge of performing the coronary bypass surgery of M in the operation. The SFA for M was seen to handover the right tool for use during the entire surgery along with assisting the surgeon in holding the wound and in the end dressing the surgical wound. It helped the surgeon performing surgery on M avoid facing hindrance during operation and act in dedicated manner to complete the surgery with no error. The role of SFA promotes positive patient journey because they act to support autonomy and non-maleficence for the patient along with delivery care with justice (afpp.org.uk, 2021). In M’s case, it was seen that SFA allowed the patient to take own decision regarding approving the surgery and delivered care in justified way by withholding personal beliefs.

The SFA role for M contributed to the benefits of the organisation to retain staff because the individuals performed all the provided responsibilities in an enhanced way due to which no work pressure was created on others. The lack of work pressure and positive working environment helps in retaining staff because the staff do not feel overworked and feels valued to execute their task (Khan et al., 2019). In order to become SFA, the qualification required is that the individual need to be a registered care practitioner with the Nursing and Midwifery Council (NMC) or Health Care Professional Council (HCPC). They are to be employed in surgical environment and required graduation in medication (bucks.ac.uk, 2022). The SFA are trained in the surgical department where they work under the direct supervision of the surgeon (rcseng.ac.uk, 2022). The Health Care Professional Council (HCPC) or the Association for Perioperative Practice (AfPP) registers the SFA (rcseng.ac.uk, 2022). The salary of SFA in the UK is on an average of £34,024 per year and get indemnity from the assistance of AfPP. They are well accepted in this role by the surgeon because it helps them to share the responsibilities of surgery of the patient and access effective help required to perform complex surgeries (rcseng.ac.uk, 2022).

Conclusion

The above discussion mentions that M is admitted to the hospital due to serious chest pain and was analysed to determine he required immediate coronary bypass surgery. His blockage of the arteries leading to the heart is at critical stage because they are transferring minimum amount of blood due to extreme constriction out of plaque deposition which is creating risk of heart attack for him that could be fatal. The advanced health monitoring of M is performed and documentation of his health through ABCDE assessment shared with the surgeon. This is to help the surgeon effectively plan his surgery to ensure his smooth recovery. A general anaesthesia is being performed on M to allow his surgery and in interoperative care condition, effective monitoring of his health condition, body temperature, blood count and others are kept to understand his response to the anaesthesia and prepare for the surgery. During handover from OT to ICU, SBAR communication tool is used to ensure safe transfer.

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