CABG

Operation report

Admit: 25/8

Operation day: 26/8

Surgeon: Mr EJB

Assistant: Sn T and Sn Sn H

Scrub nurse: Sn W

Anesthetist: Dr G

Perfusionist: MAL

Diagnosed: Coronary artery disease with EF 70%

Operation: CABG x3 with LIMA to the LAD vein graft to OM and RCA

Finding: Dilated heart

LAP 25mm very severely diseased.

OM 2mm very severely diseased.

RA 2.5mm severely diseased.

Perfusion Data

Aortic Cannula: 20FR

Venous Cannula: Sams 2 stage

Dump: Sto ckert-shiley oxygenator; capiox

By pass time: To minutes

X-clamp time: 43 minutes

The operation steps

The chest was opened via a median sternotomy. The LIMA and segment of each long saphenous vein were haruested. After systemic heparinization, cardiopulmonary by pass was established for a total of 70 minutes using a size 20 FR aortic cannula and a 2-stage venous cannula. Capliox membrane oxygenator was used. The patient's temperature was lowered to 32'C. The aorta was cross-clamped for a total of 43 minutes and warm blood cardio plegia solution infused into the aortic arrest. Subsequent doses were antegradely given every 15 minutes.

The vein graft were anastomosed to the RCA and OM using continuous 7 '0' Prolene. On removal of the cross clamp, the heart reverted spontaneously to sinus rhythm. The proximal anastonaoses of the vein grafts were performed to the aorta using a side-biting clamp.

After full systemic re warming cardiopulmonary by pass was wanted off without difficulty. Protamine was given. Hemostasis was secured. Routine de cannulation was performed. The chest was closed in routine fusion, with left pleural and mediastinal drains. The sternum was re approximated with three figure of eight wires. The subcutaneous tissues was closed with 1 '0' Vicryl suture. The skin incision was closed using subcuticular 3 '0' Vicryl.

The patient was then transfered to cardiothoracic intensive care unit intubated was satisfactory hemodynamics. The instrument and swab counts were correct at the end of the procedure.

CABG post-operative orders

Monitoring

low high unit

heart rate 50 110 bpm

systolic BP 90 140 mmHg

diastolic BP 50 70 mmHg

mean BP 70 100 mmHg

CVP 5 10 mmHg

PCNL 8 12 mmHg

CI 2.2 3.5 L/min/ msq

S.V.R.I 800 1500 v/msq

Laboratory

P.C.V 30 55 persent

pH 7.4 7.5

PO2 100 200 mmHg

PCO2 30 45 mmHg

Potassium 3.0 4.5 mmol/L

Chest Drainage

First hour less than 400ml

subsequent hour less than 200 ml/ hour

urine output > 1/2 ml/kg body weight/ hour

1. NG tube to intermittent suction. Remove when patient extubated. CBD to gravity. Chest tubes to lower suction at 20cmH2O.

2. Laboratory studies PCV, Na, K, ABG, on arrival and PRN. FBC, Renal profile, RBS on arrival and 1st POD. If patient diabetic, initial insulin protocol 4 hourly.

3. CXR within 1 hour of arrival and PRN on 1st POD.

4. Diet: Nil orally until extubated and NG tube out. Then begin clear liquids and proceed to no added salt, low cholesterol diet.

5. IV Fluid: Maintains D5% at 60 mm/hr. When patient is taking orally, may discontinue IV infusion. Leave one peripheral IV capped.

6. Antibiotic: Superazon 1gm TDS

7. Morphine infusion: 30 mg/ 50ml 5% Dextrose at 1-5 ml/hr

8. Sedation: Dormicum 2.5 mg IV 1-2 hourly for agitation.

9. Potassium infusion: 1g in 40ml 5% Dextrose at 5-20 ml/hr tilt rate to K level. Administer through central line.

10. Other medication: GTN, Controlc, Dopamin

11. (ventilator setting)

12. Extubation plan: Early extubation

13. Post extubation, give 50% oxygen by ventimask.

14. Cardia output studies are done on arrival from theatre and repeated every 4 hourly if required.

15. Inotropes and vasodilators as order by surgeon.

16. 12- leads ECG when patient's temperature 36.5'C.

17. Increase activity according to open heart surgery critical path.

18. Start Aspirin 75mg daily on 1st POD if no contraindication.

The medication the patient was on;

- IV Superazon 1gm TDS

- IV Controloc 40mg OD

- IV Morphine 30mg/ 50mls

- IV Dopamin 200mg/ 50mls

- IV KCL 1gm/ 50mls

- IV GTN 50mg/ 50mls

- IV Precedex 200mg/ 50mls

- IV Maxolon 10mg PRN/6hr

- Plavix 75mg OD

- Frusemide 40mg OD

- Slow K 2 tab OD

- Duragesic patch 25mg

- Tramadol 50mg 6hr

- Vascor 10mg ON

On the 26/8 after the operation, total drainage was 380mls and on the 27/8 was 180mls. There were still infusion of 1 pack cell of blood during the intra-operation and 2 more pack in reserve and the left over blood of the patient was infused back. And in 2 days time, Plasma gel of 1350mls has been infused for the CVP was low. Patient was extubated on the 26/8 at 2040 hours and was admitted to ICU at 1230 hours. In the morning on the 27/8 patient does not have good aptitude, the infusion D5% was continued. At 1245 hours the left pleural and mediastinal drains has been removed. After the operation, the HGT checked for the patient was slightly high, infusion insulin 1:1 was put on for 3 hours then was stopped. The K was low after the operation but manage to push back with the infusion of 30mls/hr with the lowers reading of 3.49 and was reduced to 10mls/ hr at the reading of 4.73.