Post CABG Scenario

[Ridryder911]

Case Presentation

You receive a call about a patient in one of your swankiest restaurant in town. You arrive on the scene and find a man who appears to be in his early 50's lying on a bench with sweat pouring from his face. The patients wife informs you that he was released from the hospital this morning after having emergency bypass surgery 5 days ago, and had been feeling great!" But now, she states " he just doesn't look right".

As you approach the patient you find he is warm/hot and diaphoretic, but easily aroused. When you awake him he tells you he feels fine and wants to go home and relax after his surgery. You check his pulse and it is rapid and irregular, his blood pressure 88/50. Your partner quickly establishes an IV with an 18 gauge IV and hangs a bag of saline, while you place the patient on the monitor.

The patient's wife peers over your shoulder and tells you that her husband
had been complaining of palpitations, shortness of breath, and a little chest pain right after eating some dinner, but notes that he was able to eat a hearty meal of T-bone, spinach and fries.

Questions

1. What is the most likely rhythm to occur in this patient, and why does that patient have this rhythm now?

2. When is the most " dangerous" time for post CABG's ?

3. What are the various therapeutic options for this patient and in what scenarios would be preferred over another ?

4. What are two common types of divisions of medications this patient will be placed upon, following discharge with a CABG ?

R/r 911

 

[prizonmedik]

1) Atrial Fib is the most likely rhythm, there are any number of reasons that
could predispose a post-CABG pt to AF. Most common are
age and previous AF event. And why does this pt have that
rhythm now? That's simple.....Because God wants them to.

2) The most dangerous time for a post-cabg pt seems to be
days 3-7.

3) Therapuetic options vary greatly and will depend on the
the pt. Remember we're treating our pt, not our monitor.
Treatment modalities will range for electricity, to bi-chamber
pacers, to v-rate lowering drugs. As for what to prefer in
what situation, agian that would depend on the pt. For
stable pts Diltiazem and Esmolol are preferred tx, with Esmolol
being slightly favored.

4) As for post-CABG meds, most likely there will be a bag full, but
Anti-hypertensives and Lipid-lowering meds will certainly be
included.

 

[Airwaygoddess]

S/P CABG x 5 post-op Good chance pt is in a rapid A-fib along with possible CHF.
The patient's chest pain sounds could be from his incision from his surgery. Medications could be as follows post op, Vasotec, Lasix, potassium choride, possiblie antiarryhmic, stool softners, and pain medications, and maybe sleeping pills. S/P hearts possible "trouble" zone up to 72 hours from time of discharge. Need to re-read what else was asked for this patient.

 

[Ridryder911]

Very Good!

Following a CABG there are usually two peak times in the incidence of arrhythmia's. The first in the operating room and the second usually is between the second and fifth post-op days. The underlying problems of why there is usually arrhythmia's is still unclear. But many describe them due to the effects of circulating catecholamines, changes in the autonomic nervous system tone, changes in the electrolyte imbalance, myocardial ischemia or just irritation of the heart.

Other several factors may include flux changes of the electrolytes within in K+, MG+, CA+, and maybe Dig tox effects.

You guys are right Atrial Fibrillation is the most common arrhythmia following cardiac surgery, the best management strategies is yet to be defined. Even if the patient has been on prophylactic Dig, beta blockers, transient A-Fib occurs in at least 25%-30%of patients after CABG.

New methods have been now utilized as FedMedic described. If the patient is hemodynamically stable some use of Verapamil (5mg SIVP) q every 5 minutes upt to 3-4 doses. Newer in the past 5-10 yrs is Dilitizem (Cardizem 0.25mg-0.35mg/kg bolus over 2 minutes). Esmolol (Brevibloc ) is Beta1 blocker, a newer med primarily used for SVT as well. The problem is sudden discontinuation can lead to increase . The dose is dysrhythmias usually 50 mcg/kg to 200 mcg/kg and one has to perform a "loading dose: first with a maintenance drip followed. Dosage needs to be recalculated if they are already on Beta blocker up to 50%. Some of the cardiologist I am in rotation with loves the stuff, and the other despises it.. so I have seen mix results, personally I have seen it abolish SVT in lieu of cardioversion. Professionally, have not seen it used that much for A-fib with RVR, but understand it is an alternative.

The pacemaker is newer device that has brought an alternative way for those with chronic A-fib, that is resistant to other therapy. One of the physicians father is one of the inventor of the bi-chamber pacer and as well experimental cutaneous plasty ablation that re-routes the pathway.

Speaking of SVT, is also another post CABG side effect, as well as ventricular arrhythmias. Although new conduction defects may develop up to 45% of patients following cardiac surgery, the majority are usually transient and related to the use of cold cardioplegia, hypothermia, and electrolytes shifting.

Of course other dangers include P.E.'s , arterial spasms, myocardial ischemia. Almost all patients have a pericardial effusion (fluid around the heart, within the sack). These effusions may develop into cardiac tamponade post-op and has to be considered in patients that of course have JVD, muffled heart tones, pulse paradoxus (inspirational changes in systolic blood pressure) (Beck's Triad) and or hypotension.

The other problem that I did not realize was so prominent was mediastinitis, which occurs about within 2 weeks. the usually represent fever and purulent discharge from sternal wound.

Risk factors from this is usually from prolong cardiopulmonary bypass time, excessive bleeding, and poor cardiac output. Usually, the incidence of mediastinitis is increased with both the internal mammary arteries are used bilaterally for use of conduits. Many Doc's prefer to use only to use the left internal mammary artery, especially in geriatric, and diabetics, who may already have a wound healing problem.

Usually, one obtains wound cultures as well as blood cultures and seek specific growth. Staphylococcus aureus (Staph) is the usual culprit.

The most common medication are usually as described from airway goddess described. More common are angiotensin-converting enzyme (ACE) inhibitors
and anticoagulants such as Coumadin, or Plavix. The problem with ACE is they can cause problems on the glomerular capillary pressure as well the patient has already been through nephrotoxic drugs, radiocontrast med's (they glow in the dark) and cholesterol plaque med.'s this can screw up the kidneys and cause renal failure.

Even though these procedures are considered "routine" and occur daily nationwide, and over all most do not have "drastic" effects, EMS needs to be cautious aware of potential patients as more and more are members of the "zipper" club.


Great going and good answers guys !

R/r 911

 

[Airwaygoddess]

Thank you RID!!

 

[Guardian]

Interesting discussion. I did a statistics project on post heart op complications and was amazed at the number of new onset A-fib cases.