Cardiac Surgery Nursing Guide

Cardiac Surgery Overview

CABG — Coronary Artery Bypass Grafting

On-Pump vs Off-Pump

Feature	On-Pump (CABG)	Off-Pump (OPCAB)
CPB used	Yes	No
Heart arrested	Yes (cardioplegia)	Beating
Coagulopathy risk	Higher	Lower
Completeness of revascularisation	Easier	Technically demanding
Neurological risk	Slightly higher	Lower

Conduit Harvest Sites

LIMA/RIMA Left/Right Internal Mammary Artery — gold standard for LAD; superior patency >90% at 10 yr
Saphenous Vein Great saphenous vein from leg; endoscopic or open harvest; 60–70% patency at 10 yr
Radial Artery Non-dominant forearm; check Allen's test pre-op; calcium channel blocker peri-op to prevent spasm

Valve Surgery

Repair vs Replacement

Repair — preferred for mitral valve when feasible; preserves LV geometry; no anticoagulation needed long-term
Replacement — required when repair not possible; choice of prosthesis matters

Prosthetic Valve Types

Type	Durability	Anticoagulation	Preferred in
Mechanical	Lifetime	Warfarin lifelong (INR 2.5–3.5 mitral; 2.0–3.0 aortic)	Age <60, no contraindication to anticoag
Bioprosthetic	10–20 yr	3 months only (then aspirin)	Age >65, women of childbearing age, warfarin contraindicated

TAVI / TAVR

Transcatheter Aortic Valve Implantation — minimally invasive alternative to surgical AVR for severe aortic stenosis.

Key Points for Nurses

Delivered via femoral artery (commonest), subclavian, or direct aortic approach
Patient remains on heparinised ACT monitoring throughout procedure
Post-procedure: monitor for vascular access site complications, heart block (permanent pacemaker risk ~5–10%), stroke, paravalvular leak
Dual antiplatelet therapy (aspirin + clopidogrel) for 3–6 months post-TAVI
Avoid Foley removal until rhythm stable — LBBB may progress to CHB

Monitor ECG for new LBBB / AV block every shift for 48–72 h post-TAVI.

Congenital Heart Repairs

ASD (Atrial Septal Defect)

Percutaneous closure (Amplatzer device) or open surgical patch repair
Post-op: monitor for atrial arrhythmias, residual shunt on echo

VSD (Ventricular Septal Defect)

Patch closure on CPB; peri-membranous VSDs — risk of complete heart block
Post-op: monitor PA pressures, watch for pulmonary hypertensive crisis

TOF — Tetralogy of Fallot

4 components: VSD, overriding aorta, RVOTO, RVH
Complete repair: VSD patch + RVOT reconstruction; often done in infancy
Post-op adult TOF: monitor RV function, residual PR; risk of VT/VF

Pre-Operative Assessment & Optimisation

Cardiac Assessment

ECG (12-lead baseline)
Echocardiogram (EF, valve function)
Coronary angiogram results
Exercise tolerance / METS
Carotid Doppler if indicated

Laboratory Baseline

FBC, U&E, LFTs, coagulation (PT/APTT/INR)
Blood group & crossmatch (4–6 units PRBCs)
HbA1c (target <8% pre-op)
Creatinine / eGFR — CPB risk
CXR + PFTs if pulmonary risk

Optimisation Targets

Stop warfarin 5 days pre-op (bridge if needed)
Stop clopidogrel 5–7 days pre-op
Continue aspirin unless surgeon requests stop
Treat active infection / dental work
Glycaemic control (insulin sliding scale)
Smoking cessation >8 weeks pre-op
Chest physiotherapy teaching
Sternal precaution education

Nurse role: confirm consent signed, skin prep (chlorhexidine shower x2), IV access (large bore x2 + arterial line), NBM status verified, pre-op medications given per chart.

Cardiopulmonary Bypass (CPB)

CPB Circuit Components

Venous reservoir — collects deoxygenated blood from RA/IVC via cannulae
Oxygenator (membrane) — gas exchange; CO2 removal and O2 addition
Heat exchanger — integral to oxygenator; controls blood temperature
Roller / centrifugal pump — drives blood flow; centrifugal pumps are less haemolytic

Arterial filter — catches microemboli before returning blood to patient
Cardiotomy suction — salvages blood from operative field
Cell saver — washes shed blood; returns packed RBCs; reduces allogeneic transfusion by 30–40%
ACT monitoring — Activated Clotting Time; target >480 sec on CPB

Hypothermia During CPB

Level	Temp	Use
Normothermia	36–37°C	OPCAB, short cases
Mild	32–35°C	Most CABG/valve
Moderate	26–31°C	Complex cases, aortic arch
Deep (DHCA)	18–25°C	Circulatory arrest — aortic dissection

Hypothermia reduces O2 demand ~7% per °C. Rewarming must be gradual (<0.5°C/min) to avoid neurological injury and coagulopathy.

Myocardial Protection — Cardioplegia

Warm blood cardioplegia — continuous or intermittent; better metabolic protection
Cold crystalloid cardioplegia — St. Thomas, Custodiol (HTK); single-dose options
Delivery routes — antegrade (aortic root/coronary ostia) and/or retrograde (coronary sinus)
Potassium 15–30 mmol/L → diastolic arrest
Nurse monitors: ECG flatline on arrest, cardioplegia pressures (<100 mmHg antegrade), root vent active

Cross-clamp time is ischaemia time. Surgeon aims <90–120 min; prolonged times increase risk of myocardial stunning and low cardiac output.

Post-Bypass Coagulopathy

CPB activates contact pathway → consumes clotting factors and platelets
Haemodilution from prime volume (~1.5–2 L crystalloid)
Hypothermia impairs platelet function and enzymatic clotting
Fibrinolysis activated via plasminogen activators on circuit surfaces

Management

Antifibrinolytics: Tranexamic acid (TXA) routinely — reduces blood loss 30%
Epsilon-aminocaproic acid (EACA) — alternative
FFP for factor replacement (PT >1.5x normal)
Platelets if <80 ×10⁹/L post-CPB
Cryoprecipitate if fibrinogen <1.5 g/L
ROTEM/TEG-guided transfusion reduces over-transfusion

Protamine Reversal of Heparin

Heparin dose pre-CPB: 300–400 IU/kg IV (ACT >480 sec target)
Protamine dose: 1 mg per 100 IU heparin given (or per weight-based protocol)
Given slowly IV over 10–15 min — rapid injection causes hypotension, pulmonary hypertension, bradycardia
Target ACT returns to baseline (<150 sec)

Protamine reactions: anaphylaxis risk especially in fish allergy, prior NPH insulin use, prior vasectomy (anti-sperm antibodies may cross-react). Have adrenaline, calcium, and vasopressors immediately available.

Typical CPB Times (CABG)

Bypass time: 60–120 min
Cross-clamp time: 40–90 min
Rewarming: 15–30 min

Post-Operative ICU Management

Immediate handover from theatre: verify airway security, ventilator settings, lines (arterial, CVP, PA catheter if present), pacing wires, drain outputs, temperature, haemodynamic parameters, vasoactive infusions running.

Immediate Post-Op Priorities (First 4 Hours)

Haemodynamic stabilisation — MAP 60–80 mmHg, HR 60–90 bpm
Temperature management — rewarm to 36.5°C; avoid hyperthermia (>38°C)
Haemostasis — monitor chest drains; >200 mL/h → surgical review
Ventilator management — lung-protective settings; target FiO2 <0.5 once SpO2 >95%
Pacing wires — check threshold daily; keep pacemaker connected for 48–72 h
Glycaemic control — insulin infusion; target BGL 6–10 mmol/L
Pain control — opioid PCA or nurse-controlled analgesia; paracetamol PRN
Neurological assessment — GCS, pupils on waking; report any deficit immediately

Chest Drain Management

Types Post Cardiac Surgery

Mediastinal drain — 28–32 Fr; drains pericardial space; low suction (-20 cmH2O) or water seal
Pleural drain(s) — if pleura entered during LIMA harvest; bilateral if bilateral IMA used
Epicardial pacing wires — atrial and ventricular; exit through inferior incision

Nursing Observations

Record output hourly for first 12 hours, then 4-hourly
Assess colour — bright red arterial blood vs dark venous ooze
Maintain patency — gentle milking if instructed (evidence mixed)
Removal criteria: output <100 mL/8h, no air leak, patient mobile, chest X-ray reviewed

Sudden cessation of drain output + haemodynamic deterioration = suspect tamponade. Do NOT clamp drain. Call surgeon immediately.

Vasoactive Infusions

Drug	Mechanism	Indication	Nursing Note
GTN (nitroglycerin)	Venodilator; ↓ preload; coronary vasodilator	Hypertension, coronary spasm, elevated PAWP	Titrate to MAP; tolerance develops; use glass/non-PVC tubing
Noradrenaline	α1 vasoconstrictor; ↑ SVR & MAP	Vasodilatory shock, post-CPB vasoplegic syndrome	Central line only; monitor for peripheral ischaemia at high doses
Vasopressin	V1 receptor vasoconstriction; hormone replacement	Vasoplegic syndrome refractory to NA; low dose 0.01–0.04 units/min	No dose titration as per NA; adjunct therapy; monitor for hyponatraemia
Dopamine	Dose-dependent: DA1 renal, β1 inotropic, α1 vasoconstriction	Low CO with low HR; historical use in renal protection (abandoned)	Arrhythmogenic; mainly replaced by noradrenaline + dobutamine
Dobutamine	β1 inotrope; ↑ CO, ↓ SVR	Low cardiac output syndrome, RV failure	Tachyarrhythmia risk; wean as CO improves; check lactate
Milrinone	PDE-3 inhibitor; inotrope + vasodilator	RV failure, pulmonary hypertension, weaning from CPB	Hypotension common; long half-life; load cautiously

Ventilator Weaning Criteria

Haemodynamically stable — minimal vasoactive support
Temperature 36–37.5°C
GCS 15 / responding to commands
SpO2 >95% on FiO2 ≤0.4
PEEP ≤5 cmH2O
Tidal volume >5 mL/kg spontaneous effort
RR <25 per min on minimal support
pH 7.35–7.45, PaCO2 35–45 mmHg
Chest drain output <100 mL/h
No significant arrhythmia

Extubation Protocol

Wean to CPAP/PS trial 30 min
Pre-oxygenate 100% FiO2 × 3 min
Suction ETT and oropharynx
Deflate cuff and remove under direct instruction
High-flow O2 mask immediately post-extubation
Encourage cough and deep breathing within 15 min

Fast-track extubation (<6 h) for uncomplicated CABG reduces ICU LOS and improves outcomes. Nurse-led extubation protocols are now standard in many GCC cardiac ICUs.

Sternal Precautions & Early Mobilisation

Sternal Precautions (6–8 weeks)

No pushing/pulling with arms >2 kg
No lifting >1–2 kg
Log-roll to sit up (no bed-pull)
Support sternum with pillow when coughing
No driving for 6 weeks

Mobilisation Milestones

Day 0: Passive limb exercises in bed
Day 1: Sit out of bed × 2 (post-extubation)
Day 2: Stand and transfer; short walk in room
Day 3–4: Supervised corridor walking
Day 5–7: Ward discharge criteria met

Physiotherapy Role

Chest physiotherapy: incentive spirometry Q2h
Huffing and coughing technique
Leg exercises: prevent DVT (TED stockings + LMWH)
Monitor O2 sats during exercise
Discharge: cardiac rehab referral

Chest Drain Output Tracker

Enter hourly drain outputs (mL). An alert will trigger if output exceeds 200 mL/h for 2 or more consecutive hours.

Complications Management

Low Cardiac Output Syndrome (LCOS)

Defined as CI <2.0 L/min/m² or SBP <90 mmHg requiring haemodynamic support.

Clinical Features

Cool, clammy peripheries; mottling
Oliguria (<0.5 mL/kg/h)
Metabolic acidosis; rising lactate
Low mixed venous O2 saturation (<60%)

IABP — Intra-Aortic Balloon Pump

Indications: LCOS not responding to inotropes, unstable angina, pre-op in high-risk CABG, post-CABG cardiogenic shock
Inflates in diastole (augments diastolic pressure, improves coronary perfusion)
Deflates just before systole (reduces afterload)
Counterpulsation ratio: 1:1 (every beat), can wean to 1:2 then 1:3
Anticoagulation: heparin infusion (APTT 60–80 sec)

IABP contraindications: severe aortic regurgitation, aortic dissection, severe aorto-iliac occlusive disease, significant aortic aneurysm.

Post-CABG Atrial Fibrillation

Most common post-cardiac surgery complication — incidence 20–40%. Peak onset: post-operative days 2–4.

Pathophysiology

Pericardial inflammation, atrial stretch, catecholamine surge, electrolyte disturbance

Management

Rate control — Metoprolol IV/PO; Amiodarone IV loading 300 mg over 1h then infusion
Rhythm control — DC cardioversion if haemodynamically compromised; Amiodarone
Anticoagulation — if AF >48 h or haemodynamically compromised; LMWH/heparin bridge; NOACs or warfarin at discharge
Electrolyte correction — K⁺ target 4.0–4.5 mmol/L; Mg²⁺ 1.0–1.2 mmol/L

Prophylaxis (Pre/Post-Op)

Beta-blockers pre and post-op reduce AF incidence ~50%
Amiodarone prophylaxis if beta-blockers contraindicated
Statin therapy may reduce AF risk

Cardiac Tamponade

Life-threatening emergency. Most common within 24–48 h post-op. Can occur days later if anticoagulated.

Beck's Triad

Hypotension (SBP falling, narrow pulse pressure)
Elevated JVP / raised CVP
Muffled / distant heart sounds

Additional Signs

Tachycardia; pulsus paradoxus (>10 mmHg fall on inspiration)
Equalisation of CVP, PAWP, PAD pressures
ECG: low voltage, electrical alternans
Sudden cessation of chest drain output

Management

Urgent bedside pericardiocentesis (echo-guided if available)
Surgical re-exploration if post-operative cause
Nurse role: prepare resuscitation trolley, alert surgeon immediately, IV fluid bolus, document baseline observations, consent family

Deep Sternal Wound Infection (DSWI)

Risk Factors

Obesity (BMI >30), diabetes, bilateral IMA harvest
COPD, renal failure, prolonged ventilation, re-exploration for bleeding
Organisms: Staph aureus (MSSA/MRSA), Gram-negative bacilli

Prevention (Nurse Role)

Chlorhexidine shower pre-op x2
Perioperative antibiotics: cefazolin within 30–60 min of incision
Strict glucose control: BGL <10 mmol/L perioperatively
Meticulous sterile dressing technique
Inspect wound daily: redness, warmth, swelling, discharge, sternal click

Treatment

Antibiotics guided by wound culture
Surgical debridement + VAC therapy (Negative Pressure Wound Therapy)
Sternal reconstruction with pectoralis major flap if required

Post-Operative Stroke

Incidence 1–3% post-CABG; higher with valve surgery, age >70, carotid disease, aortic atheroma.

Types

Type I — focal neurological deficit, TIA, stroke, stupor/coma
Type II — diffuse encephalopathy, agitation, confusion, cognitive deficit

Nursing Actions

Hourly neuro obs until stable: GCS, pupils, limb power, speech
FAST assessment: Face drooping, Arm weakness, Speech, Time to act
Urgent CT brain (exclude haemorrhage before anticoagulation)
Neurological team referral within 4 hours of deficit noted
Maintain MAP 70–90 mmHg (cerebral perfusion pressure)
Thrombolysis rarely used post cardiac surgery due to bleeding risk

Acute Kidney Injury (AKI)

Incidence 5–30% post CPB; 1–5% require renal replacement therapy (RRT). Creatinine rise >26 µmol/L within 48 h = AKI Stage 1.

Causes Post Cardiac Surgery

CPB non-pulsatile flow → renal ischaemia
Low cardiac output / prolonged haemodynamic instability
Haemolysis during CPB (haemoglobin nephrotoxicity)
Contrast nephropathy (post-angiogram)
NSAID use, nephrotoxic antibiotics

Management

Maintain MAP >65–70 mmHg; optimise CO
Strict fluid balance — hourly urine output; target >0.5 mL/kg/h
Avoid nephrotoxins: NSAIDs, gentamicin, IV contrast
Furosemide for fluid overload only (not renal protection)
CVVH/CRRT if oliguric AKI stage 3 or fluid overload
Daily U&E, creatinine, daily weights

Mechanical Cardiac Support

IABP — Intra-Aortic Balloon Pump

Indications

Cardiogenic shock post-CABG/MI
Pre-op high-risk CABG (EF <30%)
Unstable angina refractory to medical therapy
Bridge to LVAD/transplant
Acute MR (papillary muscle rupture)

Timing & Ratio

Trigger: ECG (R-wave) or arterial pressure waveform
Standard ratio: 1:1 (every cardiac cycle)
Wean: 1:2 → 1:3 → removal when CO adequate
Optimal inflation: dicrotic notch on arterial trace
Optimal deflation: end-diastole (just before systolic upstroke)

Troubleshooting Triggers

Problem	Cause	Action
Early inflation	Mistimed trigger	Adjust trigger sensitivity
Late inflation	Poor diastolic augmentation	Adjust inflation timing
Early deflation	Suboptimal afterload reduction	Adjust deflation timing
Late deflation	Increased afterload, LV obstruction	Adjust deflation timing urgently
No augmentation	Balloon perforation, gas leak	Remove IABP immediately — gas embolism risk

Helium gas is used (low viscosity, inert). Blood in catheter = balloon rupture. Remove immediately and notify physician.

ECMO — Extracorporeal Membrane Oxygenation

VA-ECMO (Venoarterial)

Indication: cardiac arrest, cardiogenic shock, failure to wean from CPB
Cannulation: femoral vein (drainage) → femoral artery (return) or central (RA→Ao)
Provides both cardiac AND respiratory support
Flow: 3–5 L/min; target mixed venous O2 sat >70%
Risk: LV distension (may need venting or IABP)
North-South syndrome: differential hypoxia; upper body gets native cardiac output

VV-ECMO (Venovenous)

Indication: severe ARDS, respiratory failure (no cardiac support)
Femoral vein → jugular vein return
Oxygenates blood; does NOT provide cardiac output

Circuit Monitoring (Hourly)

Flow rate (L/min), RPM, sweep gas (FiO2 & flow)
Pre/post oxygenator pressures — ΔP (>50 mmHg → clot in oxygenator)
Oxygenator inspection: dark streaks = clot; white strands = fibrin
Arterial & venous line temperatures
Cannula insertion site — check for bleeding, limb perfusion
Distal perfusion cannula for femoral arterial ECMO

Anticoagulation on ECMO

UFH infusion — target APTT 60–80 sec OR anti-Xa 0.3–0.5 IU/mL
ACT 160–200 sec during ECMO run
Hold anticoagulation if active bleeding (short periods only)
Bivalirudin — alternative if HIT suspected

Complications

Bleeding (cannula sites, surgical), HIT, thromboembolism
Haemolysis — check LDH, plasma free Hb daily
Circuit clot, oxygenator failure, pump failure
Limb ischaemia — distal perfusion cannula critical

LVAD — Left Ventricular Assist Device

Common Devices in GCC

HeartMate 3 (Abbott) — current gold standard; magnetically levitated centrifugal pump; reduced haemocompatibility events
HeartWare HVAD (Medtronic) — centrifugal; now phased out in many centres due to adverse event data but still in patients
HeartMate II — axial flow; older generation; still implanted in some patients

Indications

Bridge to transplant (BTT)
Destination therapy (DT) — permanent in transplant-ineligible
Bridge to recovery (BTR) — rare (viral cardiomyopathy)
Bridge to decision (BTD)

Driveline Care

Exit site: clean with chlorhexidine; sterile dressing change per protocol (every 3–7 days)
Immobilise driveline — prevents pump pocket infection
Signs of infection: redness, exudate, tenderness, fever — swab and culture
Driveline infection = major adverse event; antibiotics ± surgical revision

Alarm Management

Low flow alarm — assess for suction event (hypovolaemia, tamponade, high speed), RV failure, arrhythmia
Suction event — ventricle collapsing onto inflow cannula; reduce speed, give fluid
Low speed / stop alarm — check controller, battery, connections; initiate CPR if pulseless
Power alarm — change batteries (always carry 2 spare); connect to AC if available

VAD Coordinator Role

24/7 telephone support for patients and nurses
Equipment checks, patient education, outpatient follow-up
Liaises with transplant team for BTT patients
Anticoagulation management (INR target 2.0–3.0 for HM3)

LVAD patients do NOT have a standard palpable pulse — use Doppler for blood pressure. MAP target 70–90 mmHg. Traditional NIBP cuffs unreliable; many centres use Doppler MAP as gold standard.

GCC Context

Leading Cardiac Surgery Centres in the GCC

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Cleveland Clinic Abu Dhabi (UAE)International academic medical centre; high-volume CABG, TAVI, LVAD, transplant programme; JCI accredited; uses Cleveland Clinic Cleveland protocols

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Prince Sultan Cardiac Center — Riyadh, KSALargest dedicated cardiac centre in Middle East; government referral hospital; performs >4,000 cardiac surgeries/year; strong congenital programme

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King Faisal Specialist Hospital & Research Centre (KFSH) — Riyadh & Jeddah, KSAPioneer in Saudi cardiac surgery; first cardiac transplant in Middle East; LVAD programme; internationally trained surgical team

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Heart Hospital — Hamad Medical Corporation, QatarQatar's national cardiac surgery centre; CABG, valve, TAVI, congenital; close links with international centres; rapid expansion pre-World Cup 2022

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National Heart Centre — Muscat, OmanNational referral centre; growing TAVI programme; congenital heart disease programme for paediatric patients

High CAD Prevalence in GCC

The GCC has among the world's highest rates of coronary artery disease (CAD), driven by:

Type 2 diabetes prevalence 15–25% (among highest globally)
Metabolic syndrome: obesity, dyslipidaemia, hypertension
Physical inactivity; sedentary lifestyle
Genetic predisposition in Gulf Arab populations
High smoking rates, particularly in male population

Nursing Implication

CABG volumes are high — nurses must be proficient in post-CABG care pathways
Diabetic patients require intensive glycaemic management peri-operatively
Statin and antiplatelet education critical at discharge
Cardiac rehabilitation programmes underutilised — nurse-led education vital

Rheumatic Heart Disease in Expat Workers

Rheumatic heart disease (RHD) remains prevalent among South Asian and African expatriate workers in GCC countries.

Mitral stenosis most common RHD manifestation — often presents in 3rd–4th decade
Mitral regurgitation, aortic regurgitation also seen
Many arrive with advanced disease, limited prior healthcare access
PBMV (Percutaneous Balloon Mitral Valvuloplasty) for suitable MS patients
Surgical mitral valve repair or replacement for complex disease

Nursing Considerations

Language barriers — use interpreter services; translated consent forms
Understanding of anticoagulation (warfarin) may be limited — intensive education needed
Secondary prophylaxis: Benzathine Penicillin G injections monthly (document compliance)
Dental hygiene education for endocarditis prevention

Cultural Considerations in Post-Op Care

Gender-Based Care (Female Muslim Patients)

Preference for female nursing and medical staff — document patient preference on admission
Where female staff not available for urgent procedures, explain necessity with respect; ensure privacy and dignity
Chaperone policy must be followed for intimate care
Hijab/modesty — remove only what is clinically necessary; replace promptly
Female patient rooms: ensure curtains drawn; knock before entering

Family Involvement

Family presence is central in GCC culture — multiple family members may visit simultaneously
Designate a single family spokesperson for clinical updates
Extended family may wish to be present for major decisions
Respect family's role in care decisions while maintaining patient autonomy

Long-Term Anticoagulation Counselling

Warfarin in Muslim Patients with Mechanical Valves

Porcine-derived products in some warfarin formulations — clarify with pharmacist; alternatives available
INR monitoring frequency: weekly until stable, then monthly; reinforce compliance
Ramadan — fasting may affect warfarin absorption and diet (Vit K intake changes); discuss with physician; more frequent INR checks during Ramadan
Halal dietary guidance: leafy greens (high Vit K) consumed consistently is preferred over avoidance

NOACs (Rivaroxaban, Apixaban, Dabigatran)

NOACs are contraindicated with mechanical heart valves — use warfarin
NOACs acceptable for AF in patients with bioprosthetic valves (after 3 months post-op)
Simpler dosing regimen improves compliance vs warfarin
Renal function monitoring required (especially dabigatran)

Ensure patients understand: missing anticoagulation doses with mechanical valves = life-threatening thrombosis risk. Teach signs of valve thrombosis: new dyspnoea, mechanical click change, syncope.