CRITICAL PATHWAYS FOR CRITICAL PATHWAYS FOR CARDIAC SURGERYCARDIAC SURGERY

IPD CLEARANCEIPD CLEARANCE

Should not be more than 24 hrsShould not be more than 24 hrs

EXAMINATION :EXAMINATION :

Vital SignsVital Signs

HeightHeight

WeightWeight

History & Physical ExaminationHistory & Physical Examination

PREOPERATIVE DAY

CBC, Electrolyte, LFT, RFT, Coagulogram,CBC, Electrolyte, LFT, RFT, Coagulogram,Trop I in recent MITrop I in recent MIECG, CXR PA view (Lateral view and CT chest in ECG, CXR PA view (Lateral view and CT chest in re-do cases).re-do cases).Echocardiography for LV function , carotid /radial Echocardiography for LV function , carotid /radial Doppler in CABG and Annulus size in valve Doppler in CABG and Annulus size in valve cases.cases.Cross match and confirm availability of blood.Cross match and confirm availability of blood.Blood Clearance not old more than 3 days Blood Clearance not old more than 3 days

INVESTIGATION

AnesthesiaAnesthesiaSocial serviceSocial servicePatient care coordinator Patient care coordinator Physiotherapy Physiotherapy DieteticsDieteticsAny other as requiredAny other as required

CONSULTATIONS

ACTIVITYACTIVITY

Out of bed as tolerated except in left main disease.Out of bed as tolerated except in left main disease.

MEDICATIONMEDICATION

Antihypertensive and anti-anginals and anti-Antihypertensive and anti-anginals and anti-arrhythmic to continue.arrhythmic to continue.

Premedication and NPO after midnight or as per Premedication and NPO after midnight or as per PAC.PAC.

INFORMED CONSENT/SPECIAL INFORMED CONSENT/SPECIAL CONSENTCONSENT

Surgery, Anesthesia, HIV, Blood Surgery, Anesthesia, HIV, Blood transfusion, high risk consent (euro transfusion, high risk consent (euro

score form in CABG patient)score form in CABG patient)

PREPARATION OF PARTSPREPARATION OF PARTS

Use clipper only Use clipper only

Betadine Bath ,Betadine paintBetadine Bath ,Betadine paint

DIETDIET

Low fat and cholesterol.Low fat and cholesterol.Low sodium dietLow sodium diet

EDUCATIONEDUCATIONAdequate understanding on what to expect, Adequate understanding on what to expect, preliminary plan and potential risks.preliminary plan and potential risks.

INTRA OPINTRA OP

Care of CABG Patient… (Zero day)Care of CABG Patient… (Zero day)Cleaning of the unitCleaning of the unit

Post OP bedPost OP bed Disinfections of the bed by bacillocid 2%Disinfections of the bed by bacillocid 2% Linen pack with sterile four sheetsLinen pack with sterile four sheets washed blanket-1washed blanket-1

Medication TrolleyMedication Trolley Drugs-inotropes, vasodilator, vasoconstrictor, sedative, fluidDrugs-inotropes, vasodilator, vasoconstrictor, sedative, fluid Consumable-Gloves, PM line, Handrub,OConsumable-Gloves, PM line, Handrub,O22 mask, Nebulizer kit, Nasal mask, Nebulizer kit, Nasal

proneprone

Monitor set-upMonitor set-up Module & CablesModule & Cables ECG,SPOECG,SPO22, Pressure (ABP,PAP), Respiration, Temperature, Cardiac , Pressure (ABP,PAP), Respiration, Temperature, Cardiac

OutputOutput

Ventilator Set-UpVentilator Set-Up PRVC modePRVC mode

Suction & OxygenSuction & Oxygen Suction tubes & bottlesSuction tubes & bottles

Care of CABG Patient…(Zero Day)Care of CABG Patient…(Zero Day)Patient receivedPatient received

Setting of the patientSetting of the patient All linesAll lines TransducersTransducers 3 ways, Suction Oxygen 3 ways, Suction Oxygen X-Ray ChestX-Ray Chest Check position of the Ryles tube & E.T TubeCheck position of the Ryles tube & E.T Tube IABP catheter checkIABP catheter check Check all linesCheck all lines Stat ABGStat ABG Start Fluid & AntibioticsStart Fluid & Antibiotics Check Drainage & output every hourlyCheck Drainage & output every hourly E.T SuctionE.T Suction Sedation if pt. awakeSedation if pt. awake Weaning of VentilatorWeaning of Ventilator

CRITICAL PATHWAYS FOR CRITICAL PATHWAYS FOR CARDIAC SURGERYCARDIAC SURGERY

TRANSFER TO STEP DOWNTRANSFER TO STEP DOWNVITAL SIGNSVITAL SIGNSBASIC CARE (mouth care, back care)BASIC CARE (mouth care, back care)WT,FLUID BALANCEWT,FLUID BALANCEECG,CXR, CARDIAC OUTPUTECG,CXR, CARDIAC OUTPUTOO22 SATURATION x 4 HRLY while weaning O SATURATION x 4 HRLY while weaning O22,SaO,SaO22>92% on >92% on

OO22..AUSCULTATE breath sounds x 6HRLYAUSCULTATE breath sounds x 6HRLYResting HR>60 & <120/min without pacemakerResting HR>60 & <120/min without pacemakerU/O >0.5ml/kg/hr.U/O >0.5ml/kg/hr.Effective cough & airway clearance.Effective cough & airway clearance.Afebrile Afebrile Bowel sounds presentBowel sounds presentMoving all extremitiesMoving all extremitiesChest tube output.Chest tube output.

POSTOPRATIVE DAY - 1

INVESTIGATIONSINVESTIGATIONS

CXR, ECG,CBC, LFT, RFT, COAGULOGRAM.CXR, ECG,CBC, LFT, RFT, COAGULOGRAM.

ACTIVITYACTIVITY

Dangle legs after extubation, out of bed to Dangle legs after extubation, out of bed to chair,chair,

Ambulate in room with assistance.Ambulate in room with assistance.

Limit sitting with legs downLimit sitting with legs down

Dorsiflexion x 1 hrly while awake.Dorsiflexion x 1 hrly while awake.

MEDICATIONMEDICATIONAdequate analgesiaAdequate analgesia

Nebulizer to keep SaONebulizer to keep SaO22>92%>92%

Chest PT QID.Chest PT QID.

Coughing/deep breathing x 2hrly when awake.Coughing/deep breathing x 2hrly when awake.

Remove ICD according to drainage.Remove ICD according to drainage.

DIETDIET

Clear fluids.Clear fluids.

EDUCATIONEDUCATIONDorsiflexion and leg elevation. Address Patient & Dorsiflexion and leg elevation. Address Patient &

family concerns.family concerns.

CRITICAL PATHWAYS FOR CRITICAL PATHWAYS FOR CARDIAC SURGERYCARDIAC SURGERY

POST OPRATIVE DAY TWO TO FOUR

TRANSFER TO WARD

VITAL SINGS

WT., FLUID BALANCE.

BREATH SOUNDS X 6HRLY

HR>60 & <100/min without pacemakerEffective cough and airway clearance.Alert & Oriented.

INVESTIGATIONSINVESTIGATIONS

KK++

INR in VALVE CASESINR in VALVE CASES

RBS x 8 HRLY IN DIABETES.RBS x 8 HRLY IN DIABETES.

ACTIVITYACTIVITYPhysiotherapy and dietetics review.Physiotherapy and dietetics review.Consultants Round and all instruction should be noted and Consultants Round and all instruction should be noted and implemented,never overlook or change the instruction of the senior implemented,never overlook or change the instruction of the senior consultant without their permission .consultant without their permission .Ambulate gradually to one flight of steps by day 4.Ambulate gradually to one flight of steps by day 4.

MEDICATIONMEDICATIONAdequate analgesiaAdequate analgesia

SaOSaO22>95% on room air>95% on room airChest PT x QIDChest PT x QIDCoughing/deep breathing x 2 hrlyCoughing/deep breathing x 2 hrlyDressing after 48 hours and SOSDressing after 48 hours and SOSCrepe bandageCrepe bandageDiscontinue Foley's and make patient void.Discontinue Foley's and make patient void.Electrolyte replacement, Beta blockers, diuretics & Electrolyte replacement, Beta blockers, diuretics &

ACE inhibitors advised every morning.ACE inhibitors advised every morning.Amiodarone to be given to all patients with EF<40%Amiodarone to be given to all patients with EF<40%

EDUCATIONEDUCATION

Diet instruction by dietician.Diet instruction by dietician.

Address patient/family concerns.Address patient/family concerns.

Preliminary plans for discharge.Preliminary plans for discharge.

VITAL SIGNS.VITAL SIGNS.I/OI/OBREATH SOUNDS x TID.BREATH SOUNDS x TID.BASELINE WT ACHIEVED.BASELINE WT ACHIEVED.HR >60 & <120/minHR >60 & <120/minBP>90 & <160 systolicBP>90 & <160 systolicResting OResting O22 >90/on room air. >90/on room air.Effective cough & airway clearance.Effective cough & airway clearance.Afebrile Afebrile Lungs clear.Lungs clear.Alert & Oriented.Alert & Oriented.

CRITICAL PATHWAYS FOR CRITICAL PATHWAYS FOR CARDIAC SURGERYCARDIAC SURGERY

POST OPRATIVE DAY FIVE

PRE-DISCHARGE PRE-DISCHARGE INVESTIGATIONINVESTIGATION

PACING WIRE REMOVAL.PACING WIRE REMOVAL.

CXR & ECG CXR & ECG

Endocrinology consult in diabetic patientsEndocrinology consult in diabetic patients

ACTIVITYACTIVITY

Ambulate x QID.Ambulate x QID.

Stairs ½ to 1 flight under the guidance of Stairs ½ to 1 flight under the guidance of Physiotherapists.Physiotherapists.

MEDICATIONSMEDICATIONSAdequate pain control.Adequate pain control.

Laxative SOSLaxative SOS

Dressing & crepe bandage.Dressing & crepe bandage.

Oral antibiotics.Oral antibiotics.

Adjust electrolyte replacement Beta blockers and Adjust electrolyte replacement Beta blockers and diuretics.diuretics.

Prepare and check discharge summary.Prepare and check discharge summary.

EDUCATIONEDUCATIONPatient education, medication, diet, activity, Patient education, medication, diet, activity,

physiotherapy and follow-up.physiotherapy and follow-up.

THANKSTHANKS