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Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

So, when our readers opt in for their free instant impact report or for their video mini-series, we ask them what is their biggest frustration? And one of our readers put as their biggest frustration, “I’m worried about my loved one getting off the ventilator after open heart surgery for bypass grafts.” Well, it really depends on whether you should be worried about it or not.

So, here is my experience with open heart surgery after bypass grafts in ICU. By the way, I have worked in ICU for over about 20 years in three different countries, and out of those five years I was a nurse manager in ICU for over five years and that was actually in cardiac unit. So, I have seen plenty of bypass grafts open heart surgery cases.

So, should you be worried about getting off the ventilator in ICU after open heart surgery and bypass grafts, also known as CABG, C-A-B-G, (Coronary Artery Bypass Grafts)? So, most patients that go into ICU after open heart surgery and coronary artery bypass grafts should get out of ICU within less than 24 to 48 hours. Usually, the patients are on what’s called the “pathway”, and that’s of course a standard pathway, how patients should progress after open heart surgery.

It goes like, for the first 6 to 12 hours, you need to measure bleeding from the chest drain, every 15 minutes for the first four hours, then you can slow it down to checking it every half an hour and then you can slow it down to checking the drainage from the chest, every one hour. You got to watch, got to monitor very, very closely for bleeding. You also have to monitor very closely for tamponade. If there is, for example, bleeding around the heart that can’t go into the drains, that could cause a tamponade, that could cause a tension, also could cause a tension pneumothorax. So, there’s a number of complications that could occur after open heart surgery, but as long as that’s monitored in intensive care by intensive care nurses and intensive care doctors, things should go smoothly. However, there are a number of complications, and I’ll come to that in a minute.

So, when patients come back after open heart surgery into ICU, they’re usually very cold because they’ve been in the operating room or operating theater for hours and they’ve been cooled down with a bypass machine or ECMO machine. They’re coming back very cold and they’ve got to be warmed up very slowly. Once their temperature is back to normal, they’re not bleeding, they’re hemodynamically stable as well, meaning, they’re not on vasopressors or inotropes, they’re not on vasodilators, even though, sometimes they do come back, then they should check other parameters. Patients do come back after open heart surgery with vasodilators such as GTN (glyceryl trinitrate) or SNP (sodium nitroprusside) to keep the bypass grafts smooth and dilated so that the new grafts are not going to get blocked straight away. If it will get blocked, that will defeat the purpose of the surgery.

So, once a patient is warm, hemodynamically stable, not bleeding, not in an irregular heart rhythm, you can proceed to the next step. After cardiac surgery, sometimes patients go into an irregular heart rhythm such as AF or also known as A-Fib or atrial fibrillation; so, electrolytes such as potassium and magnesium have to be monitored very closely. A 12-lead ECG needs to be done when the ECG needs to be constantly monitored.

So, once all those boxes are ticked, then you can slowly wake a patient up. You can take off the propofol or the midazolam/Versed; sometimes patients are on Precedex or dexmedetomidine as well. You can slowly wake up a patient then. See if they are neurologically responding, control their pain, often with morphine or fentanyl, and try and wean them off the ventilator as quickly as possible.

Some patients come back to ICU in the afternoon at four o’clock and they’re off to the ward, to the hospital floor the next morning. If all goes well, they’re extubated, and all goes well, they can go to the ward within 24 hours to a cardiac ward of course where they can carry on post-operative nursing care.

Also, what often happens after cardiac surgery, patients come back with a Swan-Ganz or PA catheter (Pulmonary Artery catheter). There, patients are monitored for cardiac output and cardiac index. They’re monitored for SVR (Systemic Vascular Resistance). They are also monitored for mixed venous gases to, again, assess contractility of the heart, cardiac function, and if patients are tracking well. If cardiac output, cardiac index, SVR, mixed venous blood gases, and wedge pressures are fine, then Swan-Ganz or pulmonary artery catheter can be removed.

Sometimes, again, if complications occur and patients are on vasodilators, they’re hypertensive or hypotensive, and they’re needing multiple inotropes, then the PA catheter or SWAN-Ganz catheter stays in and the monitoring of cardiac output, cardiac index, SVR, wedge pressures, and so forth are ongoing. The PA or Swan-Ganz catheter shouldn’t really stay in for more than three days because of infection risk.

Now, when should you be worried about getting off the ventilator in ICU? You should be worried about if there are complications, i.e., patients not waking up for whatever reason. Maybe, God forbid, they had a stroke or a neurological event, maybe they developed some seizures. Most of all, though, if there’s bleeding or a tamponade or a tension pneumothorax or otherwise hemodynamic unstable or if an infection gets on top of things, then you should be worried because then often patients stay ventilated and in an induced coma for longer.

Also, if patients have open heart surgery and coronary artery bypass grafts such as CABG, it really depends on what condition a patient comes in. Let’s just say, they had a heart attack, and they have all these blocked arteries around the heart, and they can’t stent them in cath lab, they can’t unblock them in the catheter lab, then, patients go into ICU for open heart surgery. They are much more unstable compared to someone that might have had mild angina at home, mild shortness of breath, and comes into ICU for open heart surgery.

So, it really depends in what condition a patient comes in or, God forbid, if patient had a cardiac arrest, and then they need open heart surgery. So, a lot of it depends on how well patients are when they’re coming into ICU as well. So, you haven’t shared any of that, but I hope that sort of sheds some light on this.

Also, what happens as well is, God forbid, if a patient after open heart surgery needs to go back into the operating room because, again, maybe there is a tamponade, a tension pneumothorax, maybe there is some bleeding, then, they need to stay in the induced coma for longer. Again, the monitoring starts from scratch. Again, if patients return to the operating room, that’s when you should probably be worried about it. You should start to get worried about if someone is more than 48 hours ventilated after open heart surgery and they still can’t be weaned, they still can’t wake up.

So, I hope that helps and explains to you what you should be monitoring when your loved one is in ICU after open heart surgery.

And if you are worried about your loved one, you should contact us at intensivecarehotline.com. Contact us on one of the phone numbers on the top of our website or simply send us an email to [email protected].

Also, have a look at our membership for families in intensive care at intensivecaresupport.org. There, you have access to me and my team, 24 hours a day, in a membership area and via email, and we answer all questions intensive care related.

Also, if you need a medical record review for your loved one while they are in ICU or after ICU, especially if you suspect medical negligence, please contact us as well. But it’s much better if we can help you while your loved one is in intensive care and help you interpret clinical data and ask the right questions right from the start.

Like this video, subscribe to my YouTube channel, share the video with your friends and families, click the notification bell, and comment below what you want to see next, or what questions and insights you have from this video.

Thanks for watching.

This is Patrik Hutzel from intensivecarehotline.com and I’ll talk to you in a few days.