CABG

Coronary Artery Bypass Graft Surgery PPT

1. CABG AND ITS MANAGEMENT By Dr. Ajay Kumar Banjara (PT)

2. ANATOMY OF HEART The heart contains 4 chambers: the right atrium, left atrium, right ventricle, and left ventricle. the heart. Heart is covered by three muscular layers Epicardium Myocardium Endocardium

3. CABG – Coronary Artery Bypass Graft DEFINITION- A form of bypass surgery that can create new routes around narrowed and blocked coronary arteries, permitting increased blood flow to deliver oxygen and nutrients to the heart muscle. CABG surgery is one of the most commonly performed major operations.

4. TYPE OF CABG There are two basic ways of performing CABG: On pump CABG and Off pump CABG. They both begin with the surgeon harvesting blood vessels from the leg saphenous vein, chest internal mammary artery, internal thoracic artery or the arm radial artery, and occasionally ulnar artey . The surgeon gains access to the heart using
8-10cm midline sternotomy incision.

5. Currently, the internal thoracic artery is the standard choice for bypass surgery because of the morphological characteristics of the wall that makes less prone to developing atherosclerosis and hyperplasia . Cardioplegia A cold (4 C), high potassium content solution administered at the time of CABG bypass surgery to arrest the heart in diastole. Diastolic cardiac arrest signifi-cantly reduces leads to significant reduction in myocardial cellular metabolism and thereby reducing myocardial ischemia dur-ing the operation.

6. ON PUMP CABG In on-pump CABG the heart is stopped with the body’s blood supply being maintained by the cardiopulmonary bypass (CPB) machine. While the heart is stopped the surgeon performs the graft procedure by sewing one end of a section of a blood vessel over a tiny opening made in the aorta and the other end over a tiny opening made in the blocked coronary vessel, distal to its blockage. With the grafting complete, the body is removed from the cardiopulmonary bypass machine and the heart is restarted.

7. OFF PUMP CABG In off-pump CABG, the area around the blocked coronary artery is stabilized while the surgeon grafts the blood vessel on the pumping heart. Off pump CABG is relatively a newer procedure to On-pump CABG and doesn’t require the use of the cardiopulmonary bypass machine. Polypropylene suture is commonly used in vascular and cardiac surgeries for anastomosis due to its long-term tensile strength and minimal tissue trauma.

8. PURPOSE- Restore blood flow to the heart. Relieve chest pain & ischemia. Improves the patient’s quality of life. Enables the patient to resume a normal life cycle. Lower the risk of a heart attack.

9. INDICATION- Left main artery disease or equivalent Triple vessel disease Abnormal Left Ventricular function. Failed PTCA. Immediately after Myocardial Infarction. Life threatening arrhythmias caused by a previous myocardial infarction. Occlusion of grafts from previous CABG.

10. MANAGEMENT PHARMACOLOGICAL PHYSIOTHERAPY

11. PHARMACOLOGICAL ACE inhibitors like ramipril . Angiotensin-II antagonists like losartan. A nti-arrhythmic medicines like amiodarone. A nticoagulant medicines like warfarin. A nti-platelet medicines like aspirin. B eta-blockers like bisoprolol . C alcium-channel blockers like amlodipine

12. PHYSIOTHERAPY ASSESSMENT SUBJECTIVE :- DEMOGRAPHIC DETAILS NAME AGE GENDER OCCUPATION ADDRESS CHIEF COMPLAINT HISTORY

13. OBSERVATION OBJECTIVE FINDINGS CTVS ICU POD 1-2 MEDIASTINAL CHEST DRAIN PRESENT VITALS- HR, BP,RR, SPO2 IV LINE PRESENT / CENTRAL LINE PRESENT FOLLEYS PRESENT EXAMINATION. ROM MMT

14. PAIN VAS SCALE 1 2 3 4 5 6 7 8 9 10 AUSCULTATION Auscultation is an evaluation technique used to listen and interpret the sounds produced by the body organ with the help of stethoscope.

15. HEART AND LUNGS

16. PHYSIOTHERAPY CARDIAC REHABILITATION Cardiac rehabilitation programs aim to limit the psychological and physiological stresses of CVD, and improve cardiovascular function to help patients achieve their highest quality of life possible.

17. Goals: Short-term goals:- • Physical reconditioning sufficient for resumption of activities. • Inform the patient and family about the disease process psychological support throughout the early stages of recovery Long-term goals:-
• Identify and treating risk factors that influence the progression of disease (diet, alcohol intake, tobacco chewing)
• Teaching and reinforcing prognosis-improving health behaviours • Improving physical conditioning and making it easier to return to work and other activities.

18. PHASES OF CARDIAC REHAB

19. PHASE 1 :- In patient This phase begins in the inpatient setting soon after a cardiovascular event. Therapists start by guiding patients through non-strenuous exercises in the bed or at the bedside, focusing on a ROM and limiting hospital deconditioning ,team may also focus on activities of daily living (ADLs) and educate the patient on avoiding excessive stress. Chest Physio Nebulizer Vibration Percussion ACBT Coughing/Huffing Breathing exercises Incentive Spirometry Limb Physio – Rom for UL /LL Mobilization

20. PHASE 2 :- Out Patient Once a patient is stable and cleared by cardiology, outpatient cardiac rehabilitation may begin. Phase II typically lasts 3 to 6 weeks though some may last up to up to 12 weeks. A more rigorous patient-centered therapy plan is designed, comprising three modalities: information/advice, tailored training program, and a relaxation program. Format :- Check in (vitals assessed)
Warm Up (15 mins )
Main class (30 mins )
Cool down (10 mins )
Monitoring and reassessment of vitals and check out

21. EXERCISES GENTLE STRETCHING BREATHING EXS STRENGTHENING EXS FOR UL/LL RESISTANCE BAND EXS FOR UL/LL AEROBIC AND ENDURANCE EXS Walk/Jogging Static cycling Treadmill 6 Min walk test to assess endurance

22. PHASE 3:- Home program This phase involves more independence and self-monitoring. Phase III centers on increasing flexibility, strengthening, and aerobic conditioning. Same as phase 2 Exs Stretching Resistance Exs Aerobic Exs Relaxation Exs

23. PHASE 4:- Maintenance If you have completed the previous three stages of cardiac rehabilitation, you should have a clear grasp of your heart condition and how best to manage it. Phase 4 essentially continues for the rest of your life. Continue to follow the guidance on exercise, nutrition, and lifestyle, as set out by your rehab team. Keep up with your exercise regime, continue to avoid tobacco, eat well, and manage your stress.

24. Program should include:- • Warm up phase- only bed mobilization initially; as fitness improves patient can sit stand by the bed trunk movements can be given and stretching can be given. • Aerobic phase- walking • Cool down phase- ROM exercises, stretching • Monitoring for exercise response:-giddiness, chest pain, palpitations FITT criteria Frequency 2-3times/day Intensity RHR+30bpm Timing 5-20 mins intermittent bouts of activity <5mins interspersed with rest periods Type- sitting/standing functional activities, ROM exercises, progressive walking, climbing stairs, self care, ADLs.

25. To improve chest compliance:- • Maintenance of lung hygiene by giving relaxed deep breathing exercises and breathing control • Incentive spirometry • Splinted huffing/coughing To prevent DVT:- • Ankle toe movements • AROM exercises of lower limbs Mobilization :- • Dynamic exercises of quadriceps, hamstrings

26. Complications:- Low cardiac output MediaStinal bleeding Cardiac tamponade Deep sternal wound infection Arrhythmias Stroke Pleural effusion

27. THANK YOU