Case presentation

1. Case presentation Presented by: Amnah Mukhtar, Douha bannan, Ohoud Al-juhani

2. Outline • Case • CABG • Home points

3. Case A A is a 58 y Saudi gentleman presented with S.O.B with C.P classII, III Co – morbidity:HTN( >15 y), Hyperlipidemia (2 y), peptic ulcer. Diagnosedwith IHD (EF=50%) Social Hx:Shisha smoker Family Hx:+ve brother died by cardiac arrest

4. Cont…. C/O:S.O.B with effort. O/E: good general condition Abd. Soft, chest clear No chest pain for the last 5 days No L.L. edema No neurological history

5. Vital Signs

6. Plan: • Need TT echo. Early morning • CABG ×2 grafts using Left internal mammary artery Right internal mammary artery

7. Medication Pre-medication: • Diazepam 5 mg PO • Promethazine 25 mg IV

8. Once daily medication 28/2KCL 20mg IV PRN Morphin 2-5 IV PRN Mgso4 IV PRN 1/3 Furosemide 20mg IV 2/3Furosemide 40mg IV Tramadol 50mg PO Hydrocortisone 200mg IV repeated same after 4 hr Bramasep 1.5mg PO 3/3 Paracetamol 1g PO PRN

9. Regular medication At 28/02 Cefurxime 1.5g q8h Ranitidine 150mg PO IV DC 2/03 Tramadol 100mg PO/IV/ q8h Metoclopromide 10mg PO/IV/ TID ASA 81mg PO OD (6h post operative) Mgso4 1g IV q8h DC 29/02 Paracetamol 1g PO/ IV/ q8h

10. At 1/03 Enoxaparin 40mg SC BID Simvastatin 40mg PO OD Fosinopril 10mg PO BID At 2/03 Ipratropium 500ml inh. q6hr Lactulose 20ml PO TID Ipratropium 5ml/1.5ml Neb. PO Multivitamine 1tab PO BID Amlodipine 5mg PO OD

11. At 3/03 Omeprazole 40mg PO OD Furosemide 20mg PO BID Budesonide 0.5mg inh q12hr

12. CABG Procedure Post CABG management Complication

13. CABG overview • More than a half-million people each year. • This procedure uses blood vessels from the patient’s chest or leg to go around or “bypass” clogged coronary (heart) arteries.

14. CABG

16. Bleeding MI Heart failure Arrhythmia Stroke Changes in cognitive function Pulmonary problems Wound infection Renal failure and death. COMPLICATIONS

17. 1- Cardiac complications: • MIafter surgery • Low cardiac output can occur during or after Surgery • Tachyarrhythmias may occur after CABG. • Pericarditisis accompanied by pericardial effusion

18. 2- Neurologic complications • Stroke • Postoperative delirium • Short-term and long-term cognitive changes • Depression.

19. 3- Infection Sternal wound Diabetes mellitus, obesity, and the use of both left and right internal mammary arteries are factors associated with an increased risk for sternal wound infection. 4- Renal failure Temporary reduction of renal function may occur in approximately 5 to 10 % of patients undergoing CABG.

20. 5-Bleeding • Exposure to aspirinin the week before surgery increases the risk of postoperative bleeding • Clopidogrel and ibuprofen are generally discontinued for several days prior to coronary surgery. • Patients taking warfarinshould speak with their surgeon about how and when to stop it before surgery.

21. Cerebrovascular disease Diabetes mellitus Poor nutritional status Female gender, age Chronic renal failure Chronic lung disease Anemia Previous CABG RISK OF COMPLICATIONS

23. 1- Reducing the Risk of Perioperative Infections • Aggressive glucose control in patients with diabetes through the use of continuous intravenous insulin infusion • Preoperative Ab. administration reduces by 5-fold the risk of postoperative infection. • Cephalosporinsare the agents of choice.

24. Prophylactic Antimicrobials for CABG Surgery

25. 2- Prevention of Postoperative Arrhythmias - Withdrawal of preoperative beta-blockers in the postoperative period doubles the risk of AF after CABG. - Prophylactic use of beta-blockers lowers the frequency of AF. - For patients who have contraindications to beta-blockers, amiodarone is appropriate prophylactic therapy.

26. 3- Antiplatelet Therapy • The aspirinshould be started within 24 hours after surgery.100 to 325 mg per day appear to be efficacious. • Ticlopidineoffers no advantage over aspirin but is an alternative in truly aspirin-allergic patients. • Clopidogrelhas fewer side effects than ticlopidine as an alternative in aspirin-allergic patients.

27. 4- Pharmacological Management of Hyperlipidemia • Targeting LDL-C levels to less than 100 mg/dL. • New data: * very high risk patients: LDL-C less than 70 mg/dL

28. Pharmacological Interventions

29. Take home point • After CABG, all patients should begin taking aspirin. • Patients with a history of MI should also be given a beta-blocker, unless it is contraindicated. • ACE inhibitors should be used in high-risk patients • Statins should be used to achieve targets for LDL cholesterol • Life style modification: diet, exercise, smoking cessation

30. Discussion

31. Inotropics • Cyclic AMP-independent drugs • Digoxin: • Calcium Salts • Cyclic AMP-dependent drugs • Stimulating cAMP production • Inhibiting cAMP degradation

32. Stimulating cAMP production • Dopamine • Dobutamine • Thus, a rational choice of inotrope would take into account the effects that each drug has i.e. dobutamine – increase in heart rate greater than dopamine, otherwise similar. In practice, none of the newer inotropes has been shown to be more effective than epinephrine and, if we are to practice evidence based medicine, this is the drug of choice until proved otherwise.

33. References • http://www.cardiothoracicsurgery.wustl.edu/PatientCare/CABG.asp • http://www.texheartsurgeons.com/CABG.htm