Coronary Artery Bypass Graft Surgery, Case Study Example

Analyze Mr. Wren’s presentation in light of the relevance of the 12 lead ECG results. Given these out-of-the-ordinary occurrences, please discuss the following:

Coronary vessels involved

The 12 lead ECG findings indicate that Mr. Wren likely suffers from an acute myocardial infarction (MI). The ST segment elevation in leads V1-V4 indicates involvement of the Left Anterior Descending (LAD) artery, which supplies the anterior wall of the left ventricle. In addition, ST segment elevations in leads I and VL suggest the involvement of the left circumflex artery, which supplies the lateral wall of the left ventricle (Ahmed et al., 2022). Mr. Wren’s ECK shows damage to the first two of his heart’s major arteries (the left anterior descending artery and the right coronary artery), consistent with the findings of a research published in a Pan African medical publication. The therapeutic options for Mr. Wren include thrombolytic therapy, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Thrombolytic therapy is used to dissolve the blood clot causing the MI. PCI opens narrowed or blocked coronary arteries with a balloon or stent. CABG is used to bypass blocked vessels with a graft.

Mr. Wren has type 2 diabetes mellitus, known as non-T2DM, and has a lower chance of developing coronary heart disease (CAD). In addition, despite advancements in medicine and other treatments, the clinical results of CAD patients with type 2 diabetes remain dismal. When treating multivessel cardiovascular disease in diabetic individuals, coronary artery bypass grafting works better than percutaneous coronary intervention (Karaca, 2019). Conversely, the choice of revascularization approach depends on the patient’s medical history, any comorbidities they may have, and the intricacy of the lesion.

A thorough risk management strategy that incorporates both pharmaceutical and non-pharmacological treatments is essential, as is verification as to whether or not the risk management measures are being implemented effectively (Chris, 2020). Furthermore, non-pharmacological complications using diet and activity during the earlier stages of gluconeogenesis abnormalities, such as impaired fasting glucose, might be advantageous in avoiding the advancement or progression of type 2 diabetes and in reducing the number of cardiovascular events. This could be the case if the interventions are carried out during the previous phases of gluconeogenesis abnormalities.

Myocardium at risk

From the ECG of the patient, one can observe that the left anterior descending artery (LAD) and the left circumflex artery (LCA) are obstructed, which implies that blood supply to the anterior and inferior walls of the heart is limited. This implies that blood supply to the left ventricle is limited; hence it has the highest risk of damage. Several studies indicate that the lower pumping chamber is the most commonly damaged muscle during a myocardial infarction (Phad et al., 2022). Since the blood supply to the heart’s lower chambers is restricted, this region receives less oxygen, and the muscle cells begin to die, damaging the left ventricle.

Conduction tissue at risk

In contrast to neural tissue, the cells of cardiac muscles and conducting fibers that make up the heart’s conducting system are highly specialized for initiating impulses and the fast conduction of those impulses throughout the ventricle (John et al., 2020). They are responsible for the beginning of the regular cardiac cycle and the coordination of the chambers of the heart contracting. From the ECG, it has been established that the LAD might be compromised due to the MI; hence the conduction system below the A-V node is at the highest risk of damage. The LAD supplies most of the conduction system below the A-V node (His-Purkinje system). Once the LAD is obstructed, the conduction system receives less oxygen, resulting in tissue injury. Histological studies have shown that the His-Purkinje system is often damaged during a myocardial infarction due to obstruction of the main blood supply vessel, the LAD (Seo et al., 2018).

Potential rhythm disturbances you would anticipate.

Arrhythmia is a common complication that arises in the event of myocardial infarction. Arrhythmia is an irregular heartbeat resulting from damage to the heart’s electrical conduction system. Arrhythmia can present in two forms (tachycardia, when the heartbeat is too rapid or bradycardia, when the heartbeat is sluggish) depending on the conduction system affected by the MI (Alam et al., 2020). In the case of Mr. Wren, the conduction system is at risk of injury, which may result in arrhythmia that may manifest as either tachycardia or bradycardia.

Discuss the rationale for this medical therapy and critically reflect on the nursing management required to ensure optimum patient care.

When medical professionals observed Mr. Wren, he appeared to manifest classic acute coronary syndrome symptoms (ACS). The acute coronary syndrome refers to conditions where blood flow to the heart is compromised due to obstruction or occlusion of the coronary blood vessels. The ECG report and clinical observations of Mr. Wren informed the ACS diagnosis. Hence, the standard ACS protocol was to be initiated immediately to prevent further complications or fatality arising from the ACS (Leornadi et al., 2020). Therefore, the medical officer ordered the administration of the medication used in the ACS protocol.

The first step in the ACS protocol is to alleviate the patient’s pain by administering painkillers. In the case of Mr. Wren, 5mg of morphine was administered intravenously and titrated for pain. Pain control is especially important for patients with ACS because it modulates the activation of the sympathetic nervous system and hence reduces myocardial oxygen demand (Ghadban et al., 2019). Next, aspirin is administered to patients with ACS because it has two benefits for the patient. First, aspirin is a painkiller hence its use in conjunction with morphine will help to relieve the patient of chest pains that he is experiencing. Secondly, aspirin is an antiplatelet drug that shows a rapid effect and has been reported to reduce the mortality rate by 20% for patients presenting with ACS. Lastly, in the ACS protocol is the administration of heparin which is an anticoagulation drug. Heparin exerts antihaemostatic effects, which helps to stabilize the condition of the patient temporarily. Additionally, Aggrastat was administered to the patient as part of the ACS protocol to prevent platelet aggregation, which could be leading to thrombosis. In my opinion, the patient received adequate care as per the ACS protocol recommended in multiple studies (Singh et al., 2022).

To ensure the best outcome for the patient, the nurse should continuously monitor the patient’s vital signs, including their heart rate and blood pressure. These vital signs determine whether the patient responds to the prescribed medication according to the ACS protocol. Another nursing intervention will be to closely monitor skin temperature and peripheral plus, indicative of tissue perfusion. The nurse should also aid in administering the medication to relieve the symptoms experienced by the patient. Lastly, the nurse should encourage the patient to frequently change positions which will help to prevent fluids from accumulating in the lungs (Stepinska et al., 2020).

Following the initiation of the aforementioned medical treatment, Mr. Wren had cold sweats and dyspnea. He is awake, but hard to wake up. His evaluation of a 12-lead electrocardiogram is shown in Figure 2.

Based on the coronary angiogram conducted on Mr. Wren’s heart, he was diagnosed with triple vessel disease (TVD). A triple vessel disease is an extreme form of coronary artery disease that occurs when three of the main blood supply vessels of the heart are damaged or obstructed. In the case of Mr. Wren, the LAD and the proximal circumflex were 80% obstructed, while the RCA was completely occluded. This implied that the blood supply to the left ventricle was compromised, and the supply to the conduction system is also compromised due to the occlusion of the RCA artery (Marzlin, 2020). In addition, the occlusion of the RCA may result in an incidence of sinus bradycardia since the normal functioning of the heart’s conduction system is impaired due to injury or damage to the cells.

Following the observed conditions of Mr. Wren, a treatment plan of inotropes was started to alleviate the hemodynamic symptoms that he was presenting. Inotropes are a class of pharmaceuticals that are used to correct contractions of the heart. Inotropes are divided into positive and negative inotropes, depending on the desired effect on the heart contraction (Levi & Kimmoun, 2019). Positive inotropes are used to strengthen the force of heart contractions, while negative inotropes are used to weaken the force of heart contractions.

Once the patient’s hemodynamic status has been established, inotropes can be administered to rectify the contraction issues of the heart. In the case of Mr. Wren, he presented with low blood pressure, which was indicative of weak heart contractions. Therefore, Mr. Wren was put on a treatment plan which included two inotropic agents, dopamine and dobutamine, and his response to said agents was monitored. Dopamine and dobutamine are compounds called catecholamine, which are used for the inotropic support of the cardiac system during heart failure. Although they have similar effects, dopamine is agonistic for dopamine receptors D₁ and D₂ and adrenal receptors ? and ?, while dobutamine is active on only adrenal receptors (Rizfikani et al., 2022). A combination of the two drugs is often used to augment myocardial contractility, cardiac output, and myocardial blood flow.

The rationale behind administering dopamine and dobutamine to the patient was to treat hypotension which was being caused by the myocardial infarction. Dopamine directly exerts an agonistic effect on the beta receptors and indirectly causes the release of norepinephrine from storage sites in the sympathetic nerve. In doing so, the drug produces positive chronotropic and inotropic effects on the myocardium, which results in increased heart rate and cardiac contractility. Dobutamine will directly stimulate the heart’s beta receptors, leading to an increase in myocardial contractility and stroke volume. Several studies also suggest that dobutamine reduces myocardial necrosis by increasing myocardial blood flow and reducing the amount of norepinephrine released by the sympathetic fibers (Rizfikani et al., 2022). Therefore, a combination of these two inotropes was administered to the patient to increase myocardial contractility, which in turn will treat the hypotension observed.

Analyze the patient’s hemodynamic support using temporary pacing and IABP.

IABP indirectly helps the heart by reducing the workload. It also increases diastolic aortic pressure, which increases diastolic blood flow and, consequently, improves oxygenation of the peripheral organs and may increase coronary flow (Fisher, 2020). During the diastole contraction of the heart muscle, the based inter balloon will expand instantaneously with the closing of the heart valve and the visual appeal of a dicrotic notch. This will cause the dislocation of blood from the aortic arch into the vasculature. A rapid deflation will follow just before the beginning of the ventricular diastole cycle of the heart.

Theoretically, this increases diastole and a drop in systolic aortic pressure because it lowers the afterload. This, in turn, causes a reduction in left ventricular wall stress, which in turn lowers the myocardial oxygen demands (Melly et al., 2018). Increasing each stroke’s size, these hemodynamic adjustments boost cardiac output, which is especially beneficial for patients with impaired left ventricular function.

Inconsistent findings emerged from research examining how IABP affected coronary blood flow. Enhanced myocardial blood flow in individuals assisted by counterpulsation was most likely the result of higher diastolic aortic pressure, as shown by observations. The impact of the IABP was found to be more evident in patients whose hemodynamic circumstances were unstable than in those whose hemodynamic conditions were stable. It is essential to point out that using IABP in individuals with coronary narrowing will not result in any substantial increase in the amount of blood flowing through the arteries post-stenotic.

Until the territory of the coronary arteries has been repercussed, this condition will remain either by thrombolysis or angioplasty. This discovery helps to explain, at least in part, why previous investigations in individuals with cardiogenic shock found that the treatment reduced their risk of fatality (Patel, 2020). Because of an acute myocardial infarct (AMI) was caused by the simultaneous use of PCI and thrombolysis with IABP.

IPs may improve coronary blood flow via several mechanisms, including diastolic aorta pressure elevation due to pulsatile balloon inflation and diastolic artery dilation due to cellular membranes’ nitric oxide production from vascular stretching (John, 2021). However, the vasodilatory impact found due to NO release was more significant in the tiny arterioles than in smaller afferent arterioles.

Mr. Wren’s condition has improved much after four days, and he is no longer on a permanent pacemaker. Therefore, we feel comfortable sending him to a less intensive care facility. See Figure 3 for an electrocardiogram recording. In light of your research, please provide your thoughts on how to best proceed with Mr. Wren’s long-term care, education, and release.

Once the patient’s condition is stable, several considerations must be made for continuous patient care after discharge. Part of the responsibility of the nurse post-CABG surgery will include pain management, haemodynamic management, hemorrhage management, renal management, and neurological assessment (Mares et al., 2018). Coronary surgeries often accompany intense pain; hence, the nurse should help the patient manage the pain by administering analgesic medication such as morphine. For haemodynamic management, the nurse should closely monitor the blood pressure and arterial pressures of the patient to ensure that normal functioning is restored. To manage a hemorrhage, the nurse should check the site of surgery as well as the chest tubes for any sign of excessive bleeding and initiate relevant protocols. In addition, there is evidence indicating that patients recovering from CABG may develop renal complications; hence the nurse should monitor urinary output every hour post-surgery. Lastly, CABG surgery patients are likely to develop neurological complications, which increase the risk of stroke. Therefore, the nurse should perform regular neurological examinations to ensure the body’s normal functioning.

Upon discharging the patient, the nurse should educate the patient and caregivers about long-term care. First, in the patient, education will be on caring for the surgical wound, where the nurse will instruct the patient on special bathing instructions and regular cleanups of the surgical site to prevent infections. The patient will also be educated on the importance of regular rest to allow the body to recover from the surgery; hence the patient is advised to avoid strenuous exercises. Secondly, the patient and caregivers will be instructed to be on the lookout for several warning signs. These signs include fever, nausea and vomiting, breathing difficulties, leg swollenness, numbness in the extremities, and redness, pain, edema, or hemorrhage at the incision site. These signs may indicate post-surgery complications; hence medical attention should be sought at the onset (Aydin & Gursoy, 2019). Patient and caregiver education is vital in ensuring that the patient recovers from the surgery, complications from the surgery are addressed on time, and the patient continues on a path of wellness and health.

Part of patient education will also include lifestyle adjustments that increase the risk of another myocardial infarction. The patient should be educated on the importance of adhering to the diet and treatment plan recommended by the physician. The patient should also be informed about the relevance of regular exercise in recovery and prevention of another incidence of MI. The patient must be warned about risky behavior such as consumption of alcohol and smoking, which can increase the risk of MI reoccurring. Lastly, the nurse should advise the patient on healthy coping mechanisms to manage fear and anxiety that may arise following a coronary surgery (Koivisto et al., 2020). This patient education is critical in ensuring long-term care for the patient and reducing risks that may lead to another myocardial infarction.

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