http://doi.org/10.33698/NRF0110 Prabhjot Saini, Suresh Sharma, Jasbir Kaur, Poornima
Abstract : Coronary Artery Bypass Graft is a common procedure used to divert blood around blocked arteries in the heart. It is a procedure, which acts like a boon for people with coronary artery disease. But it has been observed that there is chance for occurrence of some of the complications even after CABG prcedure. So this study was undertaken with objective to assess the prevalence of postoperative complications, symptoms and clinical manifestations among patients who underwent CABG. Total 60 subjects who had undergone CABG in HDHI i.e Hero DMC Heart Institute, Ludhiana were included in the study. All the subjects were interviewed and observed for postoperative complications, symptoms & complications from 1-7 days of surgery and on day of discharge. Observation of subjects was done with help of written records on critical care charts (CCC). A self structured tool was developed based on the frequent post operative complications occurring among CABG patients. Findings revealed that subjects who had undergone CABG showed prevalence of post operative complications to be 100 % among this population.It was seen that majority of the subjects presented with complications during early (1-3 days) postoperative days.The most common postoperative complications observed among subjects include: Dysarrhythmias (98.3%), Hypotension (45%) while most prevalent postoperative symptoms observed include: constipation (100%), weakness (100%), Dyspnea (75%), Raised body temperature (73.3%), Tachypnea (46.7%), nausea (23.3%) while most prevalent postoperative clinical manifestations include Negative fluid balance (58.3%), leucocytosis (91.6%), hyponatremia (68.3%), hyperglycemia in Diabetic Mellitus(53.3%) and in Non Diabetic patient (30%).Moreover lifestyle pattern has a significant effect on the outcomes of postoperative complications. Thus the staff nurses who are caring for the post operative CABG patients should be careful regarding the occurrence of the complications and take an appropriate action for the better health of the patients.
Key words :CABG, Post-Operative Complications
Correspondence at :Prabhjot Saini Associate Professor, College of Nursing, DMCH, Ludhiana
Introduction:surgery also coronary ar tery bypass graft surgery and colloquially heart bypass or bypass surgery is a surgerical procedure performed to relieve angina and reduce the risk from CAD. According to Cleveland Clinic1, CABG is a heart surgery in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. These grafts usually come from patients. Own arteries and vein located in chest, leg arm. A significant problem in CABG has been the various complications that occur after the procedure and can even lead to death.According to American Hear t Association2, there are number of complications that can occur after CABG. The major complications include bleeding that requires return to operating room, heart attack, heart failure, arrhythmias stroke, changes in cognitive functions, pulmonary problems, wound infections, renal failure and death. Post-op complications can be prevented by pre-op nursing interventions.A study conducted by Acevendo J. et al include the cardiac surgical procedure coronary ar tery bypass grafting in 36 patients (49.3%), value procedure in 20 patients (27.4%) and combined coronary artery bypass grafting and valve procedure in 17 patients (23.3%). In hospital death occurred in 6 patients (8.2%), twenty one patient (28.8%) had major post operative complications including renal failure (15.1%), respiratory failure (8.2%).3 In a well designed study by Guzman M, Perez CM shows the rate of most important complications after CABG are death (3%), Myocardial Infarction (2%), bleeding (1.5%), pulmonary embolism (1%) and stroke (1%). A retrospective study was conducted by M Pelltier L, Carrier M to analyze risk factors of gastrointestinal (GI) complications following cardiac operations. Out of 3,724 consecutive patients undergoing heart operations during 8 yrs period, patients developed GI complications.4,5 Another retrospective study conducted by Youri M, Ganushchak et al to assess post operative neurological complications after CABG shows that patients undergoing CABG procedure has large fluctuations in hemodynamic parameters increasing the risks for development of post operative neurological complications.6 In health care today, the ability to predict and prevent adverse events such as postoperative pulmonary complications has become increasingly important as a measure of the safety and quality of care delivered. Traditionally, nurses have been instrumental in preventing adverse events. Preventable adverse events that have been linked to nursing care include falls, pressure ulcers, deep vein thromboses, urinary tract infections, and pneumonia. The prevention of post- operative pulmonary complications needs fur ther investigation, and nurses are well positioned to have an effect on reducing their incidence.A study conducted by Rankin SH suggests that the availability of social support improves recovery after CABG, yet functional suppor t designed to modify health and stimulate recovery remains unspecified. Advanced practice nurses (APNs) in the clinical nurse specialist (CNS) role who provide social support to recovering elders may be able to improve health outcomes for this vulnerable group.7 Therefore, with the fact, the most commonly occurring complications can be helpful for the nurses to educate the clients who are planning for CABG surgery to prevent the complications. The staff nurses, working in the recovery unit and taking care of the post-operative CABG patients, need to have knowledge about the changing laboratory parameters as well as the arising clinical manifestations and the complications Hence it is important to know the prevalence of post-operative symptoms, clinical manifestations & complications among CABG patients in our setting and the present study is an effort in this direction
Objective:To assess the prevalence of post operative symptoms, clinical manifestations & complications among CABG patients.
Material and Methodology:Study design of present study was prospective. It was carried out in Hero DMC Hear t Institute, Ludhiana which is an important unit of Dayanand Medical College and Hospital, Ludhiana. Study was carried out in months of January and February, 2008. Tool was developed which included socio demographic profile, life style history and biophysical profile of the subjects. Its second part consisted of a list of post-operative complications prevalent in CABG patients which consisted of three categories i.e.symptoms, clinical manifestations and complications. The tool was developed through an extensive review of literature and expert’s opinion from fields of cardio-thoracic surgery and validated from experts in the field of Nursing, Cardiology, cardiac surgery and Community medicine. Pilot study was conducted for checking feasibility and practicability of the tool. Reliability of the tool was checked by Karl Pearson’s co-relation coefficient formulas. Its value was found to be 0.975.Convenient sampling technique was adopted for taking sample size. Sample size of 60 subjects was taken and interviewed and observed for 1-7 days along with day of discharge. Observation of postoperative CABG complications, Symptoms and clinical manifestations was done by taking the list of patients under CABG surgery and their placement in the different wards of HERO DMC Heart Institute. Then patients and his/her records and Critical Care Charts (CCC) were approached in the respective area. The patients were followed from Post operative 1-7 days along with day of discharge. The data was analyzed using both descriptive and inferential statistics.
Results:Table-1 reveals that half of subjects (50.0%) were in age group of above 60 years, 16.6% patients were <50 years of age. The proportion of male was 81.6% and about 25% of subjects were graduate or above while illiterate subjects contributed only 6.6%.
Table- 1 : Socio demographic profile of CABG patients N=60
Variables f (%)
Age in years*
<50 years 10(16.6)
50-60 years 20(33.3)
>60 years 30(50.0)
Gender
Male 49(81.6)
Female 11(18.3)
Educational Status
Illiterate 04 (06.6)
Primary 09 (15.0)
Middle 09 (15.0)
Secondary 14 (23.3)
Higher Secondary 08 (13.3)
Graduation or above 15 (25.0)
Marital Status
| Married | 58 (96.6) |
| Unmarried | 01 (01.6) |
| Separated | 01 (01.6) |
| Habitat
Urban |
34 (56.6) |
| Rural | 18 (30.0) |
| Semi urban | 08 (03.3) |
| Religion
Hindu |
33 (55.0) |
| Sikh | 26 (43.3) |
| Muslim | 01 (01.6) |
| Occupation | |
| Business | 27 (45.0) |
| Professional | 14 (23.3) |
| Skilled | 10 (16.6) |
| Unskilled | 09 (15.0) |
| Mean age = 59.51± 10.2, | Range = 32-82 years. |
Majority of the subjects 96.6% were married and urban dwellers (56.6%). Nearly half of subjects 45% were businessman and 23.3% were professionals.
Table-2 shows life style history of subjects. Both Vegetarian and Non-vegetarian contributed 60% and 35% respectively,
Table-2 : Life style history and biophysical profile N=60
Variables f (%)
Life style pattern
Sedentary 30 (50.0)
Moderate workers 22 (36.6)
Heavy workers 08 (13.3)
Dietary Habit
Vegetarian 36 (60.0)
Non-vegetarian 21 (35.0)
Eggetarian 03 (05.0)
Addiction History
Alcoholic 21 (35.0)
Smoker 10 (16.6)
Biophysical Profile
Underweight 02 ( 3.3)
Normal range 31 (51.6)
Overweight 02 ( 3.3)
Pre-obese 18 (30.0)
Obese class1 07 (11.6) while 05% subjects were eggetarian. Half of the subjects enjoyed sedentary life style and rest of them had Moderate (36.6%) and Heavy (13.3%) life style activities. About 65% of subjects were Non alcoholic. Only 16.6%subjects were active Smokers, while 83.3% were Non smoker and BMI of subjects indicate that half of the subjects (51.6%) fall within the normal BMI range while pre-obese subjects constitute 30% and 11.6% subjects as obese class 1. Only 3.3% of total subjects were overweight while the same number comprising underweight subjects.
Table-3 depicts the distribution of subjects as per their stay in hospital post operatively and post-surgery interventions.
It revealed that more than half of subjects remained in hospital post operatively for £ 10 days (56.6%) followed by 17 (28.3%) subjects who remained for 11-15 days post operatively in hospital. There were only 9 (15.0%) subjects who were being in hospital post operatively for ³16 days. The three different aspects of post-surgical interventions are depicted. In first part it shows that more than half (53.3%) subjects remained on ventilator support for 1-2 days, while only 21.6% of subjects had ventilator support for ³3 days. In 25% of subjects ventilator was put off in <1 day.The second part reveals distribution of subjects according to number of days with chest tube. About 63.3% of subjects had chest tube even after 3 days, while 30% subjects had the chest tube for 2-3 days and in 6.6% of subjects chest tube was removed in 1-2 days
Table-3 : Distribution of subjects as per post operative stay and post- surgery interventions N=60
Variables f (%) Mean ± SD
No. of post-operative days stay in hospital
1£0 days 34 (56.6)
11-15 days 17 (28.3)
³16 days 09 (15.0)
Days on ventilator support*
<1 day 15 (25.0)
1-2 days 33 (53.3) 3.03 ± 4.34
3³days 13 (21.6)
Days with Chest tube**
| 1-2 days | 04 | (06.6) | |
| 2-3 days | 18 | (30.0) | 3.61 ± 1.07 |
| ³ 3days | 38 | (63.3) |
Day on which mobilization started***
<3 days 01 (01.6)
3-4 days 10 (16.6) 5.59 ± 2.97
>4 days 49 (81.6)
*Range = 1-27 days
**Range = 3-33 days
***Range = 3-15 days
The third part represents the day on which mobilization started. Among 81.6% of subjects mobilization was started after 4th post operative day and another 10 (16.6%) started mobilisation on 3-4 day.
Table-4 shows that on 1-3 days of surgery, postoperative clinical manifestations found among subjects include Negative fluid balance (35.0%), leucocytosis (91.6%),hyponatremia (26.6%), hypokalemia (10%), hyperglycemia (53.3%) in Diabetic Mellitus patient and (30%) in Non Diabetic patient.On 4-7 days of surgery, postoperative clinical manifestations found among subjects include irritability (5%), Negative fluid balance (23.3%), hyponatremia (11.6%). On day of discharge, No complication observed
Table- 4 : Prevalence of altered Lab investigations post operatively among CABG patients N=60
| Complications | Early * | Late ** | On discharge | ||
| f (%) | f (%) | f (%) | |||
| Lab Investigations | |||||
| RBS: DM | 32 | (53.3) | – – | ||
| RBS: NDM | 18 | (30.0) | – – | ||
| ¯ Hb | 58 | (96.6) | – – | ||
| WBC | 55 | (91.6) | – – | ||
| ¯ Na, ¯K | 22 | (36.6) | 07 | (11.6) – | |
| Na, K | 06 | (10.0) | – – | ||
| ¯ Creatinine | 04 | (06.6) | 02 | (03.3) – | |
| Creatinine | 06 | (10.0) | – – | ||
| Urea | 03 | (05.0) | – – | ||
* 1-3 post operative days ** 4-7 post operative days Table 5 shows that on 1-3 days of surgery, postoperative symptoms observed among subjects were Nausea (10.0%), Vomiting (01.6%), weakness (93.3%), Raised body temperature (65.0%), Dyspnea (66.6%), Tachypnea(43.3%).On 4-7 days of surgery, postoperative symptoms observed among subjects were nausea (13.3%), vomiting (01.6%), constipation (100%), weakness (06.6%), Raised body Temperature (08.3%), Altered mental status(03.3%).On day of discharge, No complication observed.
Table-5 : Prevalence of Postoperative symptoms among CABG patients
| N=60 | |||
| Symptoms | Early
f (%) |
Late
f (%) |
|
| Nausea & Vomiting | 07(11.6) | 9( 15.0) | |
| Weakness | 56(93.3) | 4( 6.6) | |
| Raised body temperature |
39(65.0) |
5( 8.3) |
|
| Constipation | – | 60(100.0) | |
| Dyspnea | 40(66.6) | 5( 8.3) | |
| Tachypnea | – | 2( 3.3) | |
| Altered mental status | 26(43.3) | 2( 3.3) | |
| *1-3 post operative days | ** 4-7 post operative days | ||
Table 6 reveals that on first 3 days of surgery, subjects were having complications like Dysarrhythmias (95.0%). Hypotension (40.0%), stroke (01.6%). On 4-7 days of surgery, subjects have complications like dysarrhythmias (03.3%), Hypotension (05.0%), Pleural effusion (01.6%), Pulmonary edema (01.6%). On day of discharge, all complications of were absent
Table – 6 : Prevalence of post operative complication among CABG Patients.
| Post Operative Days | Post Operative Complications | |||||||
| Dysorrhy
thmia |
Hypo
tension |
Pleural
effusion |
Pulm.
edema |
Stroke | UTI | Throat
Injection |
Presure
Sores |
|
| 1-3
4-5 |
95
3.3 |
40
5 |
–
1.6 |
–
1.6 |
1.6
– |
–
3.3 |
–
5 |
8.3
5 |
Table 7 depicts the association between life style pattern of subjects and total number of complications present among them. It revealed that the prevalence of higher number (>10)of postoperative complications were found among 62.8% subjects having sedentary lifestyle activities. On the other hand the prevalence of complications was comparatively lower i.e. 28.5% among moderate workers. Among subjects with heavy lifestyle activities, the prevalence of higher number of postoperative complications were found to be only 8.and it was found statistically significant (p<0.01as per chi square test).
Table – 7 : Association of Lifestyle pattern with number of complications N=60No. of complications
Life style pattern c2 Value Sedentary Moderate Heavy
f (%) f (%) f (%)
Higher1complication 22 (62.8) 10 (28.5) 03 (08.5) c2=5.55
Lower2complication 08 (32.0) 12 (48.0) 05 (20.0) *d.f.=1,
*While applying chi-square, frequency against moderate and heavy workers was merged. 1 >10 complication , 2 < 10 complications
(p<0.01)
Discussion:CABG remains one of the gold standard surgical treatments for coronary ar tery disease, CABG is a revascularization technique that uses the patients own veins or arteries to bypass narrowed areas and restore blood flow to heart muscle. But it has been seen that there is chance for occurrence of complications even after CABG. This study was done to assess the prevalence of post operative complications among CABG patients. (Goel Paras.)8 Various studies have been conducted worldwide to determine that prevalence of post operative complications after CABG. The present study was undertaken with preview to make an assessment for the prevalence of post operative complications among CABG patients.In present study, findings revealed that most of the post operative complications appear in first 3 days of surgery. Most prevalent postoperative complications observed among subjects include: Dysarrhythmias (98.3%), Pressure sores (13.3%), throat infection (05%), Urinary tract infection (3.3%), Stroke (1.6%), Pulmonary oedema (1.6%), Pleural effusion (1.6%). Hypotension (45%) while most prevalent postoperative symptoms observed among subjects include: constipation (100%), weakness (100%), Dyspnea (75%), Raised body temperature (73.3%), Tachypnea (46.7%), nausea (23.3%) while most prevalent postoperative clinical manifes- tations found among subjects include Negative fluid balance (58.3%), leucocytosis (91.6%), hyponatremia (68.3%), hypokalemia (10%), hyperglycemia in Diabetic Mellitus(53.3%) and in Non Diabetic patient (30%), irritability (5%) .These findings were supported by a well designed study by Guzman M, Perez M. It shows the rate of most important complication after CABG are pulmonary problem (01%), stroke (01%), infection (0.2%), arrhythmias, Tachycardia.4 A study conducted by Light W Richard concluded that large pleural effusion occurred in patients after CABG.9 In present study, subjects were observed for postoperative complications, symptoms and clinical manifestations for first seven days after surgery and on day of discharge. It was observed that most of the complications, symptoms and clinical manifestations appear on first 3 days of surgery. Moreover lifestyle pattern effects the outcome of post operative complications i.e. sedentary the lifestyle more are the prevalence of post operative CABG complications.Subjects who had undergone CABG showed prevalence of post operative complications to be 100 % among this population. It was seen that majority of the subjects presented with complications during early (1-3 days) postoperative days. Hence it is recommended that staff nurses working in recovery unit and intensive cardiac care units have to be vigilant about the early and late symptoms, clinical manifestations and complications among post operative CABG patients and they should be ready to take appropriate nursing steps to control some of these life threatening complications.
References
- http\\ Cleveland clinic.com. accessedon March 26, 2006.
- American Heart Heart Bypass Surgery URL. Accessed on March 26, (2006): 226-227.
- Escabi Mendoza J, Acevedo J, Rucabado E, Perez CM, Rodriguez-OspinoL,(2006). Early postoperative complications after coronary artery bypass grafting at the San Juan Veterans Affairs Medical Center : 786-794.
- Guzman M, Perez CM. Early postoperative complications after coronary artery bypass grafting at the Cardiovascular Center of Puerto Rico and the P R Health Sci J. 1998 Dec;17(4):353-7.
- Pelltier L, Carrier Early post operative care and complications. In : Waters D Bourassa M (eds: Cardiovascular Clinics, Care of the Patient with Previous Coronary Bypass Surgery)F.A. Company Philadelphia (1991).
- Youri M Ganushchak, Erik J Fransen, Cees Visser, EKP, Dick S de Jong, CCP,Jos G Neurological Complications After Coronary Artery Bypass Grafting Related to the Performance of Cardiopulmonary By pass. CHEST 2004 ; 125 (6): 2196-2205.
- Rankin SH. Dimensions of Critical Care Nursing: July/August 2009; 28 (4) : 189-195.
- Goel “Essentials of Cardiac Surgery”. Paras Medical Publishers. 1st Edition (2002);72-90. Available at gemilang.ukm.my/ gw_46 _3_2 /html/ default/en/modules/ nblfeb.doc accessed on 7. 7. 10.
- Light W Large pleural effusions occurring after CABG. Annals of Internal medicine. June (1999); 130: 891-96.