extubation after cabg?

  1. hi everyone~

    i am not a ICU nurse, so excuse my questions about this. i am a rehab nurse.
    my dad is scheduled to have CABGx4 this thursday. his surgeon says he will remain intubated for 24-48 hours after surgery, and remain in ICU for 2-3 days.

    i am simply curious as to why they keep him on a vent that long? i simply don't know what to expect regarding his aftercare from surgery, i was wondering if any of the CICU nurses could enlighten me? i would very much appreciate any insight you can give me!

    hoping for a quick recovery for my dear dad

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    About rehab nurse

    Joined: Jul '04; Posts: 595; Likes: 118
    healing from cancer and spinal injury, unable to work :(; from US
    Specialty: rehab; med/surg; l&d; peds/home care


  3. by   CHATSDALE
    does he have any respiratory problems...different surgeions have diffferent protocal...ask the md...some people are off the vent sooner than others
    good luck to your dad...hope everything goes well
  4. by   Dixielee
    My husband had a CABG last year and was extubated 4 hours after he returned from OR. I was fortunate enough to be with him when he woke up and I could talk him thru everything that was happening. Unless there are respiratory or other health issues, I see no reason to have someone vented that long. I have not worked open heart for a number of years, but did in the early 90's. Even then, we extubated fairly quickly. We had them out of bed the next morning and sometimes out to the floor the next afternoon. Good luck with your dad. It is scary, but he should have a new lease on life afterward.
  5. by   arbley
    I worked with fresh heart pts. up until a couple of months ago. We had some patients arrive in our unit straight from surgery already extubated. Obviously that won't work with some patients. Depends on the surgeon, the anesthesiologist, and the patient. Generally, if they did not arrive extubated, we got it done within a couple of hours, had them dangle within approx. 8 -12 hours, up in a chair for breakfast the next morning, and out to the step-down unit in that afternoon. Many studies have shown that the sooner pts are (safely) extubated and moving around, the better their recovery. Of course there are always patients that are more unstable and more challenging than others. Some do stay intubated for a few days and spend significant time in the ICU. I obviously know nothing about your father's general state of health or respiratory status, but if both are anything resembling acceptable, I would have some serious questions for that surgeon.
  6. by   snakeRN
    i work with fresh heart surgeries everyday. most of the patients come back from surgery on a ventilator mode of SIMV, which is a weaning mode. we draw blood gases upon return to the unit to check their status, then periodically. when the ABG is no longer acidotic or alkolotic, we begin the weaning process, which can take around 4-5 hours. However some pts. with respiratory problems, mainly those who smoke, can take signigicantly longer. Most however are extubated in less than 6 hours. I hope your dad does great, and the best advice i can give u for after the surgery is to not let him lay around. Get him out of the bed and get him moving and push the IS. Take care and i hope this helped.
  7. by   rehab nurse
    thanks to all for your replies!

    my dad has some significant medical problems, IDDM for 30+ years, chronic renal failure, along with the obvious CAD, he had a couple minor MI's a few years ago, had a couple stents put in, and nothing's working. but he's got no respiratory problems at all.

    he has progressively taken better care of himself over the years, esp because of the diabetes, so at least his lifestyle factors are in check. but he is young, just 61, and just had a brother die rather quickly, and is now coming to face his own immortality. and he is scared to death. he hasn't slept in a few days, i finally got a hold of the surgeon to order him something for his anxiety...now just to get him to take it.

    oy. he has to be at the hospital at 5 am thursday, his surgery is scheduled for 8 am, and the surgeon says it will be 3-4 hours. thanks for helping me know what to expect! i'll be ready for him in 3 days when he needs some rehab my specialty!

  8. by   begalli
    Hey rehab nurse, good luck! I know this can be so hard.

    I'm thinking that the docs may think that your dad's crf my play a role in his immediate post-op recovery. They may be telling you that he may be intubated for a prolonged period of time because they may think that his kidneys, already in the state they are, could cause some fluid issues that might affect his lungs. The bypass pump is not always nice to kidneys...so that's a double whammy.

    In my experience some people who you think might not do well straight out of the OR do great while others, who might not have any significant history prior to surgery, crump for hours. You just never know and the docs can never say for sure....this is probably why they said 24-48 hours intubated, 2-3 days in ICU.

    Come back and let us know how it goes!
  9. by   babylongobardi
    Hi, my name is Patti , I have work oncology for years and know 0 about coronary care. My dad had an MI and was taken for an emergency cabgx4 , he is still on the vent and it has been 53hrs out of OR , was told he has the beginnings of COPD . How long can I expect to see him on the vent? also he is in a-fib and on Dig. and cardizem , when could I expect him to return to a normal sinus rhythm? Ballon came out today.
  10. by   rehab nurse
    hi to everyone, just wanted to post an update....

    my dad went into hospital at 5am, was in preop at 7, and surgery started at 8:10am. surgeon finally came out at 1:30 and my dad was already in CVICU. i was finally allowed to see him at 3:30. he ended up having 5 grafts done.

    ICU nurse said his anesthesia should wear off in about 12 hours, i guess they don't reverse it, they just wait for it to wear off, then they will start weaning him from the vent. they said CVICU stay will last at least 36 hours, maybe more, then he'll go to SICU. overall they said his stay will be about 7 days. so i got to see him for about 15 minutes before i was ushered out again. i ended up just going home, as they strongly discouraged staying any longer, and my poor mom needed to eat. i was not prepared for how he would look, and it sure scared me. he looked so pale, lifeless, hooked up to a vent, with about 10 iv's, and syringes attached everywhere, telemetry....i am not used to that environment.

    for all you icu nurses out there, i applaud you. the nurse taking care of my dad was so nice, and very smart. he's definitely in good hands there. i don't know how you icu nurses do it, i don't think i could handle working in an environment like that. i sure do love my rehab patients! i am hoping for a quick recovery for my dad, i am looking forward to seeing him awake and off the vent.

    thanks everyone for your replies and information!!

  11. by   begalli

    Good to hear that they got your dad in and out of the OR in a relatively short period of time! That's great! The shorter amount of time on bypass the better.

    Our patient's anesthesia is not reversed before they come to us either. Some people wake up within an hour, in which case we continue them on propofol for a little while until their temp, bp, etc stabalizes, and some take literally a day to finally start coming around even without sedation. This is very individual. I wouldn't be surprised if your dad might take a bit longer with his kidneys working to clear the drugs.

    Sometimes when people first wake up they are very confused. They can be awake but not quite with it and require restraints for thier own protection. It's not because they are doing anything wrong...they just aren't aware of all of the "stuff" that they're "hooked up to" and unknowingly put themselves at risk by reaching for and pulling at things. I read on these message boards that some people itch really bad and all they are really trying to do is scratch an itch but they get tangled up in lines and tubes in the process. I try to be mindful of that and ask my patients if they have an itch I can scratch for them :chuckle .

    Seven days in the hospital sounds about right. Keep us updated. All sounds great so far. I wish you and your family only the best!

    p.s. I absolutely LOVE my job. Believe me, it's our pleasure as cticu nurses to look after someone like your dad. He's the exact reason that we choose to practice nursing in that type of unit!
    Last edit by begalli on Mar 3, '05
  12. by   rehab nurse
    well, my dad had some excessive blood loss from his chest tube, so they ended up having to give him some 2 units PRBCs, 2 units platelets, and i think 6 units of ffp. they had called me back to the hospital about 6:30p, and i got their around 7, so i got to see him for an hour before visiting hours were over.

    he was much more alert, but scared, a little groggy. but he was following commands and could squeeze my hand, and lift his head off the bed. he was a little restless. lol, when the nurses were verifying his name band to hang some packed cells, they called out his name and his eyes popped open and he started nodding, like 'yeah that's me!'...that made me laugh. then he was off to sleep again.

    the night nurse just called me, and said they were getting ready to extubate shortly hopefully, apparently he was still very groggy, itchy, nauseous, and sweaty. but his blood loss has slowed down and his blood sugars were good. his vitals were very good when i left last night. so i will be off to see him soon....
  13. by   begalli
    Quote from rehab nurse

    the night nurse just called me, and said they were getting ready to extubate shortly hopefully, apparently he was still very groggy, itchy, nauseous, and sweaty. but his blood loss has slowed down and his blood sugars were good. his vitals were very good when i left last night. so i will be off to see him soon....
    Great! I'm glad the nurse is calling you! Sounds like your dad is plugging right along. Our criteria for extubation is that the patient is awake, following commands, and can lift thier head off the pillow. Of course they need an acceptable gas on a zero rate and pressure support with a touch of peep.

    Most everyone needs fluid resus following surgery like this. Some need blood products. Do you know what his bleeding was due to? Did he not warm up right away once on the unit?

    I appreciate you sharing your story, Heather. It IS funny when patients are groggy and they suddenly awaken when they hear something familiar and then they fall right back off just as quickly as they burst onto the scene! :chuckle It's a great reminder to me to watch what I say....always!!
  14. by   rehab nurse
    thanks begalli~

    they don't know what the excessive blood loss was from. he normally takes plavix/ASA but had been off for 10 days prior to the surgery. at any rate, yesterday when i saw him, they were done with the blood, and his last hgb was 9.6.

    his problems yesterday were nausea, vomiting, very low bp's (60/70 systolic), and very low blood sugars. he got up in the chair twice, but he tires very quickly. they took one of his swans out. i don't understand why they have him on a insulin drip, but no dextrose. five times yesterday he went unresponsive because of low blood sugars. my dad has hypoglycemic episodes every day, even when he was well. in the early afternoon, and about midnight, he will drop to about 60, and that's enough for him to be symptomatic. so anyways, they're checking his blood sugar every hour. but several times it is about 80 or so, and they won't shut off the insulin. then half hour later, his eyes roll back in his head, and they have to push an amp of d50. i don't understand their thinking at all. he hasn't been able to eat anything (they have him on clear liquids, but after he eats a few bites, he vomits). i know they want his sugars less than 110, they said they have a faster healing rate that way. so then they'll keep giving him iv zofran, but it's not working. i asked his night nurse if he could have something different but she said NO. i can't understand why they'll let him continue to vomit and be nauseated almost constantly. and then he has the problem with the low blood pressures. he is on dopamine, and cardizem.

    so i don't know, i am definitely not an icu nurse. it is very hard for me to see him suffering like he was, and i can't do anything for him. they are giving him toradol only for pain every six, and where i work, most people get nauseated from that. so maybe it's that? i know my dad gets nauseated when his blood sugar is around 70-80. so maybe that has something to do with it also? at least he sleeps at intervals, but he says he really hurts about 3 hours after they give him the toradol. i told him he has to ASK for additional pain medicine, but my dad is too proud and won't. if he c/o pain while i'm there, i'll tell his nurse, then when she comes to ask, he'll say "i'm ok". his nurse must think i'm nuts. i wish they would just give him something. i never heard his nurse ask him voluntarily if he was in pain. i don't know what his fear is of getting pain meds.

    sorry this is so long. i just feel so helpless when i am there with him.

    and one more thing, i about fell out of my chair when the first surgeon he had gone to consult with (he went with the second surgeon) came in his room after he found out he was in the icu, and asked him why he didn't choose him? i thought that was very unprofessional. the reason he didn't go with him was because he didn't like his attitude/personality. he is very abrupt, and my dad didn't feel comfortable with him. my head still spins thinking about that incident!