Need Guidance for Pre-op CABG for my Pathogram

Editorial Team / Admin · Oct 12, 2012

Could be he came in for an elective heart cath, they saw something, and decided it would be better to keep him in the hospital rather than send him home. Most patients get anticoagulation of some type during a cath, so if the patient isn't critical (such as a left main blockage, which is known as the widow-maker), then the surgeon usually waits until the effects of the anticoagulation wear off. Plus, looking at your dates, the patient was in over the weekend. Typically, no scheduled surgeries on weekends, only cases that can't wait (although this varies from hospital to hospital).

Esme12, ASN, BSN, RN · Oct 13, 2012

Hey there! I'm a student working on my pathogram and discovering that I maybe didn't pull enough out of my pt's record. What my most confusing point is the dates. I thought that my pt was a direct admit for a scheduled CABG, however I am seeing that the dates just don't add up. He was admitted Fri 9/14, blood tests were done on 9/14 and 9/15, and that's it. An echo, chest CT, venous dopplers, and vein mapping were done on 9/17 and the CABG was scheduled for 9/18. If he were a c/o chest pain and SOB patient, then he would have came in through the ED and all tests would have been done right away, right? But if he were direct admit for pre-op, why did he have to come in 4 days prior? This is where I am confused. Any help is much appreciated! The only other clue I can offer is elevated clotting times on the 14th at 2 pulls; 177 the first time, then 144 with aPTT of 33 the second draw (aPTT was not done in the first draw). Draws on the 15th were WNL except for low RBC & H/H and cardiac enzymes were not even drawn (which further makes me believe he is a direct admit). Does this make any sense?? Thanks again!!

Welcome to AN! The largest online nursing community.

NO, you didn't pull enough information......you should always read the H&P and any consults that are in the record. You assumed that your patient was a direct admit...."I thought that my pt was a direct admit for a scheduled CABG"...... I always tell my kids......we all know what assume (assUme) spells. You usually will end up being incorrect.

A patient may be a direct admit for a CABG...... but on the record there will ALWAYS BE the Cath report defining the disease and the H&P along with the surgical consultation and progress notes. ie...."The patient has a c/o chest pain with exertion for 2 months. The patient had a stress test on Oct 4, 2012 which showed diffuse anoxic/ischemic changes. The LAD 80% proximal lesion with a 75% lesion in the Cx and 40 % in the high diagonal. The patient had a subsequent LHC, Left Heart Catherterization, (cardiac cath) on 9/14. The RCA shows 100% occlusion with collateral circulation from the LAD. Due to severe multi vessel disease and the high risk for developing chest pain/STEMI. The Patient is now admitted for observation, anti-coagulation prior to surgical intervention for pre-operative work-up for CABG scheduled for 9/18."

I have several questions....and you may need to get permission to either

1) call/go back to the facility to obtain the information or

2) have permission to make up what you don't have.

He was admitted Fri 9/14, blood tests were done on 9/14 and 9/15, and that's it. An echo, chest CT, venous dopplers, and vein mapping were done on 9/17 and the CABG was scheduled for 9/18. If he were a c/o chest pain and SOB patient, then he would have came in through the ED and all tests would have been done right away, right? But if he were direct admit for pre-op, why did he have to come in 4 days prior?

What is the patients previous medical history? When was the cardiac cath? What labs were drawn on 9/14-15 what were the results? What did the Chest CT show....what were they looking for? What meds was this patient on?

An echo, chest CT, venous doppler, and vein mapping were done on 9/17 and the CABG was scheduled for 9/18

Unless emergent these would be done during "normal business hours" The echo is looking for ejection fraction and wall motion to compare during the operative/post-operative period. TEE's are routinely performed intra-op for wall motion/filling pressures pre and post pump/bypass. Vein mapping is just that looking for the saphenous vein grafts.

While these are usually outpatient........if there was a concern about the patient having such severe blockages and needing to be anti-coagulated before the surgery as they performed the usual pre-operative testing. They would admit on a Friday night and monitor the patient until such testing would be done on Monday.

A likely scenario would be.....The patient, maybe with a history of HTN, previous MI, has been experiencing chest pain, SOB and fatigue. Had an outpatient Stress Test that was positive and was scheduled as an outpatient for Cardiac Cath on Friday that revealed several high grade (severe) lesions (blockages) that cardiology and the surgical service felt that the patient was safer being admitted post cath for anti-coagulation until the preoperative work-up could be completed and OR scheduled.

I hope this helped :)

lkpluskamp · Oct 13, 2012

Thanks for your comment! What you are saying makes total sense! I think I am just missing a few pieces of the picture.