What are the key things to watch for after Coronary Artery Bypass Graft (CABG) surgery?

Key Monitoring Parameters After CABG Surgery

Continuous electrocardiogram monitoring for at least 48 hours after CABG is essential for all patients to detect arrhythmias and potential ischemic events. 1

Cardiovascular Monitoring

• Continuous electrocardiographic monitoring for arrhythmias should be performed for at least 48 hours in all patients after CABG, as post-CABG atrial fibrillation most commonly occurs between days 2 and 4 after surgery 1
• Continuous ST-segment monitoring for detection of ischemia is reasonable in the intraoperative period and may be considered in the early postoperative period to detect myocardial ischemia 1, 2
• Pulmonary artery catheter placement is indicated in patients with cardiogenic shock and can be useful in patients with acute hemodynamic instability 1
• Monitor for signs of graft failure, which can present as recurrent chest pain, ECG changes, hemodynamic instability, or elevated cardiac biomarkers 3
• Beta blockers should be reinstituted as soon as possible after CABG in all patients without contraindications to reduce the incidence of postoperative atrial fibrillation 1

Respiratory Monitoring

• Monitor for postoperative pulmonary complications, including pneumonia, which occurs in up to 16% of high-risk patients without preoperative intervention 4
• Early postoperative extubation and accelerated recovery should be targeted for low to medium-risk patients undergoing uncomplicated CABG 1
• Watch for respiratory distress, abnormal breath sounds, fever, and changes in sputum production that may indicate pneumonia or other pulmonary complications 3, 4

Wound and Infection Monitoring

• Closely monitor surgical sites (sternum, leg/arm harvest sites) for signs of infection including redness, warmth, increased pain, drainage, or wound dehiscence 3
• Aggressive control of perioperative hyperglycemia with continuous intravenous insulin to maintain blood glucose ≤180 mg/dL is indicated to reduce the risk of deep sternal wound infections 1
• Preoperative antibiotic administration should be used in all patients to reduce the risk of postoperative infection 1

Neurological Monitoring

• Monitor for signs of stroke or neurological complications, particularly in high-risk patients (age >65 years, left main coronary stenosis, peripheral artery disease, history of cerebrovascular disease, hypertension, smoking, and diabetes mellitus) 1
• Watch for changes in mental status, new focal neurological deficits, or delayed awakening from anesthesia 3

Psychological Monitoring

• Assess for signs of depression and anxiety, which are common after CABG and associated with poorer outcomes 1, 5
• Cognitive behavior therapy or collaborative care for patients with clinical depression after CABG can be beneficial 1

Pain Management and Comfort

• Monitor pain levels, particularly at surgical sites, as inadequate pain control can lead to respiratory complications and delayed mobilization 6
• Patients often experience uncertainty and worries related to postoperative pain and what is normal during recovery 6

Medication Management

• Monitor for appropriate antiplatelet therapy - aspirin is the drug of choice for prophylaxis against early saphenous vein graft closure and should be continued indefinitely 1
• ACE inhibitors and angiotensin-receptor blockers given before CABG are recommended to be continued 1
• For patients with post-CABG atrial fibrillation that persists more than 24 hours, warfarin anticoagulation for 4 weeks is probably indicated 1

Rehabilitation and Recovery

• Cardiac rehabilitation is recommended for all eligible patients after CABG 1
• Monitor progress with physical activity/exercise as patients often experience uncertainty about appropriate levels of exertion 6
• Provide education and support regarding smoking cessation for all smokers 1

Common Pitfalls and Caveats

• Failure to monitor for atrial fibrillation beyond the first 48 hours can lead to missed diagnoses, as AF most commonly occurs between days 2-4 1, 3
• Inadequate glycemic control increases risk of sternal wound infections 1
• Patients often report insufficient information at discharge, creating anxiety about normal recovery expectations 6
• Lack of attention to psychological symptoms may lead to poorer outcomes, as depression is associated with adverse outcomes after CABG 1, 5
• The first month after discharge is particularly challenging for patients, with many experiencing uncertainty about medications, physical activity, and normal recovery 6