The modified Bentall procedure for aortic root replacement

AORN Journal,  July, 2006  by Cecile Cherry,  Starla DeBord,  Carol Hickey

• E-mail
• Print
• Link

TABLE 1

Factors Associated with Developing Aortic
Aneurysm and Aortic Dissection (1-3)

Aortic aneurysm

* Age (ie, older than 50 years)

* Atherosclerosis

* Autoimmune disorders (eg, ankylosing spondylitis, giant cell
arteritis, Takayasu arteritis)

* Congenital bicuspid aortic valve

* Cystic medial necrosis (eg, degeneration of the elastic and muscle
tissue in the tunica media)

* Gender (ie, men are affected two to four times more often than
women)

* Genetic factors (eg, family history of aneurysm)

* History of smoking

* Hypertension (ie, 70% to 80% of patients with thoracic aneurysms
have hypertension)

* Infections (eg, bacterial infection of the aorta [ie, mycotic
aneurysm]; aortitis due to syphilis or tuberculosis)

* Inherited connective tissue disorders (eg, Marfan's syndrome)

Aortic dissection

* Hereditary connective tissue disorders (eg, Marfan's syndrome,
Ehlers-Danlos syndrome)

* Hypertension

* Iatrogenic trauma to the aorta (eg, insertion of catheters for
cardiac catheterization or cardiac surgery, intra-aortic balloon pump
insertion)

* Trauma (ie, most commonly a rapid deceleration injury)

(1.) P C Seifert, Cardiac Surgery: Perioperative Patient Care
(St Louis: C V Mosby, Inc, 2002).

(2.) B Finkelmeier, Cardiothoracic Surgical Nursing, second ed
(Philadelphia: Lippincott Williams & Wilkins, 2000) 37-39.

(3.) J Elefteriades, "Natural history of thoracic aortic aneurysms:
Indications for surgery, and surgical versus nonsurgical risks,"
Annals of Thoracic Surgery 74 (November 2002) S1879.

TABLE 2

Equipment and Supplies Needed for
the Modified Bentall Procedure

Equipment

* Autologous blood recovery system

* Cardiopulmonary bypass machine

* Headlights and headlight boxes

* Supplies for femoral arterial and venous cannulation

* Transesophageal echocardiography unit

Instruments

* Appropriate aortic valve sizers

* Basic cardiac instruments

* Electric reciprocating sternal saw

* Internal defibrillator paddles

Medications

* Bone paste made with 10,000 units thrombin, 500 mg
vancomycin, and absorbable gelatin powder

* Epinephrine 1:10,000

Positioning aids

* Foam headrest

* Foam padding

* Full length gel pad on OR bed

* Small gel pads

Supplies

* Chest tubes

* Closed chest-drainage system

* Indwelling urinary catheter with temperature probe

* Pacemaker cable

* Temporary pacing wires

TABLE 3
Types of Grafts Used in Aortic Root Replacement

                             Advantages             Disadvantages

Composite grafts

Mechanical valve with   * More durable          * Thrombogenic (ie,
attached woven tube       than biologic           promotes the
vascular graft            valves-Expected to      formation of
                          function for the        clots)--Patient
                          life of the patient     will require
                                                  lifelong
                                                  anticoagulation
                                                  therapy

Tissue valve (ie,       * Nonthrombogenic--     * Less durable
porcine aortic valve,     Patients will not       than mechanical
bovine  pericardium)      require lifelong        valves-Patient
with attached woven       anticoagulation         may require
tube vascular graft       therapy                 re-operation for
                                                  valve replacement
                                                  in the future

Tissue grafts

Homograft or            * Nonthrombogenic--     * Storage and thawing
allograft (ie, tissue     Patient will not        of cryo-preserved
from cadaver donor)       require lifelong        human tissue
ascending aorta with      anticoagulation         requires strict
aortic valve that is      therapy                 adherence to tissue
stored frozen until     * More durable than       center guidelines
ready to implant          tissue from other
                          species
                        * Associated with a
                          lower incidence
                          of valve-related
                          endocarditis than
                          either mechanical
                          or xenograft valves

Xenograft or            * Nonthrombogenic--     * Less durable than
heterograft (ie,          Patient will not        mechanical woven
porcine aortic root       require lifelong        tube composite
with valve)               anticoagulation         graft
                          therapy

TABLE 4
Nursing Care Plan for Patients
Undergoing Aortic Root Replacement

Diagnosis         Nursing interventions

Risk for          * Assesses for preexisting conditions that
alteration          pre-dispose to inadequate tissue perfusion.
in tissue         * Identifies baseline tissue perfusion.
perfusion         * Collaborates in fluid management.
                  * Monitors physiological parameters (eg,
                    peripheral pulses, urinary output, blood
                    pressure, filling pressures).
                  * Evaluates postoperative cardiac and
                    peripheral tissue perfusion.

Risk for          * Determines knowledge level, assesses readiness
anxiety related     to learn, and identifies barriers to
to knowledge        communication.
deficit and       * Acts as a patient advocate by identifying
stress of           individual values and wishes concerning
surgery             care; maintaining the dignity, modesty, and
                    privacy of the patient; protecting the patient
                    from unsafe care; and ensuring confidentiality
                    of patient information.
                  * Explains sequence of events; reinforces
                    teaching about treatment options; provides
                    instruction (ie, verbal, written) for surgical
                    procedure and discharge based on age and
                    identified need; and ensures availability of
                    support group interaction.
                  * Verifies consent for planned procedure.
                  * Communicates patient concerns to appropriate
                    surgical team members.
                  * Evaluates psychosocial effect of plan of care
                    and response to instruction.
                  * Provides status reports to family or support
                    group.

Risk for acute    * Assesses patient's pain preoperatively.
or chronic pain   * Identifies patient's accepted postoperative
related to          pain threshold.
surgical          * Provides pain management instruction and
procedure           pain scale to assess pain control.
                  * Evaluates patient's response to pain management
                    interventions.

Risk for injury   * Verifies patient's identity, allergies, NPO
related to          status, and informed consent.
perioperative     * Assesses skin integrity, sensory impairments,
experience          and musculoskeletal status.
                  * Transfers patient, implementing protective
                    measures to prevent positioning injury and
                    maintain correct body alignment.

                  Interim out-               Outcome
Diagnosis         come criteria              statement

Risk for          The patient maintains      The patient demonstrates
alteration        adequate tissue            wound and tissue
in tissue         perfusion throughout       perfusion consistent
perfusion         the procedure as           with or improved from
                  demonstrated by            base-line levels
                  peripheral pulses          established
                  equal to or greater        preoperatively.
                  than baseline, adequate
                  urinary output, and
                  blood pressure and
                  filling pressures
                  with-in normal limits.

Risk for          The patient verbalizes     The patient demonstrates
anxiety related   * decreased anxiety and    knowledge of the
to knowledge        an ability to cope,      expected response to the
deficit and       * understanding of         procedure and discharge
stress of           individualized           care.
surgery             procedure and
                    sequence of events,      The patient and
                  * that questions have      appropriate family
                    been answered, and       members participate in
                  * expected outcomes.       decisions affecting the
                                             patient's plan of care.

Risk for acute    The patient demonstrates   The patient demonstrates
or chronic pain   adequate pain              and reports adequate
related to        management.                pain control throughout
surgical                                     the perioperative
procedure                                    period.

Risk for injury   The patient's skin         The patient is free from
related to        remains intact, and        positioning injury from
perioperative     neuromuscular functions    extraneous objects.
experience        are-maintained or
                  improved from baseline.

FIGURE 4

Excerpt from the Cardiovascutar Surgery Patient Teaching Booklet

The Cardiac Intensive Care Unit (CICU)

The CICU is a 20-bed unit where nurses are always watching and taking
care of you. The CICU is a busy place. You will stay in CICU for one
to two days until you are ready to be transferred to your room. When
you get to the CICU, you will have several small tubes attached to
machines, monitors, or containers. You will not notice this until you
start to wake from your anesthesia. Do not worry if you cannot move
your arms or legs when you first wake up from surgery. This is because
the medicine used during the surgery may result in your mind and body
waking up at different times. In a short while, your entire body will
be awake and you will be able to move your arms and legs. You will hear
the sounds of equipment and may be aware of activity around you. If
you overhear someone talking, do not think that they are necessarily
talking about you. If someone wants to talk with you, he or she will
call you by name and speak directly to you. Following are descriptions
of some CICU equipment you will have while in the CICU.

Chest tubes

Several clear tubes will come out of the lower part
of your chest to drain blood from your chest. Some
bleeding after surgery is normal. Your doctor will
decide when it is time to remove the chest tubes.

IV line

An W line is a small, soft-plastic tube in a vein in
your arm or hand through which fluid, medicine,
or blood can be administered. The W line may be
connected to a pump to help the fluid go into your
vein. You will have a least one IV line until you can
take your medicine by mouth. You also will have a
larger W line in a vein on the side of your neck
after surgery. This will remain in until the day you
go home. Let your nurse know if you have any redness,
swelling, or tenderness near the IV line.

Monitors

There will be a monitor screen on the shelf at
the head of your bed. Small round pads will be
placed on your chest to monitor your electrocardiogram
(ie, heart rhythm). While you are in the
CICU, your nurse will measure your blood pressure
and temperature all the time. You also may
have several small wires fie, pacemaker wires)
taped on your lower chest to increase your heart
rate or keep track of your heart's rhythm.

Nasogastric (NG) tube

An NG tube was put through your nose into
your stomach during surgery. The NG tube
keeps air from building up in your stomach.
This helps keep you from getting sick to your
stomach and vomiting. Your nurse will give you
ice chips after he or she removes the NG and
breathing tubes.

Oxygen mask or nasal cannula

After you are taken off the ventilator, your nurse
will give you oxygen by using a small plastic mask
or a thin, clear plastic tube called a cannula. The
mask sits lightly on your face covering your mouth
and nose. The cannula has two small, short prongs
that fit just inside your nose.

Pulse oximeter

This small device estimates how much oxygen is in
your blood. It is taped to your finger, toe, or ear.

Urinary catheter

A tube, called a catheter or Foley, will be put into
your bladder during surgery. It drains urine from
your bladder so you can rest instead of having to
use a bedpan or urinal. This makes it easier for the
nurse to keep an accurate record of your urine output.
It is normal to feel like you need to urinate.
Just relax, and let the catheter take care of it. The
catheter will be removed a few days after surgery.

Ventilator

You will have a breathing tube in your mouth or
nose when you wake up. You may have a full or
tight feeling in your throat because the tube goes
down your throat into your windpipe. You will not
be able to talk with the tube in. Do not pull the
tube or move your head too much.

The tube will be connected to a ventilator (ie,
breathing machine) that breathes slowly and
deeply for you until you are fully awake. You and
your heart will rest better while the machine helps
your breathing. The machine also gives more oxygen
to your brain. Just lie quietly and rest. Your
nurse will use various methods to find out if you
are having much pain and you can respond by gently
nodding or shaking your head.

You will have the breathing tube until you no
longer need help breathing. Since you cannot
cough up mucous, your nurse will use a tube to
suction the mucous. It may hurt a little, but it is
needed to prevent problems like pneumonia. Right
after the tube is removed, your nurse will help you
sit up in bed and will clap your back to help clear
your lungs. You will be able to talk after the tube is
removed, but your voice may be a little hoarse.

Reprinted with permission from M A Degges, RN, MSN, CCNS, the Heart
Center at University Hospital, Birmingham, Ala.

COPYRIGHT 2006 Association of Operating Room Nurses, Inc.
COPYRIGHT 2008 Gale, Cengage Learning