What is included in surgery intensive care unit (SICU) management following coronary artery bypass grafting (CABG)?

Updated: Dec 04, 2019
  • Author: Rohit Shahani, MD, MS, MCh; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

After CABG, transport the patient to a dedicated cardiac surgery intensive care unit (SICU). If the patient’s condition is uncomplicated, basic management and progress assessment include the following:

  • During the first 6-12 hours after CABG, there is usually a decline in myocardial function secondary to a number of factors, including myocardial edema and ischemia-reperfusion injury. If this occurs, the patient may require increased inotropic support or pacing. However, most patients can be weaned from inotropic support within 24 hours after the operation, and the temporary epicardial pacing wires can be removed at around 3 days.

  • In the early postoperative period, a continuous infusion of nitroglycerin should be administered if a radial graft has been used, because such grafts are prone to spasm in the period immediately following the operation, resulting in myocardial ischemia.

  • Although many patients can be extubated in the first 6 hours following CABG, the majority are not extubated until postoperative day 1.

  • The patient’s temperature should be carefully regulated. Some patients may have peripheral vasodilation and hypotension secondary to an elevated body temperature arising from difficulties in central thermoregulation. This hypotension is associated with a worse neurologic outcome.

  • There is usually a 1 mL/kg/h diuresis immediately after CABG as a consequence of the amount of fluid administered intraoperatively. The urinary catheter can be removed once the patient is mobile. Oral furosemide can be used postoperatively, if needed. If LV function is preserved and the patient’s weight has returned to baseline, diuretic therapy can usually be discontinued late in the first postoperative week.

  • Drainage from the mediastinum should gradually decrease over the first 6 hours after CABG. The mediastinal drains often can be removed on postoperative day 1 when there has been no drainage for 3 consecutive hours. After their removal, a chest radiograph should be taken.

  • Ideally, patients should be sitting in a chair on postoperative day 1 and should be mobilized as soon as possible.

Also note the following:

  • In the first 6 hours after CABG, many patients require increased insulin. Lactulose and senna can be used as a laxative from day 1. Patients are encouraged to drink fluids and ingest an advancing diet after extubation and confirmation of normal mental status. Shortly thereafter, insulin sliding scales can be stopped and normal antihyperglycemic drugs started.

  • A prophylactic dose of 75 mg of aspirin once daily by mouth should be commenced in the first 6 hours after the procedure. Statins should be started on postoperative day 1. Low-molecular-weight heparin and antiembolism stockings should be used for prophylaxis of deep vein thrombosis; the stockings have the added benefit of reducing edema in the saphenous donor leg. [49]

  • In the absence of epidural analgesia, patient-controlled analgesia should be used for pain relief once the patient has been extubated. It is usually required for only 2-3 days postoperatively, by which time orally administered analgesia typically provides sufficient pain relief.


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