What would be included in the collaborative management of a patient's pulmonary status following coronary artery bypass graft surgery?
1. Keeping the patient intubated for at least 48 hours to maximize gas exchange
2. Mobilizing the patient as soon as possible to prevent atelectasis and venous stasis
3. Evaluating readiness for extubation based on guidelines: PO2 less than 80 mm Hg with an FiO2 greater than 40% and a PCO2 greater than 45
4. Extubating when the patient is arousable to noxious stimuli and shows increased effort for spontaneous breathing
2
Rationale 1: No set timing is required for extubation "readiness" is needed. Usually the patient is on the ventilator for less than 24 hours to minimize ventilator-related problems and to maximize O2 exchange during the first 24 hours after surgery.
Rationale 2: Pulmonary functions decline with immobility. Gravitational pull on secretions to posterior areas and inadequate inflation cause atelectasis. Activity and position changes will increase mobility of secretions. Even if the patient is intubated, extra movement by changing of positions will minimize respiratory complications or congestion in the lungs, both of which will increase the work effort of the heart and decrease perfusion and ventilation if not corrected.
Rationale 3: The goal settings for adequate ventilation are off: O2 greater than 80 mm Hg, FiO2 less than 40%, and PCO2 less than 45.
Rationale 4: Weaning the patient off the intubation process needs to be done gradually and based on blood gas values, pH, O2 saturations, respiratory effort, fatigue, and coloring. This will allow for maximum gas exchange with the least O2 demand when "readiness" has been achieved. With increased respiratory effort, more O2 is required due to increased muscle efforts; thus the reasoning for gradually weaning based on each patient's response.
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