Coronary artery bypass grafting (CABG) is a widely used procedure (200,000 annual cases in the US)1 in individuals with Coronary artery disease (CAD). CAD is a build-up of plaque in the blood vessels that supply the heart, which can result from diabetes, smoking, and a vast number of other conditions. The procedure involves harvesting blood vessels (usually autografts of the patient’s saphenous vein) and surgically attaching them to the aorta and the poorly perfused area of the heart, bypassing the damaged vessels. Early mobility is now the standard of care in physical therapy (PT) practice following CABG, however some clinicians prefer to wait until the patient has left the Intensive care unit (ICU) to provide services.https://dune.une.edu/pt_studcrposter/1175/thumbnail.jp

Hall, Cody

English

University of New England

1. Weiss AJ, Elixhauser A. Trends in operating room procedures in U.S. hospitals, 2001-2011: Statistical Brief #171. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US), 2006.2. Melly L, Torregrossa G, Lee T, Jansens JL, Puskas JD. Fifty years of coronary artery bypass grafting. J Thorac Dis. 2018 Mar;10(3):1960-1967. doi: 10.21037/jtd.2018.02.433. Dong Z, Yu B, Zhang Q, Pei H, Xing J, Fang W, Sun Y, Song Z. Early rehabilitation therapy is beneficial for patients with prolonged mechanical ventilation after coronary artery bypass surgery. Int Heart J. 2016;57(2):241-6. doi: 10.1536/ihj.15-316The author of this case report can be reached at chall8@une.edu.ReferencesContact InformationEarly Mobilization and Functional Mobility Training for a Patient with Triple Vessel Coronary Artery Bypass Grafting:  A Case ReportCody Hall, B.S., ATC, Doctor of Physical Therapy StudentDoctor of Physical Therapy Program, University of New England, Portland, MaineLength of StayDiscussion & ConclusionBackground & PurposeTimelineCase DescriptionInterventions• Coronary artery bypass grafting (CABG) is a widely used procedure (200,000 annual cases in the US)1 in individuals with Coronary artery disease (CAD).2 CAD is a build-up of plaque in the blood vessels that supply the heart, which can result from diabetes, smoking, and a vast number of other conditions.2• The procedure involves harvesting blood vessels (usually autografts of the patient’s saphenous vein) and surgically attaching them to the aorta and the poorly perfused area of the heart, bypassing the damaged vessels.2• Early mobility is now the standard of care in physical therapy (PT) practice following CABG, however some clinicians prefer to wait until the patient has left the Intensive care unit (ICU) to provide services.3• The patient was a 70-year-old male who underwent an on-pump, three-vessel CABG using autografts from his left saphenous vein and left internal mammary artery.• Comorbidities included type II diabetes mellitus with peripheral neuropathy, hypertension, hyperlipidemia, post-traumatic stress disorder (PTSD), current tobacco use disorder, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and chronic pain.1.  Do not lift your arms in front of you above 90°.2.  Do not lift your arms out to the side above 90°.3.  Do not push anything greater than 10 pounds.4.  Do not pull anything greater than 10 pounds.5.  Do not lift anything greater than 10 pounds.6.  Do not drive.These precautions should be maintained for the initial 6-8 weeks following surgery.• A PT plan of care including a cardiac warm-up, mobility training as early as possible, and patient education appeared to be beneficial and timely in treating a patient post-CABG with many comorbidities.• Several unanticipated events (a brief bout of atrial fibrillation which resulted in regression back to the ICU and an episode of suspected delirium) occurred, however did not appear to affect PT outcomes.• Based on clinical judgement, the Physical Therapist and Student Physical Therapist determined that the patient may be at a high risk for sternal dehiscence due to his voiced intentions of breaking the sternal precautions while riding his motorcycle soon after discharge.The author acknowledges Amy Litterini, PT, DPT, for assistance and conceptualization of this case report, as well as Cam-Loan Nguyen, PT, DPT, for supervision of patient care, and the patient for voluntarily participating in this study.Acknowledgementshttps://ctsurgerypatients.org/procedures/coronary-artery-bypass-grafting-cabghttps://www.nejm.org/doi/full/10.1056/NEJMra1406944Goal Level of AssistanceTime Frame Status at Time of DischargePerformance of Home Exercise ProgramIndependent 2 weeks MetSupine-to-Sit TransferModified independence with the use of a hospital bed, similar to that of his own at home2 weeks Met and ExceededSit-to-Stand TransferModified independence with increased time and effort to rise allotted2 weeks Met and ExceededAmbulation of 150 feetModified Independence with use of a front-wheeled walker2 weeks Met and Exceededhttps://www.practicalcardiology.com/antithrombotic-therapy/antithrombosis-secondary-prevention-coronary-artery-diseasePast Medical History• Type II DM with peripheral neuropathy, HTN, HLD, PTSD, Tobacco Use Disorder, COPD, OSA, and chronic pain• 2 drug-eluting stent placements 13 years prior• NSTEMI 10 months priorTwo Months Prior to Surgery• Coronary Angiography revealed CAD• Triple Vessel CABG scheduled with recs from the cardiologistPost-Operative Day 1• Patient was unable to attempt any transfers or ambulation• Patient reported 6/10 pain score at rest on the NPRSPost-Operative Day 3• Patient required Mod-A and CGA for transfers• Patient ambulated with a platform walkerPost-Operative Day 7 (PT Discharge)• Patient transferred and ambulated independently• Patient scored 28/28 on the POMA (Performance Oriented Mobility Assessment)• Patient reported 0/10 pain score at rest and with activity on the NPRSTwo Weeks Post-Discharge Follow-Up• Patient reported no complications and stated he was completing activities of daily living independentlyDM = Diabetes Mellitus, HTN = Hypertension, HLD = Hyperlipidemia, PTSD = Post-Traumatic Stress Disorder, COPD = Chronic Obstructive Pulmonary Disease, OSA = Obstructive Sleep ApneaGoals Patient Experimental Group3Control Group3Length of Time on Mechanical Ventilation2 Days 8.1 Days 13.9 DaysLength of Stay in Intensive Care Unit5 Days 11.7 Days 18.3 DaysLength of Stay at Hospital 14 Days 22 Days 29.1 Days• The patient experienced better outcomes in all categories when compared to both the experimental and control groups in a study3 involving patients on prolonged mechanical ventilation who received PT in the ICU and after leaving the ICU, respectively.PatientEducationCardiac Warm-UpBedMobilityTransferTrainingGait TrainingSternal Precautions 

Early Mobilization And Functional Mobility Training For A Patient With Triple Vessel Coronary Artery Bypass Grafting: A Case Report

Background and Purpose:  Coronary artery disease (CAD) is the buildup of plaque in coronary blood vessels and is the most common type of heart disease in the United States.  Coronary artery bypass grafting (CABG) is an invasive surgical procedure used to provide alternate blood supply to cardiac tissue in individuals with CAD using autografts.  The goals of the surgery are often to prolong life, reduce symptoms, improve functioning, and improve vocational status.  The purpose of this case report was to document the outcomes of a physical therapy (PT) plan of care for a complex patient after undergoing CABG. Case Description:  The patient was a 70-year-old male with evident CAD and many comorbidities including type II diabetes mellitus with peripheral neuropathy, hypertension, hyperlipidemia, post-traumatic stress disorder (PTSD), current tobacco use disorder, Chronic Obstructive Pulmonary Disease (COPD), obstructive sleep apnea, and chronic pain who underwent triple vessel CABG at a Veterans Affairs Hospital in Palo Alto, CA.  A PT plan of care was implemented and based around the principles of early mobilization and functional mobility training. Outcomes:  Following five sessions, the patient progressed from being unable to attempt any transfers/ambulation to completing all basic transfers and ambulating independently without an assistive device at discharge.  He was discharged to home with no complications at two-week follow-up. Discussion:  A PT plan of care that included early mobilization and functional mobility training appeared to be beneficial in timely hospital discharge for a patient post-CABG with many comorbidities.  Future research that examines the effects of each comorbidity on CABG outcomes may improve the understanding of the specific needs of these patients

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Early Mobilization And Functional Mobility Training For A Patient With Triple Vessel Coronary Artery Bypass Grafting: A Case Report

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