Coronary Artery Bypass Grafting (CABG)

Over the past two weeks of clinicals, the majority of patients I saw were either cardiology or oncology patients. Since I began shadowing the physician assistants at the Heart Institute I was introduced to various cardiac-related terms, but this week, from reviewing countless charts I am much more “well-versed” in the language. CABG (pronounced like cabbage) was one of the most common surgeries my patients recently underwent. CABG stands for Coronary Artery Bypass Graft and is usually followed by the number of vessels that were repaired (i.e. CABGx4). After hearing this term over and over and knowing little about it, besides the fact that is an open heart surgery, I decided to research it.

Physicians will recommend CABG procedure for individuals with severe coronary heart disease. Coronary heart disease is characterized by plaque build up in the coronary arteries that can harden and narrow the arteries which decreases the flow of oxygen-rich blood flow to the heart. Another consequence of plaque build up is that is can rupture and cause a blood clot to form. Blood clots can partially or completely block an artery stopping blood flow to the heart. This can be detected by an individual if they report experiencing angina, or chest pain. Blood clots are the most common causes of heart attacks.

In order to repair these arteries, a CABG is one of the procedures that can be used for treatment. During a CABG, a healthy artery or vein from the body is connected, or grafted, to the blocked coronary artery to bypass the blocked portion creating a clear pathway to improve oxygen-rich blood flow to the heart. The majority of the time CABG procedures are performed on multiple vessels during one operation.

While this seems like a very tedious procedure the outlook for these patients is typically very good. Patients often remain symptom free, with reduced angina and decreased risk for a heart attack, for 10-15 years. Patients who chose to engage in lifestyle modification will typically have the best outlook. View the video below for a visual explanation.

CABG Video

So, as a dietitian what do I tell these patients? Well, I start out by determining if this is a recent diagnosis or if they had had a similar procedure before. If this is new, they may have never heard of a cardiac (heart-healthy) diet but if this is something they have previously experienced they may have received prior education. After looking at the diet habits prior to surgery I can determine a nutrition diagnosis and help the patient set attainable goals and provide them with the education that they need.

The main focus of the cardiac diet is to prevent future plaque build-up and lowering blood pressure by decreasing cholesterol and sodium intake. The major changes that cardiac patients should make include:
• Limit saturated fats and trans fats
• Increase intake of omega-3 fats
• Limit the total amount of fat that you eat to 25-35% of total calories
• Limit cholesterol intake to less than 200 mg per day
• Limit sodium intake to less than 2,000 mg per day
• Get 20 to 30g of dietary fiber per day

In addition to these guidelines these patients can benefit from establishing and maintaining a healthy weight and engaging in physical activity. See an example handout here (HeartHealthyNutritionTherapy) from the Academy of Nutrition and Dietetics that I frequently provide my patients with.

While many patients are motivated by a recent cardiac event or surgery to make positive lifestyle changes, a large percentage of patients have no desire. Over the past few weeks I have heard comments such as, “What I eat doesn’t affect me, so why would I change?” or “I eat what I want, whenever I want and I am not going to change.” If patients are unwilling to accept the education and agree to making small changes then there is nothing I can do for these patients. It is really unfortunate to hear these comments but speaking with patients who are actively engaged and motivated to set and achieve their new goals can be extremely rewarding and make up for the noncompliant patients.

My First Immersion into Clinical Nutrition!

I just finished up my first week of my clinical nutrition rotations! I have just one more week left at Monongalia General Hospital before I move on to my next set of rotations. I have learned so much this week on the overall role of clinical dietitians and how it is to really utilize the Nutrition Care Process on real patients.

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Monongalia General Hospital is one of two major hospitals in the Morgantown area – in fact they are practically right next to each other! These two hospitals serve very different needs in the community. Ruby Memorial Hospital is a large teaching hospital that is over 500 beds and is fully equipped with a cancer center, children’s hospital, and a level I trauma unit. Monongalia General Hospital is only 189 beds equipped with a level IV trauma unit. It is definitely more a community hospital with less high-risk patients, which makes it an ideal location to start for my clinical journey.

 

So, what exactly does a clinical dietitian do? This is a very common question that, unfortunately, not many know the answer to! While I knew the basics of what a clinical dietitian was responsible for, this week gave me a much deeper understanding what a typical day was like as a clinical RD. Each day there are two clinical dietitians that are available to assess and treat patients. The day begins by looking at the list of patients that have been given “consults.” These consults can be sent to the RD’s for multiple reasons. First, nursing staff always conducts a basic nutrition risk assessment on all newly admitted patients. If the patients are considered high risk, then a consult is sent to the dietitians. Physicians can also order consults on patients who they feel will benefit from a nutrition intervention, education, or that require monitoring. The final way that a consult can be sent to the RD’s is by what is called a “system consult.” System consults are triggered by the electronic medical database for patients with a length of stay greater than seven days, a stage II or greater pressure ulcer, recent cardiac surgery or diagnosis, or a variety of other scenarios. Once the dietitian receives the list of patients for the day, the assessment process beings.

 

The assessment process involves a very comprehensive reading of all the lab values, and medical notes from physicians, mid-levels, nurses, and other allied health fields. Even though dietitians deal with nutrition interventions, they are still required to understand all the lab values, medical terminology for the conditions, surgical procedures, medications, and the abbreviations that other medical professionals are required to know. Before any patient is seen there is an extensive review so that the patients’ condition can be fully understood. After preparing a preliminary chart note for the patient with the information from the electronic medical records the patient is then visited. During the visits with the patients the dietitian assesses current intake and collects any information to determine if the patient requires any education or additional nutritional intervention (i.e. Ensure, tube feeding, parenteral nutrition (IV feedings), supplements, etc.). After finishing up with the patient, chart notes must be written and entered into the electronic medical record system. In addition to visiting patients that have consults, dietitians also participate in interdisciplinary care meetings and grand rounds with the physicians, case managers, and nursing staff.

 

I always had imagined that I would end up in clinical nutrition and being able to actually assess patients, deliver nutrition education and interventions, and write chart notes on patients throughout this rotation has confirmed my desire to become a clinical dietitian! This past week I was able to assess and deliver nutrition education to a variety of cancer and cardiac patients and write the chart note! I am looking forward to this next week with Monongalia General Hospital to focus on more nutrition interventions!