Day One After Coronary Artery Bypass Grafting
A 59-year-old man is day 1 after elective three-vessel coronary artery bypass grafting via median sternotomy. He has a 40-pack-year smoking history and COPD with FEV1 62% predicted. His preoperative ejection fraction was 45%. He was extubated 6 hours ago. He is drowsy but rouses to voice. SpO2 is 93% on 4 L/min nasal cannula, respiratory rate 22/min, heart rate 96/min in sinus rhythm, and blood pressure 132/78 mmHg. He has two chest tubes with minimal serous drainage and a urinary catheter. Pain is 6/10 at the sternum when coughing. He says his chest feels tight and he is afraid to move. The surgical team has ordered chest physiotherapy and mobilization out of bed. His wife is at the bedside.
1. Assess his readiness for mobilization and list contraindications or precautions you would check before standing him up.
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He is not yet ready for immediate standing. He is drowsy, recently extubated, has a moderate oxygen requirement, and has uncontrolled sternal pain. These are relative barriers rather than absolute contraindications.
Check before mobilization:
- Airway and gas exchange: SpO2 trend, respiratory rate, breath sounds, chest drain bubbling, and absence of pneumothorax.
- Haemodynamics: systolic BP <90 or >160 mmHg, new arrhythmia, heart rate >120/min, or a significant postural drop.
- Bleeding: chest drain output >200 mL/h or sudden increase; check haemoglobin.
- Pain and sedation: pain score and recent opioid dose; he must be rousable and able to follow commands.
- Metabolic: glucose, potassium, and sodium if available.
- Sternal stability: no clicking or instability; sternal precautions apply.
Start with sitting on the edge of the bed, breathing exercises, and supported standing only when he is more alert and pain is controlled.
2. Outline an airway clearance and breathing exercise plan for the first 24 hours, including positioning, techniques, and monitoring.
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Airway clearance and breathing
- Sit him upright or in a supported high side-lying position, alternating sides if tolerated.
- Teach supported huff coughing with a pillow hugged against the sternum to reduce pain.
- Use an incentive spirometer for 10 slow deep breaths each hour while awake, aiming for a visible sustained rise.
- Add active cycle of breathing technique if secretions are present: breathing control, thoracic expansion, huff.
- Avoid percussion over the sternum and avoid vigorous chest shaking. Use gentle chest-wall vibration only if secretions are audible.
- Monitor SpO2, respiratory rate, pain, fatigue, and sputum colour. Stop if SpO2 falls below 90%, he becomes exhausted, or chest pain increases.
3. Plan mobilization progression and sternal precautions, and state criteria for stopping the session.
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Progression: day 1, sit on the edge of the bed for 5–10 min, then stand and pivot to a chair with two staff and a walking frame if stable. Day 2, walk short distances with assistance. Increase duration rather than intensity first.
Sternal precautions: no lifting more than 5 kg, no pushing or pulling with the arms, no overhead reach, and no unilateral arm resistance. Splint the sternum with a pillow during coughing and transfers. Avoid pulling on the bed rails.
Stop if: SpO2 <90%, HR >120/min, systolic BP drops >20 mmHg or he becomes symptomatic, new arrhythmia, chest pain, dizziness, or excessive drain output. Document baseline and post-session observations.