Clinical Case Solution: Prolonged Ventilatory Support and Weaning after Coronary Artery Bypass Graft Surgery

Abstract

Coronary artery bypass graft (CABG) surgery is a common surgical procedure and has low complication rates. Extubation failure and prolonged ventilatory support are the most common complications in the first 24 h. These complications can be related to bleeding, respiratory problems, neurological complications, and cardiovascular problems. We hereby present a clinical case solution of prolonged weaning in an elderly patient who underwent CABG surgery and had to stay in the hospital for 2 months until he successfully recovered. A 65-year-old man developed cardiac arrest on the second postoperative day of the CABG surgery. The patient was transported to the medical intensive care unit (MICU) due to prolonged ventilatory support and weaning failure, 25 days after the operation. On admission, synchronized intermittent mandatory ventilation (SIMV) was started, and he was treated with vancomycin and ciprofloxacin for bacterial growth in blood cultures. He was evaluated for pulmonary edema, and diuretic therapy was started to attain a negative fluid balance. During the follow-up in the MICU, endotracheal aspirate cultures revealed Acinetobacter baumannii and Proteus mirabilis in his respiratory secretions, and the antibiotic treatment was changed. Tracheostomy was performed, and T-tube trials were started at the end of the second week in the MICU. After the first two T-tube trial failures, an investigation to determine the probable underlying reasons was started. A low phosphorus level was detected in the second week of the MICU follow-up, and replacement was made. A respiratory physiotherapy program was initiated on the 30th day. On the 58th day in the MICU, the patient was transferred to the patient ward

at the end of the second month, the tracheostomy was decannulated, and he was discharged from the hospital. Prolonged ventilatory support and weaning is a common problem in MICU and surgical intensive care unit patients and is associated with increased mortality and complications. These patients must be evaluated for respiratory, cardiac, neuromuscular, psychiatric, and metabolic problems. A close follow-up of the nutritional status and muscle strength are also advised by the authors.