After/Followup

Care after surgery

Care after surgery is on same principles as after other bypass surgery. Once in recovery room most patients regain consciousness slowly following heart surgery. As you wake up you might even be wondering when the operation will begin only to be told that it is over. You will probably feel very tired and sore in chest, neck or back and you may be confused as to where you are. There will be many people around your bed, but this is no cause for alarm because they are there to help you. There will be a tube in your throat, and you will not be able to speak till such time that this tube is in place. During this period you will be able to communicate through gestures or by writing on a piece of paper provided by you nurse The tube will be removed shortly and then you can talk.

As you become aware, you will notice that there are electrodes (pads) on your chest and transducers, which are connected with electrical wires to the cardiac monitor. This will give a constant readout of your heart rate and rhythm (ECG) and blood pressure. This monitor also has a built-in warning system to alert the doctors and nurses should any changes happen outside the normal range. Two drainage tubes are placed in your chest at the end of surgery. They remove air and fluid and are connected to vacuum containers at the side of your bed. These containers make a bubbling sound you will be able to hear. These drains are generally removed 24 to 48 hours after surgery.

Normally there is a tube placed in your bladder when you are asleep so as to allow all the urine your kidneys produce to be collected and monitored constantly. Your urine output is one measure of your kidney functioning. It is generally removed a day or two following surgery.Almost every patient has "standby" pacemaker so that the surgeon can speed up a slow heart rate or control an irregular heart rate by just adjusting the pacemaker box. This is not a permanent pacemaker. The pacemaker box will be removed before you are transferred to a regular room. The wires themselves will be removed a day or two before you go home.

When you are asleep in the operating room, but before surgery begins, the anesthesiologist will insert a "breathing tube" into your throat. This tube actually is placed through your vocal chords into trachea (windpipe) and when in place will not let you speak as mentioned earlier. This tube is inserted to assist you in breathing while you are sleeping. At surgery, the breathing tube is connected to a respirator, which moves air and oxygen in and out of your lungs. It also helps in removing secretions or mucus from your lungs and breathing passages. As you recover from the effects of anesthesia, the respirator also allows you to do more of breathing for yourself.

When you are able to perform an adequate job of breathing on your own and when you are fully awake, the breathing tube will be removed (usually 6-16 hours after surgery). Within hours after the breathing tube is removed, most patients are able to drink and eat. Oxygen by way of a mist mask will be given to you for few days, so as to provide your blood with additional oxygen reserve.You will be fed through your veins for a short period after surgery, though you will also begin eating during this period. One or more tiny plastic tubes will be in arm veins, and through them you will receive fluid and medications.

How rapidly you progress through the patient care units will be determined by your condition, your body's response to surgery and most important your will power. During the first few days you will be observed constantly by the healthcare team. Your blood pressure will be taken frequently and doctors and nurses will observe your other vital signs carefully. Each day you may have a chest-X-ray and an electrocardiogram taken and blood tests done. The tubes in your body will be removed as you improve.
You will be given medication for your discomfort. "Pain" medication does alleviate most of the discomfort, but all of the discomfort is not removed. An effective "pain" medication makes it easier to cough and deep breathe, make the discomfort easier to deal with, and makes it easier for you to work towards your recovery.Your active participation is essential for your recovery.

Doctors and nurses will carry out their duties of constant monitoring and giving medications when necessary but your contribution is equally vital in keeping your lungs clean and open. You are helped to turn from side to side. Foot and leg exercises stimulate your circulation. Due to all the activity, the lack of sleep and the constant noise of the critical care area, you may find it hard to determine what day it is or what time of day it is. It is not uncommon for patients to experience "weird" dreams or be slightly confused as to recent events. All of these things are transitory and will disappear as soon as you get adequate sleep and a quieter environment. One of the most important ways you can help yourself is by coughing and deep breathing. The breathing exercise you practiced before surgery will be continued every hour for a while so as to clear your lungs of mucus. To facilitate deep breathing and promote circulation, you may be allowed to get out of bed to sit in a chair.

On the post-operative floor
By the time you move into your room, most of the tubes will be out and you will be eating and drinking. Now mobilization and rehabilitation begins and you will be encouraged to get up, walk, cough and do other things, which may seem overwhelming to you. You will still have chest X-rays, ECG, and blood tests, but not as frequently as before. You will have access to telephone and television in your room so you will feel much more in touch with outside world. You will also be able to sleep for longer, undisturbed periods.
During the postoperative period it is not uncommon for patients to experience some heart arrhythmias. These arrhythmias are generally due to the irritability of the heart and temporary metabolic changes in the body following surgery.

Family members should be aware that they might also receive the brunt of the patient's depression or anger because it is easier and safer to direct feelings at them rather than at the hospital staff. The doctors, nursing staff as well as the cardiovascular nurse and cardiovascular social worker, will be valuable resources to assist the patient and family during the difficult time.

How you Feel ?
Often, emotions are unstable at this time. It is not uncommon to feel depressed or angry or out of control at this point. There are both psychological and physiologic reasons for your emotional upheaval. Firstly, the heart carries with it many psychological connotations in our society; it is thought of as the seat of 'love' and 'emotions'. Also, the desire to get better and to go home conflicts with the reality of residual soreness and the desire to be protected from further discomfort. Manifestations of this depression can be a lack of appetite or apathy or crying but all of these symptoms should go away with time. All of these transitory personality changes should disappear by two to three months postoperatively.It may be a while before you feel a marked improvement in the sense of being well. During your recuperation you will experience "good" days and "bad" days. The recovery period can be emotionally and physically trying for both the patient and the family. Many patients feel isolated, as they begin to make the transition from illness to health. Unpleasant emotions such as anger, denial, frustration, depression and hostility can occur.

YOUR RECOVERY AT HOME
Going home
Now that your heart surgery is completed and you are in the process of healing, it is time to prepare for your return home. If you have any other questions, please ask your doctors, nurse or cardiovascular social worker about them. It is not unusual to feel apprehensive or depressed about leaving the hospital. The hospital has provided you with a sense of security. Just remember that you will not just discharged until your doctor feels you are fit. The key to a successful home recovery is moderation especially with your activity. Plan for plenty of time to relax as you begin returning to your normal activities. The following general guidelines and your doctor's specific instructions can help your home recovery to be a safe, relaxing time for you.

Your home routine
Once you are home, try to resume a normal routine. It is important to arise at a reasonable hour, shower daily and dress in street clothes. Never stay in sleeping clothes during the day. It is important for you to think of yourself as healthy and active rather than sick.Take a mid-morning and mid-afternoon rest following periods of activity. Rest periods are helpful following activity, so after taking a morning walk come home and take a short nap. You will be able to perform more activities as more time passes, so be patient. And walking is particularly good exercise and will speed your recovery.

Your recovery graph
Your initial recovery from surgery should take six to eight weeks. Given below is your recovery graph. It is full of ups and downs. During that time expect to have some good days and some days that are not as good. This is all part of the normal healing process. It is common for patients to feel sad or "blue" after surgery. This may be due to not knowing what to expect when you return home. It may also be related to not being not able to perform simple tasks without becoming fatigued. These are normal responses that will gradually go away over the first few weeks after you resume regularly activities.Also, it is very common to experience vague pains in your chest, shoulders and back region during the first six to eight weeks. These are not heart pains, these are the healing pains. Do not get upset by these muscular pains. You could seek reassurance from your family physician whenever they occur.If you become bored and feel that time is standing still, if you find that you are feeling depressed, the best way to feel better is to talk about your feelings with your spouse, family or close friends. Sometimes family members can contribute to your depression without knowing it, so discuss this too. Many patients report that this is a very trying time. You and your family may experience anger and frustration. As a rule, these feelings will subside as you resume your usual activities.

Walking
Your walking programme should begin from the 3rd or 4th day of your surgery. Walk slowly. Gradually increase the distance covered each day. Remember not to over-tire yourself, alternate your activity with rest and never take a walk immediately after your meals.

Climbing stairs
It is all right to climb stairs from the day of discharge but do it slowly. Rest frequently if you become tired, short of breath or dizzy. You should try to limit climbing stairs to once a day for the first two weeks after discharge.

Household chores
You should not plan to assume total responsibilities for the household, care of children, or meal preparation until after your checkup with the surgeon. As you feel stronger, you may help with light household duties, such as dusting the furniture, setting and clearing the table or assisting with meal preparation. Avoid any activity that causes incisions discomfort or causes you to tire easily.

Lifting and staining
Try to avoid lifting anything weighing more than 3 kgs., such as grocery bags, suitcases or briefcases and even small children. Anything that creates force in your chest/upper arms can interfere with breastbone healing while you recover.

Getting up from a chair
Try not to put your body weight on your hands while getting up from a chair. Use armrest for help but not for total support.

Getting out of bed
Getting out of bed is easier if you do the following:

• Move closer to the edge of the body by rolling over on your side.
• Swing your legs to the floor and push your upper body up with your elbow; use side rails for help but not for total support of the body weight.
• Sit on the side of the bed for a couple for minutes to make sure you will not be dizzy.
• Stand up

Pushing and pulling
To limit strain on your breastbone, avoid pushing or pulling anything heavy like furniture items, mowing the lawn, mopping, vacuuming, straining to open a stuck window, twisting a bottle cap or jar lid or pushing open heavy door.

Driving
Since it takes 7-8 weeks for your breastbone to heal let others drive during this time (arm motion from steering can intensify your chest pain). Your medications may also make you drowsy and slow your driving reflexes.You are permitted to ride in a car, but extended automobile trips should be avoided. If you have a long drive home, stop every one-hour. Get out of the car and walk around for ten minutes before continuing the trip.

Incision care
Many patients and attendants feels that they should not leave the hospital till all the stitches are removed. It is really not necessary, if you maintain personal hygiene and do proper cleaning and dressing of your stitches. This is very important in order to avoid infection. Remember that your stitches are quite safe if you take care of the following points while handling them at home:

• The incision site should not become wet.
• The stitches should be cleaned with Betadine lotion everyday.
• The attendant must wash hands properly; the nails should be clipped before cleaning the stitches.
• Pour Betadine lotion in a clean and dry bowl.
• Betadine lotion should never be diluted.
• Do not use cotton wool for cleaning the stitches. Use sterile gauge or sterile pads instead.
• You need to take four pieces of sterile gauge/pad (cut it in four pieces).
• Dip one piece of gauge/pad in Betadine lotion and gently clean the stitches in one direction.
• Do not press or rub hard. Repeat the process four times.
• Do not keep touching the stitches or place hand on the chest while sleeping.Clean the leg stitches also in the same manner. Patients with leg stitches should not sit cross-legged.

Avoid sitting on floor/low stools etc. Do not use Indian-style toilet seat. If you have to sit on a chair for a long time, place your legs on some stool/another chair i.e. at hip level. This will prevent swelling in the feet, which is otherwise very common.

Let the lotion get absorbed for at least 5 minutes before you put on your clothes.It is fairly easy to do the dressing and you do not need any professional help for this. Thus, there is no need to come to the hospital for the same.Till the stitches are removed, daily sponging is required. Use lukewarm water with few drops of Dettol or Savlon in it. Use a clean towel and make sure that the wet towel does not touch the stitches.

Wear the crepe bandage everyday for the coming eight to ten weeks. It helps prevent pain and swelling in the legs. It is important to wear it at the nighttime also till the stitches are not removed.

The crepe bandage should be washed every day with cold water. Do not use brush or squeeze hard to remove access water. It shouldn't be hung to dry. Put it on a railing/back of the chair etc.

Bathing
After the stitches are removed you could start taking bath. Please take care of the following points:

• It is advisable to sit on chair/stool while bathing.
• Avoid putting any oil or ointment on the incision site before bathing.
• Use lukewarm water for bathing.
• If using bucket, it should also be placed on another stool of equal height; do not lift or shift the bucket yourself as it would put pressure on the chest.
• Clean the incision site with any ordinary soap. There is no need to buy any medicated soap. Do not rub the soap cake directly on the incision site. Always first apply on the palm and then clean the site.
• After taking bath, pat dry the incision site with clean and soft towel.
• Always sit on the chair while wearing the clothes, as some times one can lose the balance.

Recreation
Physical activities such as tennis, swimming, bowling, golf other than walking, should be postponed for seven to eight weeks from the day of the operation. You may participate in those activities that do not require physical exertion, such as playing cards, going to the theatre, restaurant, needle work, reading, writing, visiting friends etc.

Sex
Many patients and their partners feel anxious about resuming sexual activity about surgery. Rest assured that sex won't interfere with your healing although you may feel more comfortable sharing your affection in non-sexual ways, like going out to diner, dancing or just being close for the few weeks after surgery. Talking about your feelings with your partner can help you both feel at ease. Resuming sexual relations after open-heart surgery depends on how you feel mentally and physically. Sex, like any other activity should be performed when you are rested and comfortable. The exertion reached by patient during intercourse is similar to walking approximately half a mile at a brisk pace or climbing one or two flights of stairs. So, when you can perform these activities without becoming fatigued or short of breath, sexual activity can be resumed.

When you feel ready for intercourse, any position is fine, as long as it is conformable, relaxing and allows for easy breathing. For the fist six weeks, refrain from assuming the upper prone position; rather take the supine (lower), side to side, or sitting position. Women should check with a doctor about the adequacy of previously used birth control methods and advisability of pregnancy. Women may notice some delay in the resumption of menstrual periods due to stress of surgery. This is normal. Try to make all activities intermittent and take regular rest periods. Progress is made by gradually increasing the length of time for an activity as well as the level of energy.

Rest periods
During the four to six weeks recovery period you should plan to get eight to ten hours of sleep at night. The body requires more sleep during the healing process. Activities should allow time for at least two rest periods a day to avoid becoming overtired. It is not necessary to go to bed or to sleep during the rest periods, just rest.

Visitors
Support from your friends and family can help you feel better, but you need rest and relaxation too. Feel free to ask your visitors to leave, or excuse yourself, when you begin to feel tried. During the first few weeks, two visitors a day are usually plenty.

Return to work
You may return to work in approximately eight weeks after discharge. Because it is impossible to predict the rate of recovery after your discharge, please check with your local doctor as to the exact date of your return. When you go back to work or school, try to arrange to begin on a part time basis until you feel ready to assume full time daily.
It takes a little longer for patients who have complications before during or after surgery. Also for associated problems like valve disease, cerebro-vascular accidents, renal complications etc. take a longer time to resume work.

Diet
There will be no dietary restrictions for the time being, unless you are a diabetic or have some other special problems. This will give the body time to heal. You should eat well-balanced meals. It is a good idea to avoid fatty, fried foods and foods high in salt and cholesterol. For the first four to six weeks take a high protein diet. You need the iron and protein rich diet to help promote healing and rebuild the red blood cells that were lost during surgery. Spinach and leafy green vegetables are also high in iron and should be added to the diet. Your cardiologist will regulate you diet in four to six weeks when your body has a chance to recover from the surgery. The dietician will help you to plan your long-term diet.

Patients, who have undergone valve replacement surgery and are on anticoagulant therapy, should avoid excessive amounts of foods high in vitamin K such as green leafy vegetables, like spinach, cabbage and others like tomatoes and cauliflower.

Drinking
Never drink alcohol during the recovery period. Remember painkillers, tranquilizers or sleeping pills, will increase its effect. Drinks with 10-12% alcohol content like wines are allowed to an extent of 120 ml every day. Drinks with 40% alcohol content like whisky, rum, gin, vodka etc. are allowed to an extent of 50 ml. every alternate day.

Smoking
Smoking has been proven to be an important risk factor in the development of heart disease. It is very important that you stop smoking and do not resume it. Smoking increases the heart rate, narrows the blood vessels, raises blood pressure and damages the lungs. It will be difficult to quit smoking but it is very important you do so.