Part 2: Recovery After Open Heart Surgery
You Survived the Operation, Now What?!
This article will give an overview for patients and families of a typical, uncomplicated recovery from Open Heart Surgery - up to 6 weeks post-op. I can only speak from my own experience working in a Surgical Cardiovascular Program in Canada for over 10 years. Protocols for care can vary from one hospital to the next, and the information shared here should not replace the advice you have been given by your health care providers.
Day 1: Moving out of the Intensive Care Unit
This transition from Critical Care to Acute Care can be anxiety-producing for patients and their families. Concerns that patients will not be watched closely enough, or will not have the physical assistance they need, are common concerns. However, specific protocols are set up to 'catch' any changes in a patient's condition, for example, diagnostic testing such as chest x rays, electrocardiograms (ECG's), and lab tests. In addition, most telemetry units - those that are capable of monitoring patient's heart rhythms continuously - are staffed at a lower patient to nurse ratio due to the additional workload of analyzing the data and treating any arrhythmias (irregularities in the heart rhythm).
One of the primary concerns after Open Heart Surgery is the stability of the sternum, also called the breastbone, which is divided during surgery so that the Cardiac Surgeon has access to the heart. The sternum is now a broken bone. The sugeon will typically place 4-8 surgical wire figure 8 loops through the sternum to re-join the bone. However, the bone will not be fully healed for 6 weeks. It is crucial that the patient does not move in way which strains the sternum while it is healing. Nurses and physiotherapists will stress the importance of "sternal precautions" in the recovery period. The sternum is a long and flat bone lying vertically in the mid-anterior chest where the ribs meet over the heart. It is the bone that is located when performing CPR, as it lies directly over the heart. The edges that are rejoined when 'closing' the sternum at the end of Open Heart Surgery are not very thick, therefore sternal precautions which promote bone stability are crucial for proper sternal healing.
Where I work, we provide patients with a small pillow which we use by asking the patients to "hug" their arms over the pillow when moving or coughing, to support the sternum. Arm movements 'away' from the sternum, for example pushing oneself up from a chair using a hand/arm, destabilizes the sternum and can jeapordize sternal healing.
The main activity a patient will do on the first day is to sit up for the first time. As you can tell from the previous discussion, it is critical that the patient moves carefully, following sternal precautions. In our hospital we actually teach patients before surgery, how to use the 'heart pillow' and get in and out of bed without using the arms - try it for yourself, it's not as easy as you would think!
So after sitting up, usually only on the side of the bed the first time, it can be determined if the Chest Tubes can be removed. There will be a specific parameter for drainage ordered by the doctor which determines if the chest tubes can come out.
Also on the first day, patients begin to eat and drink again, usually starting with a Clear Fluid Diet and progressing to solids as tolerated. If intake is sufficient, the intravenous line is 'capped', leaving access for fluids and medications if required.
Day Two Through to Discharge
This is the day that patients typically start walking and getting out of bed for meals. Pain should be well controlled by oral medication. Again, testing is done on a routine basis to monitor hemoglobin, kidney function, electrolytes, and xrays will compare lung volumes and heart size from previous images. The patient will still be monitored continuously with a heart monitor.
Heart monitoring may be discontinued on this day, however if there have been any arrythmias it may be continued for longer. Common arrythmias after Open Heart Surgery are Atrial Fibrillation (an irregular contracting of the heart's atria, not in conjunction with the ventricles), or a heart block.
The patient should start to make progress with mobilizing independently: getting in and out of bed, and walking. This, of course, depends upon the patient's age and condition prior to surgery. If a patient has had urgent Open Heart Surgery due to a recent Heart Attack (properly known as Myocardial Infarction - MI) activity precautions may be slightly different.
Typically a final round of diagnostic tests are performed, in anticipation of discharge. Temporary Pacing Wires are removed; these are the fine wires inserted into the epicardium, or outermost layer of the heart, during surgery. The wires exit through the skin just below the rib cage and can be attached to a Temporary Pacemaker (an external device) if the patient has a low heart rate (bradycardia) after surgery. The patient might also be allowed to shower. Dressings over incisions are normally left in place for the first 48 hours after surgery, and then changed daily or more as required. When there is no drainage on a dressing, this signifies that wound healing is adequate and the incision may be left open to the air.
If the patient is meeting discharge criteria - eating, following sternal precautions, mobilizing mostly independently, has no signs of wound infection or other complication, and diagnostic testing is satisfactory -the patient may be discharged on this day. The patient must have a companion for a specified time after surgery, usually it is best if they have someone stay with them for at least two weeks.
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The Rest of This Series
- Part 1: What to Expect After Open Heart Surgery
What a person can expect to experience in the first 24 hours after open heart surgery, including clear descriptions of the most common monitoring devices used in the Cardiac Surgery ICU.