Q. What's the average duration of a patient's hospitalization?
A. The average post-operative hospitalization ranges between 4 - 7 days. This will be adjusted based on the patient's response to surgery and convalescence. A patient will not be discharged from the hospital until all and every post-operative issue has been settled.
Q. What are the post-operative discharge plans?
A. The patient will be discharged either home or to an extended care facility, should the patient's needs exceed the support available by family members. If the patient is being discharged home, it is imperative that there is enough family-member support to provide 24-hour continuous care for the first week or so post-operatively. If that is not possible, please bring this to the attention of our case managers and social workers as soon as possible, so that alternative plans can be implemented without delaying the patient's discharge.
We recommend that patients be ready to leave the hospital prior to noon on the discharge day to permit the timely transfer of other patients from the CICU to the step-down unit. It is very important that transportation needs have been arranged in advance so as not to interfere with the discharge process. Please make every effort to cooperate with this time, as this will impact other patients' post-operative recovery and unnecessarily prolong their CICU stay. Please help us to provide the very best care to your fellow patients by meeting the discharge time goal and remember that the same courtesy was extended to you by other prior patients.
Q. What activity is allowed post-operatively?
A. No lifting anything heavier than 1 to 2 telephone books immediately post-operatively. Gradually increase your post-operative activities. We would encourage walking 4 to 5 times per day, with advancing walking as tolerated, with a goal of 1 to 2 miles per day within 4 to 6 weeks post-operatively. Do not walk outside if temperature is less than 40°F or greater than 85°F. Stop activities if shortness of breath develops or there is dizziness. There should be no driving for 4 to 6 weeks post-operatively.
Q. What kind of incisional care is most appropriate?
A. It is imperative that you keep your incisions clean. You may shower with mild soap. You should avoid tub bathing until specifically instructed to the contrary. Do not apply lotions, powders or creams to your incisions. Please notify your physician if you experience a persistently elevated temperature of greater than 101.5°F lasting longer than 24 hours, and immediately if associated with chills, nausea, or substantial fatigue. Increasing redness of the incision, particularly if accompanied by warmth, pain or swelling along the incision is also concerning and must be brought to your physician's attention. Notify your physician immediately should you develop drainage from the incision, especially if this is colored or foul smelling. Please notify your physician should you feel clicking along your chest incision.
Incisions in the lower extremities should be inspected carefully. Please contact your surgeon should any of the above findings also occur.
Q. What are the expected symptoms and findings after surgery?
A. Patients following cardiac surgery should expect to have mild to moderate discomfort for 3 to 4 weeks post-operatively at the sites of the incisions. Numbness along the arm, the leg and the chest is not uncommon. Swelling of the lower extremities, particularly on the side from which your lower extremity vein was removed is relatively common. Under these circumstances, be sure to elevate your lower extremities as much as possible when sedentary. At night while sleeping, please raise your lower extremities on several pillows. It is important to elevate the leg while sleeping to above the level of your heart so that gravity acts on the excess tissue fluid and this drains nightly. Should the edema not resolve with these maneuvers, please contact your surgeon.
It is important that post-operative surgical patients be active, since this prevents the formation of deep vein thrombosis (blood clots) in your calves. This is a serious situation and typically manifests itself as excessive swelling of the ankle and foot, and pain within the calf region. If you experience this, please bring this immediately to the attention of your cardiac surgeon.
Q. What is a typical body weight pattern following surgery?
A. Immediately post-operatively, most patients gain some weight following the operation. This is the result of fluid retention that occurs almost routinely post-operatively. Following discharge, please weigh yourself every day at the same time of the day, and wearing the same kind of clothes. Should you gain more than 3 lbs. in one day or more than 5 to 6 lbs. in one week, please bring this to the attention of your surgeons. Typically, such weight gain will be treated with diuretics.
Longer term, patients following cardiac surgical procedures tend to lose 10-15 lbs. in the immediate 4-8 weeks post-operatively. This is typical and stems from many reasons, including loss of appetite, nausea, and certain hormones being released in the post-operative period which burn your energy stores. Typically, after 4-8 weeks most patients return to baseline weight.
Q. What is the most appropriate diet post-operatively?
A. It is imperative that you stay well-hydrated. Your appetite may initially be quite poor, but with time will return to baseline. Although long-term prudent dietary and exercise regimen is very beneficial to your long-term overall health, immediately post-operatively we would encourage you to take in enough calories and protein to allow your incisions to heal. Thus, in the immediate post-operative period there should be no restrictions in terms of calories, fat and cholesterol intake. Please note that long-term, these restrictions are extraordinarily important to provide the most durable post-operative results.
Patients with diabetes should strictly adhere to a diabetic diet and meticulously maintain blood sugars under 200, as this has been shown to decrease post-op complications.
Q. What is a normal pulse rate post-operatively?
A. Typically, most patients will be discharged on a beta blocker which is a group of medications that slows the heart rate and decreases blood pressure. Typically, patients should be concerned if their heart rate is less than 50, particularly if associated with symptoms of dizziness. Should that occur, please notify your physicians.
Patients who have undergone cardiac surgery are predisposed to developing rapid arrhythmias. The most common such arrhythmia is known as atrial fibrillation. In this condition, patients frequently experience heart rates in the 120-180 range. Typically, these are felt as palpitations and may be accompanied by symptoms of dizziness, fatigue, perspiration and chest discomfort. Please take your pulse routinely, several times per day. Should the pulse be irregular, quite fast or slow, please notify your surgeon.
Q. Are emotional swings common after surgery?
A. Most patients recovering from cardiac surgery do show some element of emotional volatility, but typically these subside within 4-8 weeks of operation. If these emotional swings interfere with your recovery, please notify your physician.
Q. Can I drink alcohol?
A. We discourage alcohol intake within the 4-8 weeks post-operatively.
Q. When can I take an airplane flight?
A. Typically, we discourage flying in an airplane for the first 4-8 weeks post-operatively. However, exceptions can be made based on each individual's circumstances.
Q. Is walking up and down stairs safe?
A. Yes, provided that you pace yourself. It is not uncommon to have fluctuations in your energy level post-operatively and thereby one day an activity can be accomplished with minimal exertion yet, at other times it may take substantially more effort to accomplish the same activity. The overall pattern, however, should be of increasing activity as you progress through your recovery. If normal activities are persistently requiring more effort, are accompanied by significant shortness of breath, or if you are doing less and not more with time, please notify your physicians.
Q. Is shortness of breath normal?
A. Some element of shortness of breath is normal, especially as you push yourself to be active. Persistent, significant shortness of breath, especially if accompanied by rapid breathing, perspiration, wheezing, rapid heart beat and a trend of decreasing activity are clearly abnormal and need attention. In a small number of patients, fluid will accumulate inside the chest and compress the lungs, interfering with your breathing. This is called a pleural effusion and requires a chest X-ray for diagnosis. A pleural effusion may require treatment with diuretics or a procedure in which the fluid is drained with a needle placed into the chest cavity.
Another reason for severe shortness of breath may be from fluid accumulating around your heart. The fluid interferes with the heart function and causes shortness of breath and swelling of the ankles. This requires a cardiac echo for diagnosis and most likely will require treatment or careful observation.
Q. What should I do if I experience anginal chest pain?
A. The point of coronary artery bypass surgery is to improve the blood supply to your heart muscle and alleviate angina, which is the set of symptoms that result from an imbalance between the amount of oxygen that the heart needs and the amount that the heart actually obtains. It is sometimes quite difficult to distinguish anginal discomfort from incisional discomfort, but for most individuals that differentiation is relatively clear-cut. If a patient experiences post-operative angina, it is important that the surgeon and/or the cardiologist be notified immediately.
Q. When can I swim?
A. Swimming is discouraged for the fist 4-6 weeks post-operatively. This can be addressed on a case-by-case basis depending on individual circumstances.
Q. When can I resume sexual activity?
A. Typically, we discourage sexual activity for the first 4-6 weeks post-operatively. Sex can be resumed after being able to complete 2 flights of stairs or walking 3 or 4 blocks without shortness of breath or fatigue.
Q. What sort of medications will I be taking after cardiac surgery?
A. Most patients will be discharged with a pain medication which is typically a narcotic. Although narcotics are used to minimize post-op pain, these medications should be taken for as short a time as possible. Narcotics have a number of side effects, including sweating, nausea and constipation.
In addition, patients will be discharged on a number of medications that are indicated for specific positive short-term and/or long-term effects.
- Aspirin/Plavix. These preparations are utilized to increase the patency of bypass grafts. These preparations inhibit the activity of platelets, which are blood components that participate in the formation of the blood clots. It is thought that platelets are instrumental in the formation of blood clots within newly placed bypass grafts, and consequently the inactivation of platelets has been shown to favorably impact the durability of bypass grafts. The better the graft patency, the better the long-term results will be.
- Beta Blockers. Beta Blockers are utilized for several reasons. Immediately after the operation, beta blockers are utilized to control your heart beat and to prevent the development of fast arrhythmias. Long-term beta blocker use has been shown to increase the longevity of patients undergoing cardiac surgery. (Examples: Lopressor, Atenolol, Toprol, Coreg)
- Statins. Statins are medications that optimize cholesterol levels. Statins have been shown to improve the long-term survival of patients post-operatively. Statins have also been shown to increase the patency rates of bypass. (Examples: Lipitor, Zocor, Crestor, Zetia, Vytorin)
- ACE Inhibitors. ACE Inhibitors (Angiotensin Converting Enzyme Inhibitors) are medications that control your blood pressure and have a number of other effects in patients with a diminished cardiac pumping capacity. ACE Inhibitors have been shown to prevent development of congestive heart failure and maximize the patient's ability to exercise by optimizing the heart function. In those individuals with a normal heart function, ACE Inhibitors have been shown to favorably impact patency of bypass grafts and consequently are encouraged to be taken in the post-operative period. (Examples: Lisinopril, Ramipril, Captopril, Enalapril, Accupril)
- Amiodarone. This preparation is an anti-arrhythmic that is frequently used to control and prevent fast arrhythmias. Typically, the patient will be maintained on this preparation for 4-6 weeks post-operatively. At that point, the tendency to develop recurrent arrhythmia typically disappears and the medication can be discontinued.
- Diuretics. Because of the normal tendency for the body to retain water and fluids in the post-operative period, patients are frequently discharged on diuretics. These preparations increase urine output and are helpful in controlling peripheral edema manifesting as swelling of the ankles. Patients who are on diuretics must also take a potassium supplement to assure that blood chemistries are not adversely affected by diuretic use.
- Coumadin. Coumadin is used as a blood thinner and there are a number of reasons that Coumadin is used in the post-operative period. Typically, we use Coumadin in cases of patients who underwent valve surgery. In the case of a valve repair or in the case of implantation of a biological prosthesis, Coumadin utilization will be required for between 4-8 weeks post-operatively. In the case of mechanical valve implantation, Coumadin utilization will be indefinite.
In those individuals who develop arrhythmias (atrial fibrillation) that can not be successfully terminated, Coumadin use is also required to minimize the risk of a stroke.
Patients who were taking Coumadin pre-operatively should resume this preparation, unless instructed otherwise. Usually a much smaller dose will be required post-operatively.
While on Coumadin, it is extraordinarily important that the prescribed dose be carefully taken on a daily basis. You will be instructed in the appropriate blood drawing regimen to monitor the level of Coumadin effect. You will be contacted by your physician with instructions based on these blood draws. Prior to discharge you will be informed of the physician that will guide you in the appropriate Coumadin dose. Please contact that physician if your dietary habits change or if you change your medications, as Coumadin dosing is affected by a number of factors, including diet and interactions with other medications.
Q. When is it appropriate to resume smoking post-operatively?
A. NEVER. Nicotine utilization in the post-operative period has been shown unambiguously to decrease the long-term patency of bypass grafts placed at the time of the operation. In addition, nicotine utilization has also been shown to impact the development of recurrent blockages in your native blood vessels. Thus, it is absolutely imperative that there is no further nicotine exposure in the post-operative period indefinitely. If you find yourself craving nicotine, please notify your physician so that appropriate interventions can be instituted to alleviate that craving. Regardless of whether you had or did not have an operation, the best intervention for long-term heart health is smoking cessation.
Q. What kind of follow-up will I require in the post-operative period?
A. Follow-up in the post-operative period is coordinated by the cardiac surgeon, the cardiologist, and the primary care physician. You will be instructed prior to discharge as to when to make those appointments. Please keep in close contact with the above physicians to assure a safe and uneventful post-operative convalescence.
Q. Should I participate in cardiac rehab?
A. Cardiac rehab is a valuable investment of your time. It will allow you to recover in a structured environment and you will be exposed to a host of useful information. The experience will also allow you to network with other patients who have undergone your operation and thus provide mutual reassurance.
We will provide you with appropriate contact information to facilitate easy enrollment in cardiac rehab.