Part 1: What to Expect After Open Heart Surgery

I have worked in on a Surgical Cardiovascular Unit since 1999, and for the past year in a Cardiac Surgery ICU. My experience is limited to Canada and to some travel nursing in Australia, and care may be different in other places. However, after caring for hundreds of Open Heart patients, I know that this type of surgery is truly life-altering. Anyone undergoing this procedure must ultimately acknowledge that there is a certain risk involved, including death. Facing one's own mortality is scary, and recovery from Open Heart surgery is not just a journey of physical changes, but emotional ones. This article will focus on what can be expected in the first 24 hours after surgery, and an upcoming article will discuss the healing experience up to six weeks postoperatively.

After Open Heart Surgery, patients are brought directly from the Operating Room (OR) to a specialized Cardiac Surgery ICU. In the OR, patients are usually cared for by a Cardiac Surgery Team, consisting of the Cardiac Surgeon, usually 1-2 'Assists' (other Surgeons, or General Practitioners or Nurse Practitioners with specialized skills), 3-4 Registered Nurses, an Anesthesiologist (a Doctor who specializes in Anesthetic Care and hemodynamics), a Perfusionist who runs the Cardiopulmonary Bypass machine, and sometimes a Respiratory Therapist (RT). The patient is brought out of the OR by the Anesthesiologist, and several other team members to ensure a safe trip out of the OR and to manage all of the equipment.

On arrival, the patient - who is still intubated - will be connected to a ventilator. Until the ventilator is connected, the patient is 'bagged' with an Ambu bag by the Doctor or RT. All of the patients monitoring and intravenous (IV) lines are then checked and confirmed by a nurse, and connected to a bedside monitor as required. Drainage tubes are also checked and outputs are monitored every 15-30 minutes until the patient is stable. Most patients in any Critical Care Unit have vital signs, medications, fluid inputs and outputs all documented at least hourly. This is the reason that the nurse:patient ratio is 1:1.

Typically, most Open Heart Patient will have the following:

1. 1-2 peripheral IV lines (usually in the hands or arms) for giving IV fluids and some medications.

2. A special Central IV Line through which fluids may be administered at a rapid rate, and medications may be given that are too 'irritating' to the smaller arm vessels. This Central Line is usually inserted into the right or left internal jugular or subclavian veins.

3. The Central Line also usually serves as a pathway or introducer for a special monitoring line called a Swan-Ganz catheter (or Pulmonary Artery catheter) which is used to check Cardiac Output and guide treatments such as giving fluids or drugs that affect heart function.

4. Arterial Line: this is a special arterial pressure monitoring line that is used to determine blood pressure. This is called invasive blood pressure monitoring and provides a continuous blood pressure reading as opposed to a regular 'cuff pressure' (where a band is placed around the upper arm) to check blood pressure. You may still see nurses checking cuff pressures, they do this to confirm that the invasive and non-invasive blood pressures correlate. Arterial lines are usually placed in the right or left radial artery, but can sometimes be found in the femoral arteries as well.

1. The most obvious tubes after Open Heart Surgery is the Endotracheal Tube used to protect the patient's airway and allow the patient to be ventilated (use a breathing machine). The patient is normally ventilated for at least 4 hours after surgery. This tube is secured with tape or a special device so that it cannot move.

2. The patient will have 1-3 Chest Tubes which drain fluid from the surgical site or help re-inflate a collapsed lung or both lungs.

3. The patients may also have special drains in the incisions from where veins were harvested if they were taken out to be used for bypasses, usual sites for this are the legs or arms.

4. A urinary catheter will be in place for at least 48 hours until the patient is awake and able to have some bladder control.

5. Temporary Pacing Wires: these are very fine insulated wires which are placed on the epicardial (outermost) surface of the heart and the ends are brought out through the skin just below the rib cage. The wires can be attached to an external Temporary Pacemaker if the patient becomes either bradycardic (has a slow heart rate) or if a higher heart rate is needed (for example to maintain an adequate blood pressure). These are typically left in for at least 4 days after surgery.

Usually two nurses will work together to admit a patient into the ICU after Open Heart Surgery. There is a lot of documentation required, and the first few hours is the period where the patient is most unstable and may require continuous adjustment to medications, and possible transfusion of blood or blood products. There are a number of tests which are completed on admission to the ICU as well: labs, chest x rays, Arterial Blood Gas analysis (ABG), and electrocardiogram (ECG). The surgeon hopefully will contact the family and let them know that the patient is out of the OR and give a general update on the outcome of the surgery.

The patient is kept sedated and given analgesic (pain medicine) so that they are comfortable. Many sedatives and narcotics commonly used have some amnesic qualities so that the sometimes-distressing period of waking from surgery is generally not remembered. Most patients also require a special set of drugs used in Critical Care called vasopressors and inotropes which maintain a satisfactory blood pressure, heart rate, and cardiac output.

Once the test results are in, and if the patient is not showing signs of bleeding, and blood pressure, heart rhythm, and oxygenation are satisfactory, the doctor will decide if the patient is stable enough to wake up and to extubate (remove the breathing tube). In order to extubate, the patient must be able to protect their own airway, follow commands, and have a reasonable ABG. With adequate preoperative teaching, many patients are prepared sufficiently so that they wake up calm and can follow commands well. Others react to some of the medications and anesthetic agents and can be quite wild and agitated, sometimes needing to be re-sedated or restrained for their safety. This period can be distressing for families to observe and so visitors are often restricted during this time.

The patient is usually kept on bedrest for 24 hours after surgery. If stable, the patient is then sat on the side of the bed and even stood to see if this is tolerated - meaning vital signs are stable and pain is controlled. If drainage from the Chest Tubes is minimal and the chest xray is satisfactory, the chest tubes are often removed by the nurses on the first day after surgery. This can be anxiety-producing for patients but it is a quick procedure and pain medicine will be given as required. The sites where the chest tubes were inserted are closed with a purse-string suture which stays in place for 5-7 days. All surgical incisions are kept covered with a sterile dressing for at least 48 hours, and then the dressings are changed as required (hopefully at least daily). The chest tube sites are covered with an airtight (occlusive) dressing, especially if any tubes were pleural (meaning they entered the lung).

Before patients are transferred out of ICU, arterial lines, the PA catheter and the central line are also removed.

Where I work, we offer a surgical teaching program and bring most patients and families through our unit the day before their operation, so they have some idea what to expect after the operation. Many families are very grateful to be prepared in this way.