General info

Can I get through it?'
Is there anyone who goes through surgery without a worry? It's normal for people to be afraid or to wonder if they are going to make it. Fears and doubts are common and you should not feel odd if you have them, nor should you feel uncomfortable talking about them. It helps to share your feelings about heart surgery with someone who cares for you. Even if talking about it makes you a little anxious, it can bring out good feelings. It can make you and your family or friends feel closer

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At admission time

Be sure you know the date and time of check-in to the hospital. You should come directly to the 5th floor, Dharma Vira Heart Centre, while your relative or friend can go through the admission procedure on the 5th floor itself, (or some times after working hours at the admission counter,~ .ground floor). Do not bring extra clothes with you. Hospital dress will be provided to you throughout your stay. There is no need to come empty stomach to the hospital. You can have your breakfast before coming for admission. You should bring along personal toiletries like a toothpaste and toothbrush. If you are taking blood-thinning drugs like Aspirin, Ticlopidine, Clopidogrel or Acitrorn, they should be stopped 3-5 days prior to admission as per the directions given by the surgeons. Your surgeon will give clear instructions in this regard.
After registering at the admission office of the hospital you will be admitted one to two days prior to your operation to the room you have opted for. Sometimes we prefer to admit the patient directly on the 5th floor in the surgical intensive care unit in order to monitor the vital parameters. This is done in the interest of your safety, which is of prime importance. Usually a patient is admitted to the hospital with enough time before the operation date to allow diagnostic tests to be done. These routinely include, blood and urine tests, Electrocardiogram (ECG), chest x-rav, liver and kidney function tests, computerized lung function tests, echo study of heart and similar studies of arteries of the brain. If your cardiac catheterization and angiography has been done outside this hospital, then bring the CD/ angio film in original along with you. You must also bring your entire medical records.

For open heart or bypass surgery, 4 units of blood have to be arranged. In cases of repeat or re-do surgeries, the requirement is more and up to 8 units could be required.

Payments and Accounts
Most heart surgeries at Sir Ganga Ram Hospital are performed under a package system. There is a package 6days for closed heart surgeries and :8days for open heart and bypass surgeries. The package starts one day prior to surgery. The exact financial implications will be told to you by the doctors. However these packages are not watertight as there are certain restrictions / stipulations as to what all the package covers. Also, 5% of the patients who may develop some complications, may have to over stay the package in which case they will be billed on a day-to-day basis after the expiry of the package. Complete expenses have to be deposited one day prior to surgery, which is usually the day of admission. The money can be deposited either in cash or by bank draft. Cheque payments are not acceptable.
Credit card facilities are available. For any doubts you may contact the surgeon on duty (extn. no. 1506).

After taking Admission
A nurse will show you your room/bed and will take and record your temperature, heart rate, respiratory rate, blood pressure, height and weight. A urine sample may also be obtained. The surgical staff will visit to examine you, discuss the details of the operation and answer questions. The nursing staff will also evaluate your needs, make you as comfortable as possible, provide information and answer questions. In addition, the an esthesiologist will evaluate you and discuss plans for the care of vital body functions dur ing the operation. Other members of the technical staff may come to draw blood, insert intravenous catheters, instruct you about how to breathe and care for your lungs after the operation
You will also be told when the operation will be conducted. Heart operations are usually scheduled in advance and begin on time. Occasionally an operation may be delayed because other patients have emergency needs. If this happens, your operation will be rescheduled as soon as possible. At times the initial examination and investigation may reveal the need for further investigations, corrective treatment and medication. In such situations surgery may have to be postponed for a day or two.

Preparation
Before your operation much of your body hair will be shaved off, especially from your chest and legs. You will probably be asked to shower and wash with antiseptic soap to remove bacteria from the skin. This reduces the chances of infection. You should remove personal items such as glasses,contact lenses, dentures, watches, bangles, jewellery etc. and give them to family members for safekeeping. Ladies must remove their nail polish. No under garments should be worn.
You will be served a light meal the night before surgery and given the pre anaesthetic medications prescribed. A good night's sleep is important. Your body needs to be fresh and strong. Ask the doctor or the nurse any last minute questions; tell them if you are feeling any discomfort or symptoms you may suddenly develop at this stage. Also please inform the doctor/nurse about any drug reaction, allergies that you suffer from, bleeding tendencies, any unpleasant experience with previous surgery/ anesthesia or any major past illness. Ladies must inform the doctor, if they are expecting or having menses.

Operation day
Medications that will make you feel relaxed will be given about an hour before the operation. You may feel drowsy. It is desirable and advisable for you to remain in bed and try not to move around too much.
At the appointed time, you will be taken to the opera tion room. The anesthesiolo gist will give you an anaes thetic that brings sleep and relief from pain during the operation and then the operation will be per formed.

Duration
How long do these operations usually last?
Open Heart and Coronary artery bypass graft operations usually last from three to six hours. Their length depends upon what has to be done. Each operation varies in complexity, so its duration can only be estimated roughly. Closed heart operations take two to three hours.

Intensive Care Areas - Recovery - Surgical ICU - Surgical IMCU
When your surgery is over, you will be taken to the re- covery or surgical ICU for your postoperative recovery. You will remain in these areas until your condition is stable and you are ready to be transferred back to the ward- This usually takes two or three days. In these areas your vital parameters, especially heart & lung functions and urine output, are carefully monitored.
In the recovery room you will become aware of the sounds of equipment and various patient safety alarm systems. There will be a number of tubes and pieces of equipment attached to your body, which are essential for your proper and safe treatment.
An endotracheal (breathing) tube will be in your mouth, which passes through the vocal cords into the windpipe. While this tube is in place you will not be able to talk, but the nurses are specially trained and will anticipate your needs. This tube is connected to the artificial breathing machine (Ventilator), which assists you with your breathing. When you are fully awake after the operation and no longer require assistance with your breathing, the tube will be removed.
The nurse will help you sit up in bed and cough vigorously to clear your lungs of secretions. For the next day or two you will receive oxygen through a mask. In addition you will have several cannulae (small tubes) in your veins to administer fluid, blood and medications. These tubes will be removed one by one over the next couple of days.
A urinary catheter will drain 'your bladder continuously and enable the nurse to keep an accurate record of your urine output. Sometimes it may give you a feeling of pressure in your bladder and make you feel as if you need to urinate. This is usually removed two days after surgery.
Drainage tubes are placed around your heart at the time of surgery and pass through the skin near the lower end of your chest incision. The drains ~ prevent blood from accumulating around the heart during the postopera- tive phase. Sometimes small wires are taped on your lower chest. They have been placed at the time of surgery to control your heart rate. These wires will be removed before you go home

How Long Will I Stay in Intensive Care Areas?
Usually on the 1st or 2nd post operative day (for practical purposes, the day of the operation is considered as day 0), patients are shifted to Surgical ICU. Here, under close observation, your mobility and activity will gradually increase. Doctors, nurses and physiotherapists will assist you in all possible ways but you will need to make efforts ~ as well. To make your recovery smooth and uneventful you will need to pay special attention to the following:

Coughing frequently - to ensure that your lungs remain clear and infection free

• Walking about - do take care not to overdo it. If you feel dizzy, return to bed.
• Going to the toilet - do not lock the door, as it is essential to have help near at hand

• Most patients pass stools on 4th or 5th day for the first time. This is because during & immediately after surgery most of your intake is liquid & so stools are not formed. It does not hamper your recovery but if you feel uncomfort able please inform the nurse who will give you a gentle enema or a laxative to help you evacuate your bowels.
• Immediately after surgery you might loose your appetite and not feel hungry at all. Eat whatsoever you feel like. Your appetite will improve by each passing day.
• You may also have a hoarse voice or a sore throat from the tube. This will go away in a few days time. All you need is a little voice rest & steam inhalation
• Pain, tingling, numbness, sense of weight or pain in chest are very common after surgery. Just ignore them. They will go away in 4-6 weeks time.
• Lack of sleep or disturbed sleep is common after any surgery. If it bothers you, then the nurse will give you a sleeping tablet.

Excessive sweating is another frequent minor complaint which is best ignored.

From here you will be shifted to the ward/room that you have opted for after about 2-3 days. l3ut that will depend upon your clinical condition and the availability of beds. Don't get anxious if you are not shifted

In the ward/room
In the ward, the routine will be almost the same. The major difference is that you will have your relatives with you and your friends can visit you.
After cardiac surgery it is normal to. experience some incisional, muscle and bone discomfort. Use good posture when you sit and stand. Take short but frequent walks within the corridors. Pain medication is available and will be given by the nurse when you ask for it. It is not uncommon to have fever for 5- 6 days after surgery until your lungs are cleared of secretions. You may perspire during the day and particularly at night. This may continue for several weeks after discharge from the hospital. It is not unusual to experience "ups" and "downs" during recovery days, both in hospital and at home. Having a bad day after one or more good days does not mean you are worse. If you have difficulty sleeping at night, you may need to be more active during the day. Take fewer daytime catnaps and drink less of tea or coffee. As a last resort you may take a sleeping pill at night. Sleeping habits usually return to normal in a few days following surgery. Neuro psychiatric disturbances are common in the recovery period. One should not get alarmed if you have emotional or depressive tendencies. These subside gradually with mild tranquillizers. It is normal to have shortness of breath for one or two weeks. This is because you have just undergone a major operation and some amount of generalized weakness is bound to be there. It is also not uncommon to be aware of your heartbeat. This feeling of heartbeat will go off in a couple of weeks. If you are of a heavy build you will be provided a chest corset to support your breastbone. For the leg incisions, crepe bandage will be given to you. Your nurse will put them on and will teach you how to do it at home. The foot end of the bed should be elevated to reduce swelling of feet which is very common after bypass surgery, where veins have been harvested from the leg.

Arrangements for the family members and daily briefings

Hospital has places where your family and friends can wait during surgery. Be sure the surgeon knows where your family will be waiting during the surgery. Two of your relatives can wait in the surgical lobby (on 5th floor in front of lift no. 4) while the surgical procedure is going on. Flowers and bouquets are strictly prohibited in intensive care areas. As soon as the operation is over, relatives will be informed about it and about your progress and well-being.Once the surgical procedure over one relative should stay in cardiac waiting area situated at 2nd floor in old building. After surgery you will be kept under strict surgical and nursing surveillance in the recovery ward, which is located within the operating theatre premises. Usually on the 1st or 2nd post-operative day you will be shifted to the Surgical ICU. Depending on your condition, you will be wheeled to the waiting area to meet your relatives briefly on the 2nd or 3rd post operative day. However your relatives can come to the surgical lobby every day between 7 & 8 in the morning. The duty doctor will brief them about your progress. They can also personally meet Dr. Ganesh Shivnani at 9 AM everyday in his office.
Under no circumstances will the patients' relatives be allowed to visit the recovery room, surgical ICU or surgical IMCU. However, you can speak to your near and dear ones over the in-house telephone.
The hospital premises have a shopping mall including a cafeteria and a chemist on the ground floor, for the convenience of the visitors.
Telephone services including ISD/STD are also available in the hospital and are situated at the ground floor. The hospital has bank services (Syndicate Bank) on the ground floor. Relatives can make use of the religious services located at the ground floor level within the hospital premises.

Returning Home

It is not at all unusual to feel apprehensive about returning home. Some- times these feelings are prompted by concerns about leaving the security of the hospital, with its expert medical team and equipment. Remember that no patients are allowed to go home until the doctor thinks their condi- tion is satisfactory for them to continue their safe recovery at home. Dependinq on your recovery, the surqical team will organize your discharge. Since you have been through a major operation, the preparation of the discharge summary may take some time, as it has to be checked and re-checked to ensure that an accurate account of your treatment has been stated. One of the members of the team will go through the discharge summary with your relatives. You should also read the discharge summary in details and any factual error should be brought to the hospital's notice immediately. Once the discharge summary has been issued, no changes can be made in it under any circumstance. Also one of your relatives will need to go to the accounts department on the ground floor to get the final clearance of accounts.
The hospital normally makes it possible for you to check out by 10 AM.
Transport will have to be arranged by your relatives or friends and it is perfectly safe for you to travel home sitting in the car.
Long distance journeys should not be taken for a week or so. This is only to ensure that help is close at hand should you need it.
Recovery from heart surgery usually takes 4-6 weeks. During this time, you start to build up your strength and get back to your normal routine. When you first get home, your activities should be the same as they were in the hospital. Do a little more each day. Rest when you are tired. Don't overdo it. Don't set goals. Face each day as it comes. Do things pragmatically and within your capabilities. Do not compare yourself to some one else. No two people are alike, neither in their looks, nor be- havior, so how can they be alike in their recovery?

Your Emotions

It's normal after surgery to have a "let down" or depressed feeling. You may be tearful or cry. At times you may be irritable. Some people have bad dreams. Others have a loss of memory or can't concentrate. These emotions should go away by the end of your recovery (4-6 weeks). There is no embargo on speaking or interacting socially, as long as you do not feel tired & exhausted.

Incisions

During the first week after surgery, your chest incision may be bruised. It may also itch, feel numb or be sore. At times your back or shoulder may also feel sore. All of these things are common and will go away slowly.
For back and shoulder soreness, maintain good posture and move your neck & shoulder muscles in a normal way. A good posture means sitting or walking straight, without resorting to a slump. Do not raise your hand above the shoulder height and do not lift heavy weights. A mild pain reliever may also help. If a vein graft was taken from your leg, you may notice some swelling. Elevating your legs will help. If an arterial graft was used from your arm (radial artery), you may notice some numbness in your thumb and index finger. This will improve with time. It takes 6-12 weeks for the breastbone to heal completely. Wires hold this bone together, but you can't feel them. During this healing time you may notice slight clicking or movement of sternum (breast bone) when you breathe or turn. This is common and should go away when your sternum heals. Women may find that wearing a brassier can add support and reduce parn.' Choose a comfortable but a firm and fitting brassier that is not binding.

Walking & Exercises

Take several short walks between times of rest. This keeps you from getting too tired while you are building your strength. You can climb stairs, but take your time and go slowly. Sit down and rest if you become tired, short of breath or dizzy. Do not cross your legs while sitting as it hampers blood circulation in the legs and increase the chances of clot formation in legs. Do the amount and kind of exercise your doctor or physiotherapist suggests. Exercise improves muscle tone and strength after surgery. You can start going out of your house for short walks, but always keep help at hand.

Bathing

At first you may be weak, so have someone close by to help you if needed. Until you feel stronger, it may help to place a stool in the shower. Wash your incisions gently with soap but DO NOT SCRUB. Pat dry. Leave wounds open, unless they are weeping & wet. Taking bath daily is desirable and strongly recommended.

Diet

Eating well-balanced meals will speed your healing and make you less tired after surgery. Your appetite may be down but it will pick up as you start to recover. Try eating small meals more often rather than two or three large ones. If you have diabetes, it is important to keep your blood sugar under control. A healthy heart diet is low in cholesterol, saturated fats, sugar, salt and calories. The doctor (cardiologist), dietitian or nursing staff will explain how to modify your eating habits. It is wise to reduce coronary risk factors as much as possible by reducing saturated fats, cholesterol and salt in the diet. It is very important to avoid being overweight. Obesity is bad for any heart patient. Generally the same food as the rest of family can be taken, if tolerated. Avoid salty foods such as potato chips. Salt should not be added to your plate but normal cooking salt is all right. Fatty foods are best avoided, so are aerated drinks. Take plenty of fruits, fresh vegetables & roughage in diet. Avoid confectionary and bakery products. Do keep track of invisible fats and calories especially in the form of major snacks between meals

Cholesterol

Nutrition experts generally agree that keeping blood cholesterol at normal levels reduces the risk of heart complications in persons who have coronary artery disease. It is a good idea to check your blood cholesterol periodically. If it is high you will have to reduce it by proper diet and exercise. If diet and exercise don't do the job, medication may be needed.

Cooking

Use small amounts of vegetable oil in cooking. Corn, Soy, Sunflower, Peanut and Olive oils are better to use. Bake, boil, steam or grill. Don't fry and don't add salt at the table. Don't refry food & don't reuse oil after it has been used once as repeated heating of oil leads to production of transfatty acids which are harmful to your heart and lead to cholesterol deposition in the arteries of the heart.

Driving

Do not drive a car or scooter for about 4-6 weeks after surgery. During recovery your reaction time will be slowed due to weakness, fatigue or medicines. If you unfortunately meet with an accident, even while wearing a seat belt, you could hit the steering wheel and re-injure your sternum.

Household chores

Wait until after 4 to 6 weeks to begin household duties (child care, making meals etc). During the first two weeks at home, as you get stronger, you may feel like:

Setting and clearing the table

Dusting furniture

Potting plants

Shopping!

Any thing that is very tiring or causes discomfort should be stopped until after recovery. Do not lift more than 2-4 kg at a time for 4 to 6 weeks after surgery.

Smoking

For some of you, surgery forced you to stop smoking. It is very important that you continue to not smoke. It may be hard not to smoke again, but you can do it. Stopping to smoke is one of the best things you can do for your heart and your health. Smoking has a bad effect on the heart, as well as on other parts of the body. It is a major risk factor for additional heart dis- ease after your surgery. If you smoke, quit and if you don't, please don't start.

Support Stockings

You may be asked to wear support stockings or crepe bandages during the first part of your recovery when you are less active. These stockings/ bandage aid blood flow and help reduce swelling in the legs. Keep wearing the stockings/crepe bandages for 4-6 weeks or till your activity is back to normal and swelling of the legs has disappeared.
If you have a problem with leg swelling
Raise your legs when sitting or lying down so that your toes are above the level of your heart
Don't stand for long periods of time.

Alcohol

Drink only if you have no addiction problem. You may drink alcoholic beverages, in moderation only, NEVER exceeding two drinks per day (60ml of 80% proof whisky or 200-300ml of red wine). Too much alcohol can weaken the heart muscles.

Recommended Food Products after Coronary Artery Surgery

Skimmed milk and its products.

Lentils.

Low cholesterol butter.

Poultry, fish, white of egg.

Soups.

Butter milk, coconut water, lime juice.

Wheat flour with bran, besan.

Green leafy vegetables.

Fruits - apple, orange, sweet lime, grape, pears, water melon, musk melon.

Grilled, baked, sesamed and roasted foods.

Dry Fruits - 15-20 gm / day

Medications

You should take only those medicines, which have been prescribed in the discharge summary. Don't keep taking medicines that you took before the operation unless they are specifically prescribed. Before you leave hospital make sure you know which medication you have to take and what each tablet is for. This is most important. If you are to take anticoagulants (blood thinning tablets) you must understand how often the follow-up blood tests are to be done.

Anticoagulants (blood thinning tablets)

Some people get blood clots inside an artery, a vein or the heart. This may be a problem in people with irregular heartbeats, previous blood clots or heart valves that have been replaced. To lower the chance of having blood clots, an anticoagulant (such as Acitrom) is prescribed. Anticoagulants (often called "blood thinners") prolong the time it normally takes for blood to clot. If you are taking a blood thinner, keep appointments for regular blood tests (Prothrombin time/INR). This test tells your doctor how long it takes your blood to clot. This time is used to decide the right dose of blood thinner for you. While you are in the hospital, your blood will most likely be checked daily. When you first go home, PT/INR should be done twice a week for the 1't week, then once a week for the next two weeks. Later this test may be needed only once a month. The level of anticoagulation for you will be mentioned in your discharge summary.

Caution: Watch for signs of bleeding, if you are taking a blood thinner. Let your doctor know right away if you have:

Black stools

Pink or red urine

A lot of bruising or unexplained swelling

Severe headaches or abdominal pain

Vomit that looks dark coloured

Bleeding from nose or gums

More than the usual menstrual periods

If any dental work or surgery is planned, let the dentist or surgeon know that you are on anticoagulants. Your doctor may ask you to stop taking them for some time

Spectacles

After any open-heart surgery, there is water retention in the body. Even the lens of the eye gets swollen and therefore you may get haziness of vision and inability to read small prints. Please do not change the lens of your glasses as this problem will go away automatically in 4-6 weeks time and you will be able to see normally once your lens tension returns to base line.

When should the doctor be contacted ?

Usually patients are called for follow up on Saturdays in the OPD, room No.19, ground floor in front of the Echo lab, but you can always contact us any time during the day or night if there is any problem. The surgeon's role is very specific and technical, so usually only one or two postoperative visits need to be made with us. Your cardiologist shall do your regular follow up & risk factor control. Also your referring cardiologist will wish to follow your progress. So after your visit to the surgeon, make sure you have appropriate appointments with your cardiologist. Call the Doctor on duty if there is any problem (phone numbers have been provided in the booklet and in the discharge summary), viz if there is any sign of infection (redness or discharge from the incision), fever, chills, increased fatigue, shortness of breath, increased swelling on ankles, weight gain over 2 Kgs in 5 days, change in heart rate or rhythm or any other sign or symptom that seems disturbing. Please always contact the surgeon on duty in the hospital and refrain from ringing consultants directly at their residence numbers or mobile phones. If need be, the surgeon on duty shall contact the consultants who are available 24 hours and would visit you in the hospital.

Returning to Work

For sedentary workers, the average recovery time is four to six weeks. For persons who must perform heavy work, the time is six weeks or longer, varying from patient to patient.

Routine at home

Patients should follow these principles

Get up at your normal waking time

Bathe or shower daily if possible

Always dress in regular clothes (don't stay in sleeping clothes during the day) & take interest in personal grooming.

Take a rest period in the mid morning, at mid afternoon or after a period of activity.

A typical six weeks' programme

Week 1

Light activities

Avoid any heavy lifting, stooping or bending

Limit visitors

Frequent 5-10 meters walks around house and garden

Stairs - when essential, go slowly, and rest mid way

Week 2

Gradually increase to moderate activities, more moving and for longer times

Walking 10-15 minutes twice daily at a comfortable pace

Start receiving visitors

Week 3

Continue increasing activities

Half day outings and small social outings, but not till late at night

Walk 15-20 minutes twice daily

Week 4 - 5

Longer activity times, faster walking

Carrying light weights

Walking 20-30 minutes, aim to walk 1 mile twice daily

Social outings; such as cinema/theatre/temple

You can visit a restaurant up to 3 hours

Week 6

Most activities, unless exceptionally heavy

Drive your car

Normal sexual activities

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