Monitoring post Open Heart Surgery: could someone help me out...:(

While monitoring the patient with open heart surgery, you must be aware of the complications of the surgery that may arise, the apparatus used in monitoring the patient and should be well aware of the physiotherapy procedures used in cariac surgery. But let me tell you all the operations performed in thoracic region whether it is cardiac or pulmonary surgery have the same mamagement regarding the monitoring and physiotherapy with slight modification needing care and due to change in drug regimn, so not much different difference with almost same physiotherapy programme. Post operatively the patient is managed in the intensive care unit, then shifted some days in the ward after being more stable and requiring less care and exposure. You may have a look over the detail as under:

Complications of Cardiac surgery

The likely complications are:

1. Respiratory
(a) Infection of lung tissue.
(b) Consolidation or collapse of whole or part of the lung.
(c) Pneumothorax.
(d) Haemothorax.

2. Cardiovascular:
(a) Deep venous thrombosis, with resultant danger of pulmonary embolus.
(b) Cardiac arrest.
(c) Cardiac arrthymias.
(d) Tamponade- collection of blood in pericardial cavity which compresses the heart, reducing its capacity to fill with blood during diastole and leading to cardiac arrest.
(e) Emboli from diseased valves may break off, lodge in a cerebral vessel and cause a stroke.
3. Wound:
(a) Infected.
(b) Unhealed.
(c) Adherent.

4. Joint Stiffness
(a) Shoulder and shoulder girdle.
(b) Thoracic spine.
(c) Cost vertebral joints.
The shoulder and shoulder girdle complex is especially prone to stiffness unilaterally following a lateral thoracotomy and bilaterally following a median sternotomy.

5. Muscle Weakness:
(a) The muscle affected by the incision will be weak.
(b) Leg and abdominal muscles become weak during bed rest.

6. Postural deformity
(a) Protraction (rounding) of the shoulder after median sternotomy.
(b) Scoliosis, concave on the operation site after a lateral thoracotomy.

The Danger signals

Monitoring of the patient by the various machines connected to the lines and tubes used post operatively is under the control of the surgeon and nursing staff. A physiotherapist working in the cardiothoracic unit, or intensive care unit, must be familiar with the function of the machines, their danger signals, and with the action to be taken according to the policy of the unit.

The physiotherapist may be the first to detect the diminished chest expansion which predisposes to consolidation of the underlying lung tissue. He is also likely to be the team member to detect developing joint stiffness or postural deformity.

Lines, tubes and drains

1. Endo tracheal tube- This is a tube that extends from mouth to the trachea. It allows attachment of the ventilator and facilitates suction of secretions from the trachea.
2. Humidifier- There are a number of types of humidifier, but the function of them all is to moisten the air or gas mixture entering the patient’s lungs, so that secretions do not become encrusted in the trachea or on the end tracheal tube. There is always a humidifier when a patient is on a ventilator.
3. Oxygen- This may be delivered by mask or nasal cannulae or via end tracheal tube where one is in situ.
4. Drainage tubes- There may be one to drain the fluid and/or one to drain air from the pleural cavity. There may be mediastinal and pericardial drains to redivac bottles. Where the great saphenous vein is removed to provide material for coronary artery grafting or valve replacement, there will be drain in the affected leg.
5. There may be one drip in the arm or leg to provide blood transfusion saline or plasma, i.e. fluids to maintain fluid and electrolyte balance. There may be a tube in a jugular vein passing to the right atrium for administering drugs.
6. Central Venous Pressure- CVP recording is used to monitor the force of venous return and can detect the onset of cardiac failure. The line passes from the recording instrument through a vein, such as internal jugular, through the superior vena cava, to the right atrium. (The same tube may be used for CVP recording and drug administration.)
7. Arterial Pressure- A tube in an arm artery may be used to record arterial pressure or may be used to obtain blood samples.
8. Ryle’s tube- This is tube that passes through the nose to the stomach. It enables aspiration of gastric juices to be performed and can help to prevent vomiting.
9. Pacemaker leads- The patient may be linked up to an external pacemaker with leads attached to the chest.
10. Electrocardiography- Usually four leads connect the patient to an electrocardiograph for continuous monitoring.
11. Urinary catheter- This may be placed in the urethra to prevent the urinary complications.

The tubes or lines inserted into the patients are referred to as invasive and there are hazards to the patient with them all. Surgeon, engineer, electronics experts and a large number of scientists are always searching for useful non invasive techniques. Blood gases, blood flow and pH of the blood can now be assessed with non invasive techniques using sensors placed on patient chest.

Post operative treatment

For the first 48 hours after the cardiac surgery, the patient will be in the intensive care unit, because he will be under continuous supervision and skilled personal are immediately on hand to deal with any emergency.

Aims of Physiotherapy

The aims of physiotherapy are as follows:

1. To maintain a clear air way
2. To prevent the lung collapse and consolidation
3. To help the patient to maintain good posture.
4. To ensure that the mobility of shoulder, neck, trunk and legs is maintained.
5. To prevent deep venous thrombosis later, i.e. after 48 hours up to 2 weeks.
6. To restore the patient confidence
7. To increase the patient’s exercise tolerance.
8. To teach the patient a home exercise programme.

Outline of an uncomplicated recovery following an operation with Open Heart Surgery

Day of operation

The physiotherapist must note the position of the drips, tubes and lines. He must check recordings such as temperature, blood pressure, ECG, pulse rate, respiration rate, and time of administration of analgesic drugs. He will know, from discussion with the staff, of any complications during surgery.

If the patient does not require artificial ventilation and there are excessive pulmonary secretions, physiotherapy may be delayed until the end tracheal tube has been removed.

The patient is helped to sit forward from half lying and physiotherapist listen to the breath sounds, especially in the posterior basal area. With the incision supported, the patient is encouraged to take three breaths and to try one or two huffs. He is then repositioned in half lying with full support for his head and trunk from pillows.

Day1

Treatment is given four times during the day. Diaphragmatic and bilateral basal breathing exercises are practiced with huffing then cuffing when the patient can manage. Each treatment session is a mixture of treatment and assessment in that, as the physiotherapist instruct the patient in breathing exercises, she can assess thoracic expansion at the same time. Position sense training is incorporated because the shoulders, head and neck should be aligned before breathing exercises are performed and relaxation after breathing.

If the patient has a lateral thoracotomy, the arm of operation side should be assisted into elevation at two of the treatment sessions. Foot movements- five times in each direction must be and one hip and knee bending and stretching should be performed 3-4 times at two of the treatment sessions.

At the end of this day most of the dips and drains will be out and the patient will be beginning to feel more human.

Day2

The physiotherapy will be the same as for day1. A rope ladder may be tied to the end of the bed to enable the patient to sit up himself, but not all patients like this after a median sternotomy. Arm movements should be full range on the side of a lateral thoracotomy. Where the incision has been a median sternotomy, the patent may start bilateral shoulder movements.

By the fourth treatment session the patient may be up to sit beside his bed, and breathing exercises are given in this position.

Day3

The patient will be clear of all drips, drains and lines and will be back in the ward of the cardiothoracic unit. Physiotherapy may be reduced to three visits. Breathing exercises and huffing should continue. General arm and trunk exercises will be included in at least one session and the patient may be taken for a short walk (within the ward) on another session. Posture correction and arm swinging should be incorporated into the walking practice.

Day4

The patient should be up and about independently and allowed to go to toilet on his own. The physiotherapist must assess chest expansion at least. Arm trunk and leg activities may be performed with other patients in a ward class.

Day 5-14

Activities until the day of discharge-usually two weeks after the operation-must be geared to the individual patients. Around days 5-7 the patient should be able to walk upstairs (about 8-10 stairs) and an exercise programme may be developed along the lines of the patient recovering from the myocardial infarction.

Before Discharge

The patient should be confident that he will be able to cope with his home situation; otherwise he may go to a recovery unit if the hospital has one. He must has full thoracic expansion and know how to practice breathing exercises every day. He must also have full joint mobility. The progression of the length of walking and daily activities, and the date of return to the work, is for the surgeon to decide at follow up appointments.

Variations

Ventilated patients

Some patients may be on a ventilator for the first 12-24 hours after cardiac surgery. Physiotherapy may be required if there is evidence of collection of the secretions in the patient’s lungs. Vibration and suction then may be given but the vigor and the length of treatment are dictated by the patient overall condition, especially in relation to the stability of the cardiovascular system.

Operations not using the cardiopulmonary bypass machine

This a comparative minor compared with other cardiac operations. A pacemaker is an electrical device used to treat patients with heart block. The incision may be simple in that the device s placed under the skin of axilla but a thoracotomy may be necessary. Physiotherapy should be given to prevent chest complications.

Development of complications

Lung collapse due to accumulation of the secretions may have to be treated with vibrations and manual hyperinflation. If the patient is on a ventilator, then vibrations are given on during the expiratory phase after which suction is given, to remove the secretions.

Wound infection may be treated by ultraviolet rays-E4 dosage from a water cooled mercury vapour burner. A slow healing wound may be treated by application of an E2 dosage.

Joint stiffness may require treatment by specific techniques such as hold relax and repeated contractions. Muscle weakness can be treated by graduated exercises.

Children

Children age over 4 years follow the same sort of postoperative recovery as adults. They need more encouragement to practice breathing exercises and general activities with games rather than formal exercises. Patient under 4 years old are cared for in a special children unit where, although the principle of treatment are same, techniques must be modified. Variations are finer than those used for adults using, for example using only two fingers. Activity is encouraged, only where necessary, as when the child is not moving enough naturally.