The surgery itself has one goal: to help you live beyond the surgery. However, before “beyond” comes, you have to get through weeks & months of post surgery recovery. This blog describes steps one needs to re-enter a “normal” life.
This blog is part 4 of a five-part blog about heart surgery:
1: Heart Surgery – Highly Likely for You or a Family Member
2: What Brings Us to the Operating Room Before Surgery
3: Valve Surgery Operation and the Intensive Care Unit
4: Life Beyond: Post Surgery Recovery
5: Heart Surgery Cost – Medicare Coverage and Hospital Staff
Surgery Recovery, Near Term
Immediately after discharge, the heart surgery patient embarks on weeks and months of surgery recovery:
– The patient may not drive a motor vehicle until seeing the surgeon in person for examination and approval. After a mini surgery, this will not happen for at least two weeks after hospital discharge.
– During surgery recovery, the patient may not handle any kind of weight. A typical restriction forbids lifting more than 5 pounds for two weeks, and 10 pounds for the following four weeks.
– In my case, I had an infection (endocarditis) in addition to my cardio condition (mitral valve failure). The infection required me to continue IV infusions of antibiotics for weeks following hospital discharge as part of my surgery recovery.
– Three to four months of blood thinners. In my case, my cardiologist Dr John prescribed twice-a-day Eliquis as my blood thinner. It’s a relatively expensive medication, $400 per month, but greatly superior to cheaper alternatives such as warfarin. My drug insurance covered most of the cost but my co-pay was still high, $45 per month.
– Patients who show any symptoms of atrial fibrillation will also take three months of an anti-A-fib medication. Since my heart showed fibrillation during surgery, the doctors automatically prescribed daily doses of amiodarone, which is fortunately an inexpensive drug.
– I was overdue for my every-five-years colonoscopy. However, Dr John had me postpone that until she studied an EKG and echocardiogram, and then not until after six months of surgery recovery.
As part of surgery recovery most heart patients must also undergo cardiopulmonary rehabilitation, which may last for six months or even for several years. Rehab begins with blood analysis and an exercise stress test, followed by a custom exercise and life-style program.
In my case, Dr John had approved me going to Hawaii for a long-planned seven-week trip. However, she forbade me to handle any luggage. My dear Nola stepped up to the plate and wrestled all our suitcases, coming and going. What an angel!
I would have been tempted to help her, but Nola had been present for Dr John’s instructions and would not hear of it. Instead, I tried to help by packing a larger number of lighter weight bags.
During the trip, Nola and I maintained our normal program of walking several miles a day. When I returned, Dr John questioned me and found that I had experienced no heart-related symptoms. In addition, I had no other risk factors such as smoking, high blood pressure, high blood lipids or excessive weight. For these reasons, Dr John stated that I was past the point of needing rehab and I could omit this from my surgery recovery program. I was really happy to receive this assessment from my cautious cardiologist!
If I had required open-chest surgery rather than the mini operation, I would probably have been tossed into an immediate rehab program. Since the only hospital in Maui is an hour away from our condo, I would probably have had to stay in Michigan and would have missed my Hawaii trip.
Surgery Recovery, Long Term
Heart surgery is one of those gifts that keeps on giving. A patient who has completely successful surgery and finishes surgery recovery is not yet done. He or she will require medical follow-up for literally the rest of their life:
– A visit to a cardiologist every six months.
– Pre-medication with an antibiotic (amoxicillin) before every dental procedure, even including tooth cleaning.
– Pre-medication with specific antibiotics (such as cefalexin) before other procedures. These include biopsies, colonoscopies and even minor surgeries such as skin cancer excision.
– A medical history given to every new doctor that you see, since you are deemed to be at higher risk for many medical treatments.
– Instructions to never physically strain. That means no shoveling of snow. It also means no upper body exertion that causes you to make a “straining” face. A sign of strain is an immediate reason to stop whatever you are doing.
– Disclosure to the medical staff prior to any magnetic resonance imaging (MRI) test. Why? Because a magnetic scan can move metal around, or deposit energy that warms it up. In addition, metal can degrade the quality of the MRI image. Artificial valves contain a great deal of metal. However, tissue valves may also contain metal. Tissue valves are often built around a stent, a stiffening framework, and those stents may be made of metal. Even a valve like mine with a plastic stent also contains a stainless steel wire for radiopacity (visibility to x-ray imaging). The MRI tech may need to adjust imaging parameters for patient safety and effective imaging.
– If the patient receives an artificial valve, he or she will need a daily dose of blood thinner, “forever,” plus in many cases blood tests every four to six weeks.
The PICC Line
Since I had had a failing heart plus a bacterial infection, my surgery recovery also required me to have antibiotics. Curing endocarditis, plus some other infections, requires at least six weeks of intravenous medication.
The hospital infectious disease team had given me intravenous Vancomycin every day since they admitted me on October 28. Therefore, after hospital discharge on November 13 I still needed four weeks of an IV. I barely had time to complete this before my scheduled trip to Hawaii on December 12.
To provide this additional treatment my surgery recovery would require me to have a PICC (Peripherally Inserted Central Catheter) line. The hospital called their in-house expert to install a PICC in my upper right arm.
Is PICC A Good Thing?
On the face of it, a PICC line sounds like a great idea. After all, no one would have to poke me for a blood sample, since they could just draw it out of the PICC. But of course, this benefit comes with an offset. Because it’s a window into your body, it has to be kept pristinely clean and sealed all the time you’re not using it.
The PICC delivers medicine directly to the heart thru a long catheter. It is used not only for antibiotics, but in chemotherapy and other treatments. The internal part of the PICC is a tube about 1 mm in diameter and 36 cm long. The external part is a tube with a manual valve and a self-closing access port.
Don’t PICC This Option If You Can Avoid It
However: the PICC line is a nuisance. The installation was briefly painful, but it did not hurt after that. However, the PICC requires daily maintenance:
– The nurse instructed me to take daily showers, while keeping the PICC site dry. This involved donning an arm-length plastic glove. A strap at the top of the glove cinched it, to exclude water. What little water seeped in had to be dried off quickly after my shower.
– When not being used for an infusion, the external part of the PICC line had to be protected. If it snagged on clothing or something else, it could get ripped out of my arm, and that would be really bad. So I had to carefully coil up the PICC tube and cover it with a sort of sock or sleeve that I wore day and night.
– The nurse initially installed an 18” external tube so that I could use both of my hands to perform infusions at home. When I began going to the infusion center their nurse shortened the tube to 3” so it would more easily fit beneath the sock.
Antibiotic Infusion at Home
I had been receiving Vancomycin every 12 hours in the hospital. The infectious disease doc prescribed a continuation of the same therapy at home during my surgery recovery. Such frequent infusions cannot be done at an infusion center, because those centers are only open 8 to 5. Thus I used a service that set me up for infusions at home.
A Beaumont Home Infusion Service nurse visited to teach me how to give myself infusions. Thereafter, a nurse came once a week to change the PICC line dressing and replace its external tube. She also took a blood draw to determine that the antibiotic was still at an adequate concentration prior to each infusion.
Nurse visits were covered by my Medicare insurance. However, I had a co-pay of $35/day to cover supplies, plus the cost of the antibiotic, an additional $6 per day. Supplies were delivered once a week to my home. Large bags of antibiotic were packed in freezies and had to be stored in my refrigerator until use.
Home Infusion Procedure
Home infusion is inconvenient because you have to follow a strict procedure to avoid infection and avoid blocking the line with a blood clot. In addition, depending on the antibiotic, infusion during surgery recovery may consume a lot of time.
Twice day I went through the following steps:
– Remove the sleeve from the PICC line.
– Twenty seconds of hospital-quality hand washing.
– Alcohol wipe of every connector, before and after its use. I consumed about 200 alcohol wipes during 17 days of home infusion.
– A syringe of saline into the PICC to verify that the line was open. This syringe also cleared the line of blood and left-over heparin, so that the antibiotic would not mix with them.
– The infusion itself. Vancomycin is one of the antibiotics that irritate the vein if too rapidly infused. Thus the infusion had to proceed slowly. Each infusion required 75 to 90 minutes.
– Frequent timing of the infusion rate. The infusion system they gave me was very low-tech, with infusion rate measured by a chamber containing a calibrated drip tube. I used the stop watch function on my iPhone to make sure that 16 drips occurred every 15 seconds. The drip rate would vary during the course of the infusion and I had to correct it by the very tiniest adjustment of a primitive tube-squeezing device.
– Another syringe of saline to transfer the last bit of antibiotic into my body, and to avoid mixing antibiotic with heparin.
– A syringe of heparin, a blood thinner, to prevent blood clots within the PICC line between this infusion and the next one.
– Coil the PICC line and cover it with the protective sleeve.
This total process took about four hours per day.
A New Allergy
After a week and a half of home infusions I started developing a red rash. Within a couple of days the rash had covered literally all of my body from the neck down, except for the genitals. It didn’t itch, but it was truly alarming to see.
The Internet informed me that Vancomycin causes a condition called Red Man Syndrome, which exhibits flushing and a rash.
I phoned the nurses for guidance and they suggested that I take over-the-counter antihistamines to clear up the rash. The one they felt would be most effective was a generic version of Benadryl. A few days of this medication did absolutely nothing to clear up the rash.
On November 30 I visited my principal infectious disease doctor, Dr Healy, for guidance. He informed me that if I had the condition, which he commendably called Red Person Syndrome, it would have appeared within a few days after starting Vancomycin therapy. In addition, Red Person typically only affects the face, neck and chest, not the entire body. Therefore, I didn’t have that syndrome.
What had happened is that during four weeks of therapy, I had acquired an allergy to Vancomycin. Dr Healy found this sufficiently interesting that he asked permission to take a photo of my rash-decorated skin.
However, my surgery recovery still required almost two weeks more of antibiotic infusion. Dr Healy chose a different antibiotic, one that would also be effective against the offending bacteria that the lab had identified in my blood cultures.
Antibiotic Infusion at a “Center”
Dr Healy changed my infusion prescription to Daptomycin. Unlike Vancomycin, Daptomycin only needed injection once every 24 hours. This schedule of therapy meant that I could have the drug infused at the Beaumont Infusion Center rather than at home. This new protocol began the very next day – medical folks are very quick to adapt to doctors’ changes!
The Beaumont Infusion Center offered several advantages to me:
– 100% insurance coverage with no co-pay, unlike home infusion.
– Daily contact with a nurse who could spot any problems quickly.
– An infusion environment that was more sterile than I could achieve at home, despite my training.
On my very first visit to the center, an additional advantage became clear. Although Vancomycin required over an hour for infusion, Daptomycin could be injected in under five minutes. The infusion center was a twenty drive from my home, so my day’s obligation was over within one hour. This approach therefore gave me back three hours of time every day compared with Vancomycin!
I completed my six weeks of therapy and the Infusion Center removed my PICC line Dec 11, just before my departure to Hawaii on Dec 12. Was I ever glad to get rid of the PICC! I pity folks who require PICCs for longer periods.
This installment of the Heart Surgery blog brings me through surgery recovery and back to “normal life.” However, it would be wrong to ignore the finances of my surgery. The next and last part of this blog does that: “Surgery Cost: Medicare Coverage and Hospital Staff.”
Image Credits: Photos by Nola & Art Chester