47 Su r g ic a l D iS e a Se S iSSN 2413-6077. iJMMr 2021 Vol. 7 issue 2 DOI 10.11603/ijmmr.2413-6077.2021.2.12556 REHABILITATION OF PATIENTS AFTER CARDIAC SURGERY T.V. Romaniuk, V.S. Moroz, S.M. Maslii, Z.V. Vivchar I. HORBACHEVSKY TERNOPIL NATIONAL MEDICAL UNIVERSITY, TERNOPIL, UKRAINE Background. Patients undergoing cardiac surgery are under a high risk of post-operative reductions in respiratory muscle strength and pulmonary function as well as lowered functional capacity. In-hospital physical inactivity and inappropriate rehabilitation increases the chances for development of these complications and affects patients’ future independence in daily routine. Cardiac rehabilitation is crucial in preventing complications and assisting the early function recovery. However, despite the evidences for its benefits and strong guideline recommendations, the uptake of cardiac rehabilitation remains poor. Objective. this study is aimed at promotion of cardiac rehabilitation and sharing successful experience of using it. Methods. Post-surgical treatment and rehabilitation of 387 patients with cardiovascular pathology in the Department of Vascular and Cardiac Surgery of Municipal Non-Commercial Enterprise “Ternopil Regional Clinical Hospital” of Ternopil Regional Council has been analysed. Results. The experience of successful post-surgical treatment and rehabilitation allowed establishing the basic approaches to perioperative management of patients with cardiovascular surgical pathology. Key principles include minimized ICU stay and artificial ventilation time, early verticalization and beginning of physical activities, early removed drainage tubes, tracheobronchial tree drainage, nutritional balance, lymphatic drainage massage, application of elastic jersey on the lower extremities, early transferring to the surgery ward and returning to the regular daily activities, circumstantial health education, complex work of a multidisciplinary team. Conclusions. This set of rehabilitation measures helps prevent complications after cardiac surgery as well as provide a faster patient’s daily routine. KEYWORDS: cardiac surgery; cardiac rehabilitation; exercise; recovery of function; health education. *Corresponding author: Taras Romaniuk, Associate Professor of the Department of Surgery No.2, I. Horbachevsky Ternopil National Medical University, Ternopil, 46001, Ukraine. E-mail: romaniuk_tv@tdmu.edu.ua International Journal of Medicine and Medical Research 2021, Volume 7, Issue 2, p. 47-50 copyright © 2021, TNMU, All Rights Reserved T.V. Romaniuk et al. Introduction The increasing prevalence of risk factors such as age, obesity, diabetes, hypertension and dyslipidaemia in patients undergoing cardiac surgery causes a significant rise of possible complications [1]. Those patients commonly experience reductions in respiratory muscle strength and pulmonary function [2-3]. These complications lead to longer hospital stay, higher rehospitalisation risk, reduced health-related quality of life and higher costs for healthcare [4-6]. Also, makeable reduction in functional capacity can occur, which only gets worse if patients spend the majority of their time sitting or in a supine position due to the inappropriate care [7-8]. In-hospital physical inactivity causes muscle weakness and aerobic capacity decrease, which can seriously affect patients’ independence in daily routine [9-10]. Cardiac rehabilitation is crucial in prevention of these complications and assisting the early function recovery [11]. Cardiac rehabilitation is a complex intervention that includes post- operative management, exercise training, physical activity promotion, health education and psychological support [12]. Special em pha- sis in the latest guidelines is made on involving a multidisciplinary team to the rehabilitation complex [13]. In addition to cardiac surgeons and ICU anaesthesiologists it should include cardiologists, nursing specialists, physiothe- rapists, nutritionists and psychologists, trained in the core competencies of a comprehensive cardiac rehabilitation programme. However, despite the evidence for its benefits and strong guideline recommendations, the uptake of cardiac rehabilitation is poor [14]. Therefore, nowadays promotion of cardiac rehabilitation and sharing the successful experience in this field is essential, as the success of heart surgery depends not only on its type or the patient’s 48 Su r g ic a l D iS e a Se S iSSN 2413-6077. iJMMr 2021 Vol. 7 issue 2 health before the surgery, but also on proper rehabilitation, both in the early and late post- operative period. Methods Post-surgical treatment and rehabilitation of 387 patients with cardiovascular pathology in the Department of Vascular and Cardiac Surgery of Municipal Non-commercial Enter- prise “Ternopil Regional Clinical Hospital” of Ternopil Regional Council has been analysed in this study. Results The experience of successful post-surgical treatment and rehabilitation allowed estab- lishing the basic approaches to perioperative management of patients with cardiovascular surgical pathology. We are supporters of the fast and early activation concept or “Fast Track”. During the ICU stay we adhere to the following principles: time of intubation and artificial ventilation is minimized; physical activity usually begins 12-15 hours after the surgery. The patients are verticalized – helped to sit and stand under doctor’s supervision. At the same time, we help patients to perform a small walk on place. This improves blood flow to the right heart chambers. Walking also helps to restore motor function of the intestine. Verticalization of the patient helps to restore vascular tone, and is also one of the mechanisms of hypertension correction. Tracheobronchial tree drainage is performed by hyperventilation of the patient, as well as by forced coughing along with vibrating chest massage. This improves oxygenation and pulmonary function. After the first activity session the stability of haemostasis in the chest is checked and if no signs of bleeding are observed, drainage tubes are immediately removed. Delay in this can lead to the patient’s prolonged ICU stay, immobilization in bed, respiratory function limitations and development of arrhythmias caused by irritation of the heart reflex zones. One more vital thing is the nutritional ba- lance. Thus, before the operation, the patient’s diet includes high-calorie food rich in protein, vitamins and microelements that provide a good “pool” for rapid recovery of the patient in the post-operative period and high reparative potential for wound healing. In the postoperative period along with the restoration of peristalsis, the patient begins to drink, and after a short time to eat liquid, easily digestible food. This contributes to the full recovery of the gastro- intestinal tract and improves the overall psycho- emotional state of the patient. Lymphatic drainage massage, application of elastic jersey on the lower extremities has a good therapeutic effect on the swelling caused by congestive heart failure. If no major complications take place by the middle of the first post­operation day the pa­ tient is transferred from the ICU to the surgery ward. It also helps motivate our patients for early returning to their regular daily activities. They are trained to do exercises and are infor- med about all the restrictions for protection of the breastbone during physical activities and sleep time. Also, we provide some health education consultations in order to inform the patients about their state and the following rehabilitation programme, which may last up to 6 months. Discussion The efficacy and safety of complex cardiac rehabilitation in patients provided with different kinds of surgical procedures was evaluated in the study. A short-term impact of different procedures on patients might differ significantly, as valvular surgery, CABG, surgery on thoracic aorta and their various combinations are provided in our clinic. Post-isolated CABG patients might therefore respond differently to the rehabilitation complex compare to those who underwent a complicated combined sur- gical procedure. We tried to develop a unified complex of rehabilitation measures according to the International Guidelines and our own experience. Not separating and analyzing pa- tients as separate groups might therefore be a limitation to this study. While current guidelines of the European Society of Cardiology [15] emphasize mainly on exercise-based cardiac rehabilitation after heart surgery, our findings coincide more with the Cochrane systematic review by Abraham et al., who recognized that rehabilitation interventions complex may also need to include breathing and coughing exercises and vocational eva- luation advice in addition to the physical exer- cises [16]. Conclusions Key principles include minimized ICU stay and artificial ventilation duration, early ver­ ticalization and beginning of physical activities, early removed drainage tubes, tracheobronchial tree drainage, nutritional balance, lymphatic drainage massage, application of elastic jersey T.V. Romaniuk et al. 49 Su r g ic a l D iS e a Se S iSSN 2413-6077. iJMMr 2021 Vol. 7 issue 2 on the lower extremities, early transferring to the surgery ward and returning to the regular daily activities, circumstantial health education, complex work of a multidisciplinary team. This set of rehabilitation measures helps prevent complications after cardiac surgery as well as provide faster patient’s daily routine. Conflict of Interests Authors declare no conflict of interests. Acknowledgements This paper and the research behind it would not have been possible without the everyday great dedication and hard work of a great multidisciplinary team of the Department of Vascular and Cardiac Surgery of Municipal Non- commercial Enterprise “Ternopil Regional Clinical Hospital” of Ternopil Regional Council. Author's Contributions Volodymyr Moroz, Taras Romaniuk – con- ceptualization, methodology, formal analysis, writing – original draft, writing – reviewing and editing; Sofiia Maslii, Zoriana Vivchar – data curation, writing – reviewing and editing, in- vestigation, formal analysis. ОСОБЛИВОСТІ РЕАБІЛІТАЦІЇ ПАЦІЄНТІВ ПІСЛЯ КАРДІОХІРУРГІЧНОЇ ОПЕРАЦІЇ Т.В. Романюк, В.С. Мороз, С.М. Маслій, З.В. Вівчар ТЕРНОПІЛЬСЬКИЙ НАЦІОНАЛЬНИЙ МЕДИЧНИЙ УНІВЕРСИТЕТ ІМЕНІ І. Я. ГОРБАЧЕВСЬКОГО МОЗ УКРАЇНИ, ТЕРНОПІЛЬ, УКРАЇНА Вступ. Пацієнти, які перенесли операцію на серці, мають високий ризик післяопераційного зниження сили дихальних м’язів і функції легень, а також зниження функціональних резервів. Відсутність належної фізичної активності у ранньому післяопераційному періоді та невідповідна реабілітація збільшують ймовірність розвитку цих ускладнень і впливають на майбутні можливості пацієнтів щодо їх повсякденної діяльності. Вирішальну роль у попередженні ускладнень та сприянні ранньому відновленню функцій організму відіграє кардіологічна реабілітація. Однак, незважаючи на її доказові переваги і сильні рекомендації світових гайдлайнів, якість кардіологічної реабілітації залишається слабкою. Мета. Метою цієї роботи є популяризація кардіологічної реабілітації та обмін успішним досвідом у цій сфері. Методи. Проаналізовано післяопераційне лікування та реабілітацію 387 пацієнтів із кардіо- хірургічною патологією відділення судинної хірургії з кардіохірургією Комунального некомерційного підприємства «Тернопільська обласна клінічна лікарня» Тернопільської обласної ради. Результати. Проведений аналіз успішного досвіду післяопераційного лікування та реабілітації пацієнтів із кардіохірургічною патологією дозволив нам встановити основні принципи їх пери- операційного ведення. Вони включають мінімізацію часу штучної вентиляції легень та перебування у реанімаційному відділенні, ранню вертикалізацію та початок фізичних навантажень, раннє видалення дренажних трубок, дренаж трахеобронхіального дерева, збереження нутрітивного балансу, лімфо- дренажний масаж, накладення еластичного трикотажу на нижні кінцівки, раннє переведення в палату хірургічного відділення та повернення до звичайних повсякденних справ, ретельне навчання пацієнтів, комплексна робота багатопрофільної команди. Висновки. Цей комплекс реабілітаційних заходів допомагає запобігти ускладненням після кардіо- хірургічних операцій, а також забезпечити швидке повернення пацієнта до нормального життя КЛЮЧОВІ СЛОВА: кардіохірургія; кардіологічна реабілітація; фізичні вправи; відновлення функції; медична освіта. Information about the authors Taras V. Romaniuk – Associate Professor of the Department of Surgery No. 2, I. Horba chevsky Ternopil National Medical University, Ternopil, Ukraine. ORCID 0000­0001­9279­3711, e­mail: romaniuk_tv@tdmu.edu.ua Volodymyr S. Moroz – PhD Student of the Department of Surgery No. 2, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine. ORCID 0000­0001­6880­5110, e­mail: moroz_vs@tdmu.edu.ua Sofia M. Maslii – Assistant Professor of the Department of Internal Medicine No. 3, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine. ORCID 0000­0001­5849­7791, e­mail: maslii@tdmu.edu.ua T.V. 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This is open access article distributed under the Creative Com- mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Zoriana V. Vivchar – Intern of the Department of Surgery, Faculty of Postgraduate Education, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine. ORCID 0000­0002­2609­1583, e­mail: vivchar_zovo@tdmu.edu.ua T.V. Romaniuk et al.