Preparing and planning for your child's surgery

• What Your Child May Look Like After Surgery
• When Do We Get To Go Home?
• Tips for Parents while in the Hospital
• How You Can Help Us
• Children's Preoperative Instructions

 What Your Child May Look Like After Surgery

Lots of tubes and lines are needed to monitor and care for your child while in the hospital. Even when you know what to expect, it is overwhelming to see the amount of "stuff" that will be on your child when they arrive in the intensive care unit after surgery for recovery. Below are some of the tubes and lines you might see on your child and what function they serve. Most of these will be seen right after surgery, but some of them can be needed at any time during the hospitalization.

Monitoring Equipment
In the intensive care unit and the intermedate care unit, the patient's vital signs are monitored by equipment at the bedside. This equipment records heart rate and rhythm, respiratory rate, the amount of oxygen in the blood, blood pressure and other such pressure readings. All of these numbers are used to evaluate heart function and oxygenation of the tissues. This equipment contributes to the noise in the room and alarms frequently. Look to your bedside nurse for insight into when these alarms are concerning and when it is nothing significant.

Intravenous (IV) Lines

• Peripheral Intravenous Lines (PIVs) - This is a soft catheter placed in a small vein through which intravenous fluid and medcations can be given

  One of these will be placed upon admission into the hospital. Numbing ointment is available and can be applied to your child's skin prior to sticking them for the peripheral line. This cream numbs the skin so that your child, hopefully, will not feel the poke.

  Your child will have a PIV in place throughout their hospitalization

• Central Lines - This is a soft catheter placed (usually during surgery) in a large vein or a chamber of the heart for monitoring of heart pressures or administration of IV fluids, medcations and nutrition. The insertion site can be located in the child's neck, chest, groin or umbilicus. These are usually removed prior to transfer from the ICU.

• Arterial Lines - This is a soft catheter placed (usually during surgery) in an artery to measure blood pressure and remove blood for lab samples. These can be located in the wrist, foot, groin, or umbilicus. This is removed prior to transfer from the ICU.

IV Infusion Pumps and Drip medcations
Multiple pumps will be at your child's bedside infusing potent medcations that the heart needs for support until the heart muscle has had time to recover from the trauma of surgery. Patients are typically kept on continuous drips to manage pain immedately after surgery and while they have a breathing tube in place. Fluid providing glucose and electrolytes will be given through one of the IV lines while your child is not able to eat by mouth.

Breathing Tube (Endotracheal Tube or ET Tube)
A tube inserted through the mouth into the airway so that a machine can breathe for your child while sedated during and after surgery. Your child will be given medcation prior to tube insertion so that it will not hurt and they won't remember it. The tube is removed when the child's heart is functioning well on its own and the child is strong enough to breath on their own. The amount of time the tube is needed varies significantly from patient to patient.

Ventilator
The machine by which we can breathe for your child while they are sedated. It allows for delivery of oxygen and removal of carbon dioxide. The ventilator is connected to the ETT and can alarm often for various reasons.

Nasogastric or Orogastric Tube (NG or OG tube)
A tube placed through the nose or mouth into the stomach so that stomach contents and bile can be continuously drained. Your child will have this tube in place until the endotracheal tube (ETT) is removed.

Surgical Incision
Two types of incisions can be med in the operating room. The type of repair dictates which type of incision is performed They are called a sternotomy or a thorocotomy.

A sternotomy is an incision med on the front of the chest over the sternum. The sternum is then separated and opened to allow the surgeons access to perform the operation. The sternum and this incision are usually closed after the repair is complete using sternal wires and skin sutures; however, sometimes it is necessary to leave the sternum open after surgery for a brief period (usually 1-3 days) to allow time for swelling to decrease in the area, at which time the sternum and the incision can be closed. For the open sternum, a dressing is sewn to the skin edges and covers the heart. A clear dressing is then placed over this which covers much of the chest wall. This dressing stays in place until the chest is closed. For the closed sternum, a sticky tape called steri-strips and/or a skin glue called collodion is applied over the incision to keep it clean while it heals. This skin glue wears off over about a two week period at which time the skin should be completely healed.

A thorocotomy is an incision med on the patient's side that usually begins just below the armpit and extends around to the back. This incision is always closed and covered with steri-strips and collodion.

Chest Tubes or JP Drains
Small tubes placed in the space around the heart or lung to prevent accumulation of blood and body fluids after surgery. These drains are connected to a collection device for measurement of fluid drained and are removed when the amount of fluid draining drops off significantly (usually within a few days of surgery).

External Pacing Wires
Sometimes after open heart surgery, the heart's natural pacing mechanism that keeps the heart in a normal rhythm is altered due to swelling or injury to the tissue that stimulates normal electrical activity. If the rhythmedes not support adequate blood pressure and oxygen delivery to the tissues, an external temporary pulse generator (pacemaker) is needed to maintain adequate heart rate until the heart's normal pacing function returns. This is usually a temporary problem but occassionally can be permanent. External pacing wires are small wires placed in the heart muscle during surgery through which electrical impulses can travel to the heart These wires exit the chest wall and can be attached to a pulse generator.

Pacemaker or Pulse Generator
An external pacemaker is the small box that generates the electrical impulse that is sent to the heart muscle to stimulate contraction.

Foley Catheter
A soft tube placed in the bladder to drain urine into a collection bag. Urine output is monitored closely as this is an important indicator of heart function. This catheter stays in place for as long as the patient remains continuously sedated after surgery (narcotics can cause you to retain urine) and/or frequent assessment of urinary output is needed.

. . . . .

Please feel free to ask your bedside nurse again for clarification of what each tube and line is once in the intensive care unit after surgery. They will be happy to provide further explanations. Patients often have swelling all over their body after surgery due to being on the bypass pump used during surgery. The most swelling typically occurs within the first 24-48 hours. Once the swelling stops, your child's body will reabsorb all that extra fluid and "pee it out", returning to their normal size. Your child will be closely monitored while in the intensive care and frequent blood tests, x-rays and echocardiograms may be needed to evaluate heart function. The bedside nurses will also be continuously monitoring your child for pain or discomfort for which there are many different types of medcations available to treat. It is important that once your child is hemednamically stabilized, they become more active and eat well. Your child needs to start getting out of bed and walking usually before they feel like they are ready. Activity helps keep your lungs clear of fluid and mucous, increases bowel activity, strengthens muscles, decreases stiffness (once they get over the discomfort of getting out of bed that first time!) and is good for their emotional well-being.

What Your Child May Look Like After Surgery | When Do We Get To Go Home? | Tips for Parents while in the Hospital | How You Can Help Us | Children's Preoperative Instructions

 When Do We Get To Go Home?

We know that this is one of the most important questions to address. In talking about the time period after surgery is performed we can break it down into three hurdles that your child must overcome in order to go home. The 3 major hurdles in the postoperative period are:

Hurdle #1: Hemednamic Stabilization

After a successful operation, your child will come to the pediatric intensive care for recovery. Sometimes patients are hemednamically stable within hours after surgery and sometimes it can take much longer. Surgery is a stressor on the body and it takes the heart muscle time to recuperate. How sick your child is after surgery varies from patient to patient and is dependent on the severity of their defect and any complications experienced during or after surgical repair. The parameters listed below are what the team of doctors and nurses look at when determining how stable your child is: - Stable blood pressure (within the desired range)

• Stable oxygen saturations (within the desired range)
• Good pulses in the hands and feet
• Good color
• Warm skin temperature
• Urine output greater than 1ml/kg/hr
• Minimal bleeding from the wound site
• Stable heart rhythm

Hurdle #2: Extubation
This means taking out the tube through which your child's breathing is assisted and being able to breathe adequately on their own. Sometimes this happens within hours after surgery and sometimes it can take longer. As long as your child's heart is sick after surgery, they will likely remain on the breathing machine. If your child had significant congestive heart failure or repeated respiratory infections prior to surgery, it may take longer for them to be able to breathe adequately on their own. Removing the breathing tube occurs when your child is hemednamically stable and has enough strength to support adequate breathing. It takes strong muscles to breathe in and out to take in enough oxygen, and it takes a strong heart to pump enough blood to deliver that oxygen to all the body's tissues.

Hurdle #3: Nutrition
Your child must be able to consume enough calories to meet the metabolic demands of the body. After surgery, your body needs extra calories to help the body heal. Your child must be hemednamically stable, off of the breathing machine and breathing easily on their own before they can eat by mouth. Sometimes a feeding tube is placed if your child needs to be on the breathing machine for an extended period of time or if your child cannot consume the calories required. The feeding tube gives us a route through which we can deliver liquid nutrition (different types of formula or breast milk). If your child did not have a chance to feed prior to their surgery, or if they've had significant trouble feeding prior to their surgery, they will likely have trouble after their surgery in this area. This is a common challenge and we have skilled therapists that are experienced at helping babies learn to feed if they are having difficulty. This can be a frustrating thing as it requires a lot of patience and involvement on your part to help get your child over this challenging hurdle.

We hope this answers some of your questions about what to expect after surgery. Know that when you see your child overcoming each of these hurdles, they are one step closer to going home! Discharge happens when your child is ready, and unfortunately, the number of days you will spend in the hospital cannot be predetermined based on the type of operation or defect. Know that we encourage lots of questions and we want you to be as involved in your child's care as you would like to be. The bedside nurse will be your guide. Please don't hesitate to ask them anything about your child's condition at any time.

What Your Child May Look Like After Surgery | When Do We Get To Go Home? | Tips for Parents while in the Hospital | How You Can Help Us | Children's Preoperative Instructions

 Tips for Parents while in the Hospital

1. Keep a notepad close by on which to write down all of your questions. The surgeons and cardiologists visits are brief and it can be easy to forget the questions you have in the time that they are at your bedside.

2. Ask lots of questions. We want you and your child to have a thorough understanding of your child's condition, the plan of care, medcations they need and why, etc. It is important to us that you feel comfortable asking for information and with the answers you are receiving.

3. If you do not understand an answer you receive to a question, ask the question again. medical terminology can be confusing, and sometimes it may seem like we are speaking a foreign language. It is our desire to address all of your concerns, and this is accomplished by ensuring that we are giving you understandable, digestible information.

4. Taking better care of yourself helps you take better care of your child. Try and get plenty of rest and eat well. This is a very stressful time for your entire family. As parents, we are better able to focus on the needs of our children when our own needs are being met. We encourage your involvement in your child's care, but we also encourage taking time for yourself and your family whenever you can.

What Your Child May Look Like After Surgery | When Do We Get To Go Home? | Tips for Parents while in the Hospital | How You Can Help Us | Children's Preoperative Instructions

 How You Can Help Us

1. Provide emotional support for your child. You are who they trust the most. They will likely look to you for reassurance. This is why it is so important for you to be comfortable with your surroundings and with the care we are providing.

2. Assist us in identifying things that may make your child more comfortable. You know your child better than anyone and know what works for them.

3. Encourage your child to cooperate with things that may seem unpleasant, but that are necessary for recovery. (ie. Getting out of bed and walking)

4. Be involved in your child's care. Begin learning early about the care your child will need once you are home. (ie. medcation administration)

What Your Child May Look Like After Surgery | When Do We Get To Go Home? | Tips for Parents while in the Hospital | How You Can Help Us | Children's Preoperative Instructions

 Children's Preoperative Instructions

Pre-Surgery Bath: You will be given a special soap, chlorahexidrine (Cida-stat) to use on your child. This soap is to be used to bathe your child from under the chin down to the toes on the front and the backside. Your child needs this bath the night before surgery and the morning of surgery.

Eating and Drinking: Before surgery, your child will not be allowed to eat or drink anything for several hours. The stomach must be empty before surgery. This may be hard if the child is fussy or is asking for something to drink. Your doctor will tell you when your child needs to stop eating food or drinking liquids, milk, and formula.

Medications: If your child is on medications, the doctor will tell you when to stop the medcation.

Don't forget to bring your child's favorite toys/stuffed animals to the hospital.

If your child becomes ill, has fever, a cough or runny nose, please notify Brenda Cabaza immedately - 210-562-5378 or 210-567-5617.

When you and your child come to the hospital, you will report to the Children's Outpatient Surgery department (COPS) on the 1st floor.

If you have any questions, please call Brenda Cabaza, nurse for the Pediatric Heart Surgery program, Thoracic Surgery Department, 210-562-5378, or 567-5617.

Children's Outpatient Surgery phone number is 704-2587.