Rehabilitation Perioperative Cardiac Surgery

Deddy Tedjasukmana1
1
Department of Physical Medicine and Rehabilitation, Dr. Cipto Mangunkusumo Hospital,
University of Indonesia, Jakarta, Indonesia

Keyword: Rehabilitation, Cardiac Rehabilitation, Perioperative, Cardiac Surgery

Abstract: Cardiac rehabilitation is a multidisciplinary program of exercise program, education, risk factor
modification, and psychosocial counseling resulted in reduces mortality and hospital stay, improves quality
of life in patients with heart disease. In Indonesia, 1.5% Indonesian suffer from coronary heart disease and
approximately one million of patients worldwide underwent revascularization program every year.
Perioperative cardiac rehabilitation helps patients to overcome the stress of surgery, prevention of
complication caused by prolonged bed rest. It also promotes physical and psychological readiness for
surgery, reduces length of stay, and improves the transition from the hospital to the community. In most
current guidelines of cardiovascular societies, cardiac rehabilitation is a class I recommendation.

1 INTRODUCTION social support that was given. Initiation of cardiac

rehabilitation program for patients underwent
National Heart Lung and Blood Institute (NHBI) cardiac surgery should start as soon as possible after
defined coronary heart disease as a condition caused patient condition was stabilized (Tedjasukmana and
by the buildup of plaque in the arteries that supply Putra, 2016) .
oxygen-rich blood to the heart (National Heart Lung
dan Blood Institute, 2012). In Indonesia, 1.5%
Indonesian suffer from coronary heart disease. 2 DISCUSSION
According to Survey Sample Registration System in
2014, deaths due to coronary heart disease were Cardiac rehabilitation is a multidisciplinary program
accounted for 12.9%. The highest prevalence of of exercise program, education, risk factor
heart disease in Indonesia is at the age of 75 years modification, and psychosocial counseling that
old (Kementrian Kesehatan RI, 2018). reduces mortality and hospital stay, improves quality
Approximately one million of patient worldwide of life in patients with heart disease (Beatty et al,
underwent revascularization program every year, 2017). The first objective of cardiac rehabilitation is
with the distribution between operation and to improve regular physical activities and control the
catheterization almost equal. Recent reports suggest modifiable risk factors (smoking cessation, blood
that more than half of cardiac surgeries are being pressure, diabetes, cholesterol). Another objective is
performed on older adults who are more likely to be therapeutic education that emphasizes the
frail and have multiple comorbidities. Cardiac importance of the healthy lifestyle. Lastly, helping
surgery has been shown to improve the outcomes of manage psychosocial and professional problems of
these patients (Kehler DS et al, 2017). the cardiac patients because depression is quite
The recovery period for each individual was frequent following after coronary events. Thus,
affected by age, gender, premorbidity status and depression was associated with lower exercise
operation technique. The recovery period varied capacity, fatigue, reduced quality of life and sense of
from a few days to weeks caused by clinical and wellbeing (Mampuya, 2012). Cardiac rehabilitation
nonclinical effect from cardiac surgery. At the are consist of breathing exercises, early
beginning of postoperative period, depression is mobilization, and strength exercises. Research
more likely to develop, but as time goes, depression conducted by Maines et al, showed that exercise
rate will be lower due to the recovery process and therapy improves exercise capacity by around 16%.

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Tedjasukmana, D.
Rehabilitation Perioperative Cardiac Surgery.
DOI: 10.5220/0009087401680171
In Proceedings of the 11th National Congress and the 18th Annual Scientific Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI
2019), pages 168-171
ISBN: 978-989-758-409-1
Copyright c 2020 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
 Rehabilitation Perioperative Cardiac Surgery

The improved exercise capacity will lower the reduces skeletal muscle fatigability, improve skeletal
mortality by 12% for every one metabolic equivalent muscle metabolism, increase blood flow within the
improvement. In addition, regular exercise decreases active muscles, and reduce dependence on anaerobic
mortality by 28% which is associated with metabolism. Exercise also has some other benefits
improvements in quality of life (QoL) (Seo et al, such as lessen the intensity of breathing and muscle
2017). discomfort, improve quality of life, attenuate or
reverse skeletal muscle atrophy and increase
2.1 Cardiac Rehabilitation endothelium activation. Therefore, it believes that
Perioperative exercise training prolongs exercise duration, lowers
cardiovascular demand, lowers ventilator
Cardiac rehabilitation perioperative consist of requirement, allows higher exercise intensity, and
preoperative, intraoperative and postoperative. reduces symptoms of dyspnoea and leg discomfort.
Prehabilitation helps patients to overcome the stress This is in turns lead to increase independence and
of surgery by improving functional capacity. improvement in general sense of
Preoperative exercise decreases sympathetic wellbeing(Mampuya, 2012; Priscila et al, 2017;
overreactivity, improves insulin sensitivity, and Price et al, 2016; Seo et al, 2017).
increases the ratio of lean body mass to body fat. It
also promotes physical and psychological readiness 2.3 The Role Of Cardiac Rehabilitation
for surgery, reduces postoperative complications and
length of stay, and improves the transition from the In most current guidelines of cardiovascular
hospital to the community. Patient who were given societies worldwide, cardiac rehabilitation is a class
education regarding postoperative mobilization I recommendation. (Tedjasukmana and Putra, 2016).
before surgery will respond more positively and Coronary artery bypass grafting (CABG) is a
enthusiastically to the program (Kementrian procedure which artery or vein are use as graft to
Kesehatan RI, 2018). revive the coronary artery (bypass) which is
occluded partially or totally caused by
2.2 Cardiac Rehabilitation After atherosclerotic process. The procedure explain as
Surgery making a new route around the occluded coronary
arteries with the aim of expediting blood flow so the
After the surgery was perform, there is no place for intake of oxygen and nutrients to the myocardium is
“bedrest” in the management of patient with maintained. CABG usually uses saphena veins or
cardiovascular disease. Early mobilization of patient internal mammary veins, in addition to the radial
after cardiac surgery shown to be beneficial for arteries and gastroiliac arteries although its rarely
patient’s recovery. Initiating physical activity in the use (Tedjasukmana and Putra, 2016).
early period after cardiac surgery, especially walking CABG usually needs an in-hospital stay for a
exercise is recommended since it can prevent week and, after discharge, patients usually need a 2-
complications. Phase 1 begins after the patient has to 6-week recovery period, necessary to recover and
been considered clinically compensated due to the adapt to daily activities, including return to work. A
optimization of the clinical treatment and/or the use significant proportion of patients need to overcome
of an interventional procedure. In this phase, a some problems, like heart failure, anemia, atrial
combination of low-intensity physical exercise is fibrillation, pulmonary abnormalities, and
indicated as well as stress management techniques, thoracotomy- and saphenectomy-related pain.
and education in relation to risk factors. The Cardiac rehabilitation is important considering the
duration of this phase has decreased in recent years, facts that patient’s need to achieve a full and prompt
due to shorter hospitalizations (Alexiey et al, 2017; physical recovery to allow a fast adaptation of daily
Priscila et al, 2017). life activities (including return to work), the need of
Cardiac rehabilitation contributes to the healthy lifestyle and specific pharmacological
prevention of lung complication and decondition regime for a lifetime (Mendes, 2016; Tedjasukmana
caused by prolonged bedrest after cardiac surgery. and Putra, 2016; Priscila et al, 2017).
Exercise-based cardiac rehabilitation decreases
hospital stay, speeds returns to work and reduces
costs in public health. Exercise training can partially
reverse activation of the neurohormonal system and
reduce levels of pro-inflammatory cytokines,

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KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientific Meeting of Indonesian Physical
Medicine and Rehabilitation Association

2.4 Cardiac Rehabilitation Program

There is no differences perioperative cardiac than 30 times/minutes. Walking is the most
rehabilitation program between patients underwent recommended exercise for postoperative program,
coronary artery bypass graft and valve cardiac where the post CABG as well as post valve surgey
surgery. Exercise training before preoperative are have several characteristic which need special
(Tedjasukmana and Putra, 2016) : attentions to the range of motion (Tedjasukmana and
• Breathing exercise, consist of deep breathing Putra, 2016).
and diaphragm breathing 10 times each After the operation, exercise recommendations
• Incentive spirometry exercise and effective for patient are (Tedjasukmana and Putra, 2016):
cough • Breathing exercise and pulmonary expansion
• Mobilization of neck and shoulder along with • Cough exercises
chest extension • Range of motion exercise for upper and lower
• Streching exercise of extremity extremity
• Shoulder muscle exercise for flexion and • Spirometry
extension • Mobilization exercises as recommendation
Postoperative patient can begin cardiac shown in table 2.
rehabilitation sooner which resulted in faster According to Krusen’s Handbook of Physical
recovery. The exercise focus on flexibility Medicine and Rehabilitation (1990), rehabilitation
prioritizing the upper limb. During exercise, for postoperative cardiac surgery shown in table 2.
symptom of stenosis or occlusion need to be Patients who have undergone cardiac surgery are
evaluated. The limitations during exercise are borg recommended to avoid strenuous upper extremity
scale and resting heart rate which increases more exercise until the wound is stable (Seo et al, 2017).

Figure 1: Rehabilitation Postoperative Cardiac Surgery

STEP POD NURSING OCCUPATIONAL PHYSICAL EDUCATION

ACTIVITY THERAPY ACTIVITIES THERAPY
ACTIVITIES
I 1 Up in chair Introduce self and program Introduce self and Cardiac
program Rehabilitation
II 2 Self-feeding Lifestyle assessment Walking short Risk factor
Bedside Work simplification distances, active
commode Energy conservation assisted range of
Walking short motion, or 1-3 MET
distances calisthenics
III 3 Walk in hall 3x Activity precautions Walk in hall x3 METs level
Bathroom Pulse monitoring 1-4 MET lv
privileges Smoking cessation calisthenics
Partial self-bath
in bed
IV 4 Walk ad lib ADLs and METS Walking ad lib Phase II
Partial self-bath Smoking cessation 2-4 MET lv
Out of bed 3-4 calisthenics
hours
V 5 Walk ad lib Relaxation training Walk ad lib Discharge
Increasing Smoking cessation 3-5 MET lv planning
distances Work equivalents as calisthenics
appropriate Stair climbing

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 Rehabilitation Perioperative Cardiac Surgery

3 CONCLUSIONS Cardiac rehabilitation is a multidisciplinary program

of exercise program, education, risk factor
modification, and psychosocial counselling that Priscila A, Kondo NN, Guillermo M., et al. 2017. Physical
reduces mortality and hospital stay, improves quality Training Programs After Coronary Artery Bypass
of life in patients with heart disease. Cardiac Grafting. Intech open science; pp 149-162.
rehabilitation perioperative consist of preoperative, Price KJ, Gordon BA, Bird SR., et al. 2016. A Review of
Guidelines for Cardiac Rehabilitation Exercise
intraoperative and postoperative phase. The
Programs: Is There an International Consensus.
programs of cardiac rehabilitation are breathing European Journal of Preventive Cardiology 23 (16),
exercises, early mobilization, and strength exercises. pp 1715-33.
Prehabilitation helps patients to overcome the stress Seo GY, Jang MJ, Park WH., et al. 2017. Inpatient
of surgery and reduces postoperative complications. Cardiac Rehabilitation Programs’ Exercise Therapy
Initiating physical activity in the early period after for Patients Undergoing Cardiac Surgery: National
cardiac surgery shown to be beneficial for patient’s Korean Questionnare Survey. Journal of Exercise
recovery. Phase 1 begins after the patient has been Rehabilitation; 13(1), pp 76-83.
considered clinically compensated due to the
optimization of the clinical treatment and/or the use
of an interventional procedure. Patients who have
undergone cardiac surgery are recommended to
avoid strenuous upper extremity exercise until the
wound is stable. In most current guidelines of
cardiovascular societies, cardiac rehabilitation is a
class I recommendation.

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