Cardiac Surgery Flashcards
Open Heart Surgery
Indications
- coronary heart disease
- valvular disease
- congenital defects
Procedure
‘median sternotomy’ - sternum is split down the middle and spread open
- both lungs completely deflated
- post surgery sub-costal catheters and sternum wired back together
Can be off pump or use cardio pulmonary bypass
Coronary Artery Bypass Graft
form of OHS
- blockage in coronary artery, use another artery/vein from somewhere else in the body to form separate blood flow route around the blockage
- new vessels also susceptible to blockage - need to modify lifestyle
surgery can last 3-4 hours and be in hospital for 5-7 days
Cardiopulmonary Bypass
during surgery - blood removed from heart and oxygenated by machine, removed from IVC/SVC and returned via the aorta
aorta is cross clamped to prevent backflow
myocardium cooled and covered in cardioplegic gel to reduced metabolsim
max time before starts to become dangerous = 3 hours
Off Pump Cardiac Surgery
heart continues to beat
for high risk patients who can’t have their heart stopped
quicker recovery/ reduced LOS hospital
more difficult procedure
Heart Valve Replacement
replacement of a disease heart valves typically OHS with CPB
either replaced with mechanical valve or tissue
mechanical - lasts longer but increased risk of clotting
natural tissue - either from cadaver or animal
- need to be replaced every 5-10 years
Pacing Box
attachment post OHS
patient either fully dependent or its just a precaution
after being stopped for so long can be difficult for heart to regain normal rhythm
maintains normal heart rate and rhythm
need to be aware of how reliant they are on it - if completely dependent, need to take extra caution with treatment as box CANNOT become unplugged
Underwater Seal Drain with ICC/SCC - DO
- take not of content of bottle prior to mobilisation, if there is any excessive change with mobilisation need to stop and get medical staff
- pay attention to swinging, if stops need to stop activity and check tube, notify medical staff
- pay attention to bubbling, if changes with treatment need to stop activity and get medical staff
- pay attention to quality and quantity of draining, if changes drastically need to stop treatment and seek medical attention
- if drain falls out, initiate emergency response
Swinging USD with ICC/SCC
fluid should move towards and away from the patient’s chest as they breathe in and out
if swinging stops - means potential blockage in teh tube
Bubbling USD with ICC/SCC
if present in the bottle means patient has a persistent air leak in their chest
any drastic change with treatment - need to stop and seek medical assistance
Draining USD with ICC/SCC
need to be aware of what is being drained
if contents change during treatment, amount increases significantly or stops, need to stop and seek medical assistance
Underwater Seal Drain with ICC/SCC - DON’T
- raise bucket above point of insert into chest without clamping tubing
- never clamp tubing for extended periods of time
- don’t ignore changes in swinging, bubbling and draining
- don’t knock the bucket over
Cardiovascular Implications Post Op
reduced FRC
phrenic nerve paralysis
reduced chest wall compliance from sternotomy
reduced chest wall stability from sternotomy
usual GA side effects
blood loss/transfusions
electrolyte imbalance
increased troponin and inflammatory markers
may have cardiac shock
Potential Post-Op Complications
DVT stroke tamponade - fluid fills space between heart and pericardium intra operative MI reduced cardiac output atrial fibrillation altered blood pressure lower lobe collapse pleural effusion pleural infection pulmonary oedema pneumothorax/haemothorax wound infection intellectual impairments renal impairment
Physio Management - Prehabilitation
aims to reduced PPC and improve QoL post op
- screen for risk factors
- educate expectations post op
- pre op exercise and breathing exercises
Physio Management - Clinical Implications
pain
reduced lung volumes
impaired gas exchange
musculoskeletal dysfunction
Physio Managment - Intervention
Pain
- educate use PCA
- supported cough/huff
- time interventions around analgesia
- advocate for the patient with other staff
Reduced Lung Volumes
- mobilise early
- upright sitting - advice on avoiding bed rest and staying upright in chair as much as possible
- TEEs/DBExs
Impaired Gas Exchange
- optimise O2
- appropriate positioning
- mobilise
Musculoskeletal Dysfunction
- thoracic, cervical, and shoulder exercises
- take caution with sternal healing
Sternal Stability
AVOID
- reaching overhead with one arm
- pushing large heavy objects
- carrying weight greater than 1kg per post op week
- heavy manual tasks
- sporting activity that use on side of the body at a time
- exercise with arm weight
Exercise Prescription
Frequency - 3-4 times a day for first 1-3 days
- twice a day from day 4 onwards
Intensity - RPE <13, resting HR + 30bpm
Type - preferably walking, gentle UL, thoracic and neck mobility exercises, DBExs, supported coughing
Time - intermittent 3-5 minute intervals
rest for 1-2 mins, always shorter than exercise duration
Progression - 15 mins continuous exercise, increase intensity
Discharge
progression to 3-4 walks a day
participation in in-patient gym exercise class
Stair Test - able to walk up 1-2 flights of stair and have normal physiological response
HEP
education
referral to cardiac rehab program
Effects GA
reduced ventilatory drive - results in reduced tidal volume and respiratory drive, can cause atelactasis
reduced FRC from long term supine position
impaired MCC from drying effect of oxygenation
Phrenic nerve depression - reduced respiratory muscle function
reduced chemoreceptor sensitivity - reduced response to low oxygen, results in hypoxaemia
ventilation - causes slow, rhythmical breathing pattern, result in no sigh
