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CI1 > Cardiac Surgery > Flashcards

Cardiac Surgery Flashcards

1
Q

What is the most common incision used for cardiac surgery?

A

Median sternotomy: Sternal saw cuts through sternum then a rib spreader is used, sternum closed with wires

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2
Q

What are chest drains used for post surgery?

A

To drain fluid and air from the mediastinum

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3
Q

When are chest drains removed?

A

Generally after 24 hours (better outcomes if removed in first 24 hours)

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4
Q

What can result if chest drains are left in for too long?

A
  • Mechanical irritation of pericardium
  • Infection
  • Pain/discomfort
  • Less able to mobilise due to pain - muscle wasting
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5
Q

What are the key safety points for handling chest drains?

A
  • Take care when handling patient - keep tube visible
  • Ensure unit is visible to avoid damage
  • Avoid application of positive airway pressure unless indicated
  • Check before disconnecting suction prior to intervention
  • Maintain drain below level of the chest
  • Ensure clamps are available for emergencies
  • Monitor pain associated with drains
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6
Q

What are some of the common cardiac procedures?

A
  • Coronary artery bypass graft (CAG, CABG)
  • Valve repair/replacement (AVR, MVR)
  • Repair of congenital defect
  • Heart transplantation
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7
Q

What is an alternative to CABG surgery that is becoming more common?

A

Percutaneous coronary intervention (PCI)

  • Patient is awake
  • Wires inserted into arteries to clear blockages
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8
Q

How does surgical management compare to conservative in cardiac illnesses?

A

Surgical results generally better than conservative for some conditions

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9
Q

What are the functions of a heart-lung machine (cardiopulmonary bypass machine)?

A
  • Receives blood
  • Adds O2
  • Eliminates CO2
  • Controls body temperature
  • Returns blood under pressure & flow
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10
Q

What are the consequences of a heart lung machine?

A
  • Lungs aren’t fully expanded (risk of PPCs)
  • Non-pulsatile perfusion (abnormal organ blood flow)
  • Activation of inflammatory cascades (hypotension)
  • Blood component factors (bleeding, coagulopathy)
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11
Q

What is one of the risks of cannulation?

A
  • Clamps arteries shut, causing a blood clot

- When released, can release the blood clot

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12
Q

What is the risk of a LIMA (left internal mammary artery) harvest?

A
  • Proximity of phrenic nerve

- 2-10% diaphragmatic paralysis

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13
Q

What are the CABG graft sites?

A
  • Aorta
  • Right coronary artery
  • Left anterior descending coronary artery
  • Circumflex coronary artery
  • Left main coronary artery
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14
Q

What are the two most common CABG graft harvest sites?

A
  • Saphenous vein graft (SVG) - 25-50% functional 10 years post
  • Left internal mammary artery (LIMA) - 90% functional 10 years post
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15
Q

What occurs at the conclusion of open heart surgery?

A
  • Sternal closure
  • Routine ventilation 4-8 hours
  • Multiple drain tubes
  • Temporary pacing wires
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16
Q

What are the possible complications of cardiac surgery?

A
  • PPC
  • Infections (wound, UTI)
  • DVT
  • Haemorrhage
  • Renal failure
  • Ventricular dysfunction
  • AMI
  • Cardiac tamponade
  • Abnormal BP
  • Cardiac arrhythmias
  • Cerebral complications
  • Musculoskeletal problems
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17
Q

What are the operative risk factors?

A
  • Obesity
  • Diabetes
  • Smoking
  • Pre-existing lung disease (restrictive/obstructive)
  • Osteoporosis
  • Increased age
  • Co-morbidities (renal failure, malnourished, unwell)
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18
Q

How can cardiac surgery affect the pulmonary system?

A

Lower lobe atelectasis (mainly left, 30-88% patients)

  • Compression of LLL
  • Cold injury to phrenic nerve

Pulmonary oedema

  • Agressive fluid replacement
  • Consequences of heart lung machine

Pleural effusion (30%, mainly left side)

  • Heart failure
  • Trauma
  • Unknown origin

Pulmonary embolism
Pneumothorax

19
Q

What has physio management of cardiac surgery patients traditionally focused on?

A

Prevention of PPCs

20
Q

What are the musculoskeletal complications of cardiac surgery?

A
  • Brachial plexus injuries
  • Sternal instability
  • Drain site adhesions
  • C/S & T/S dysfunction
  • SC & MS subluxaion
  • Rib fractures
  • Phrenic nerve palsy
  • Scar thickening
  • Chest wall hypersensitivity
  • Deep chest wall pain
  • Paraesthesia
21
Q

What are the possible reasons for MS complications?

A
  • Sternal retraction
  • Dissection of IMA
  • IJV cannulisation
  • Patient position
  • Devascularisation of sternum
22
Q

What are some of the questions that should be asked in the pre-op subjective Ax?

A
  • Mobility/gait aids
  • Home situation
  • MS deformity/dysfunction
  • Type/date of procedure
  • Reason for procedure
  • Previous experience of post op physio
  • Risk factors for PPCs
  • Usual sputum load
  • Language/communication barriers
23
Q

What does post-op respiratory care involve?

A
  • Positioning (high sit is best)
  • Mobilisation
  • TE techniques
  • FET/coughing with wound support
  • PEP devices
  • ACBT
  • CPAP
  • Humidification if indicated
24
Q

What does post-op MS care involve?

A
  • Reinforce sternal precautions
  • Assessment, monitoring, management of sternum
  • Thoracic/shoulder ROM
25
Q

What generally happens day 0 post op?

A
  • Extubated within 10-12 hours (breathing tube removed)

- No physio

26
Q

What generally happens day 1 post op?

A
  • SOOB
  • Physio chest Rx if indicated
  • Transfer to ward
  • Mobilise with physios
  • Remind patient of sternal precautions
27
Q

What generally happens day 2 post op?

A
  • Removal of pacing wires
  • Mobilise
  • Further chest Rx
  • Encourage SOOB all day
  • Independent mobilisation if possible
  • Introduce UL/thoracic ROM exercises
28
Q

What generally happens day 3-4 post op?

A
  • Increase independent mobilisation

- May not require physio if managing chest & mobilisation

29
Q

What generally happens day 5 post op (discharge)?

A
  • Stair check with physio
  • Sternal check
  • Group education session (sternal precautions, exercise guidelines, ADLs, exercises)
30
Q

How long does the sternum take to heal post sternotomy?

A

8-12 weeks

31
Q

What are some of the symptoms of sternal instability?

A
  • Clicking
  • Instability of chest
  • Pain & discomfort
32
Q

What are the risk factors for sternal instability?

A
  • Smoking
  • Osteoporosis
  • Female with large breasts
  • Bilateral IMA harvesting
  • PVD
  • Prolonged mechanical ventilation
  • Higher disability classification
  • Obesity
  • COPD
  • Blood loss
  • Resternotomy
  • Diabetes
33
Q

What occurs in sternal instability?

A
  • Separation of sternum at midline
  • Due to fracture/disruption of suture line
  • Separation may be total or partial
34
Q

What are the clinical features of early sternal instability?

A
  • Broken/loose wires +/- infection
  • Friction, pain, discomfort
  • Excessive motion, clicking
  • Wire/bone fracture, non-union, skin breakdown, infection
35
Q

What are the clinical features of late sternal instability?

A
  • Crepitus
  • Clicking/clunking
  • Pain/muscle guarding
  • Disruption of ADL
  • Increased morbidity/mortality
  • Increased LOS
36
Q

What is the rationale behind sternal precautions?

A

Restrict range/load applied to ULs to minimise shearing and/or distraction forces at sternal edges & facilitate bone healing

37
Q

What activities should be kept to a minimum for 8-12 weeks?

A
  • Activities above head
  • Pushing large objects
  • Carrying weights > 5kgs
  • Heavy manual tasks
  • Swimming
38
Q

What additional sternal precautions are given to patients?

A
  • Perform activities with 2 arms symmetrically
  • Avoid heavy activities with one arm
  • Ensure good posture
  • Safe driving dependent on stable sternum & sound concentration levels
39
Q

How is sternal instability diagnosed & measured?

A
  • CT scan
  • X ray
  • Ultrasound (reliable & valid)
  • Physical examination (subjective/objective)
40
Q

What does sternal stability palpation involve?

A

Palpation of median sternal edge during:

  • Deep inspiration
  • Cough
  • Unilateral/bilateral flexion & abduction of arms
  • Lateral flexion of trunk
  • Rotation of trunk
41
Q

What is the standard for sternal stability testing?

A
  • Record wound appearance
  • Record patient position
  • Record position of fingers
  • Record degree of palpable separation
  • Record extent of excessive motion
  • Eliminate other sources of clicking
  • Relate subjective & objective findings
  • Assign grade that matches findings
42
Q

What is the scale used for grading sternal instability?

A 
0 = Clinically stable (no detectable movement)
1 = Minimal separation (slight increase)
2 = Partial separation (regional, moderate increase)
3 = Complete separation (entire length, marked increase)
43
Q

What is the management for sternal dehiscence & instability?

A
  • Exercise & activity modification guidelines
  • Ortho stabilisation devices (brace)
  • Surgery (parasternal weaving, pec muscle advancement)

CI1 (21 decks)

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