Cardiac Surgery Flashcards
What is the most common incision used for cardiac surgery?
Median sternotomy: Sternal saw cuts through sternum then a rib spreader is used, sternum closed with wires
What are chest drains used for post surgery?
To drain fluid and air from the mediastinum
When are chest drains removed?
Generally after 24 hours (better outcomes if removed in first 24 hours)
What can result if chest drains are left in for too long?
- Mechanical irritation of pericardium
- Infection
- Pain/discomfort
- Less able to mobilise due to pain - muscle wasting
What are the key safety points for handling chest drains?
- 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
What are some of the common cardiac procedures?
- Coronary artery bypass graft (CAG, CABG)
- Valve repair/replacement (AVR, MVR)
- Repair of congenital defect
- Heart transplantation
What is an alternative to CABG surgery that is becoming more common?
Percutaneous coronary intervention (PCI)
- Patient is awake
- Wires inserted into arteries to clear blockages
How does surgical management compare to conservative in cardiac illnesses?
Surgical results generally better than conservative for some conditions
What are the functions of a heart-lung machine (cardiopulmonary bypass machine)?
- Receives blood
- Adds O2
- Eliminates CO2
- Controls body temperature
- Returns blood under pressure & flow
What are the consequences of a heart lung machine?
- 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)
What is one of the risks of cannulation?
- Clamps arteries shut, causing a blood clot
- When released, can release the blood clot
What is the risk of a LIMA (left internal mammary artery) harvest?
- Proximity of phrenic nerve
- 2-10% diaphragmatic paralysis
What are the CABG graft sites?
- Aorta
- Right coronary artery
- Left anterior descending coronary artery
- Circumflex coronary artery
- Left main coronary artery
What are the two most common CABG graft harvest sites?
- Saphenous vein graft (SVG) - 25-50% functional 10 years post
- Left internal mammary artery (LIMA) - 90% functional 10 years post
What occurs at the conclusion of open heart surgery?
- Sternal closure
- Routine ventilation 4-8 hours
- Multiple drain tubes
- Temporary pacing wires
What are the possible complications of cardiac surgery?
- PPC
- Infections (wound, UTI)
- DVT
- Haemorrhage
- Renal failure
- Ventricular dysfunction
- AMI
- Cardiac tamponade
- Abnormal BP
- Cardiac arrhythmias
- Cerebral complications
- Musculoskeletal problems
What are the operative risk factors?
- Obesity
- Diabetes
- Smoking
- Pre-existing lung disease (restrictive/obstructive)
- Osteoporosis
- Increased age
- Co-morbidities (renal failure, malnourished, unwell)
How can cardiac surgery affect the pulmonary system?
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
What has physio management of cardiac surgery patients traditionally focused on?
Prevention of PPCs
What are the musculoskeletal complications of cardiac surgery?
- 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
What are the possible reasons for MS complications?
- Sternal retraction
- Dissection of IMA
- IJV cannulisation
- Patient position
- Devascularisation of sternum
What are some of the questions that should be asked in the pre-op subjective Ax?
- 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
What does post-op respiratory care involve?
- Positioning (high sit is best)
- Mobilisation
- TE techniques
- FET/coughing with wound support
- PEP devices
- ACBT
- CPAP
- Humidification if indicated
What does post-op MS care involve?
- Reinforce sternal precautions
- Assessment, monitoring, management of sternum
- Thoracic/shoulder ROM
What generally happens day 0 post op?
- Extubated within 10-12 hours (breathing tube removed)
- No physio
What generally happens day 1 post op?
- SOOB
- Physio chest Rx if indicated
- Transfer to ward
- Mobilise with physios
- Remind patient of sternal precautions
What generally happens day 2 post op?
- Removal of pacing wires
- Mobilise
- Further chest Rx
- Encourage SOOB all day
- Independent mobilisation if possible
- Introduce UL/thoracic ROM exercises
What generally happens day 3-4 post op?
- Increase independent mobilisation
- May not require physio if managing chest & mobilisation
What generally happens day 5 post op (discharge)?
- Stair check with physio
- Sternal check
- Group education session (sternal precautions, exercise guidelines, ADLs, exercises)
How long does the sternum take to heal post sternotomy?
8-12 weeks
What are some of the symptoms of sternal instability?
- Clicking
- Instability of chest
- Pain & discomfort
What are the risk factors for sternal instability?
- Smoking
- Osteoporosis
- Female with large breasts
- Bilateral IMA harvesting
- PVD
- Prolonged mechanical ventilation
- Higher disability classification
- Obesity
- COPD
- Blood loss
- Resternotomy
- Diabetes
What occurs in sternal instability?
- Separation of sternum at midline
- Due to fracture/disruption of suture line
- Separation may be total or partial
What are the clinical features of early sternal instability?
- Broken/loose wires +/- infection
- Friction, pain, discomfort
- Excessive motion, clicking
- Wire/bone fracture, non-union, skin breakdown, infection
What are the clinical features of late sternal instability?
- Crepitus
- Clicking/clunking
- Pain/muscle guarding
- Disruption of ADL
- Increased morbidity/mortality
- Increased LOS
What is the rationale behind sternal precautions?
Restrict range/load applied to ULs to minimise shearing and/or distraction forces at sternal edges & facilitate bone healing
What activities should be kept to a minimum for 8-12 weeks?
- Activities above head
- Pushing large objects
- Carrying weights > 5kgs
- Heavy manual tasks
- Swimming
What additional sternal precautions are given to patients?
- Perform activities with 2 arms symmetrically
- Avoid heavy activities with one arm
- Ensure good posture
- Safe driving dependent on stable sternum & sound concentration levels
How is sternal instability diagnosed & measured?
- CT scan
- X ray
- Ultrasound (reliable & valid)
- Physical examination (subjective/objective)
What does sternal stability palpation involve?
Palpation of median sternal edge during:
- Deep inspiration
- Cough
- Unilateral/bilateral flexion & abduction of arms
- Lateral flexion of trunk
- Rotation of trunk
What is the standard for sternal stability testing?
- 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
What is the scale used for grading sternal instability?
0 = Clinically stable (no detectable movement) 1 = Minimal separation (slight increase) 2 = Partial separation (regional, moderate increase) 3 = Complete separation (entire length, marked increase)
What is the management for sternal dehiscence & instability?
- Exercise & activity modification guidelines
- Ortho stabilisation devices (brace)
- Surgery (parasternal weaving, pec muscle advancement)
