cardiothoracic surgery and organ transplant Flashcards
PTCA and CABG
treat CHD
improve flow of O2 blood to heart
The number of people undergoing CABG has decreased by about a third in the past 10 years, which is linked to the development of drug-eluting stents that are used during PTCA. Drug-eluting stents have a polymer coating that slowly releases a drug over time to help prevent the blockage from recurring.
PTCA is not advisable for everyone with CHD. E.g. people who have triple-vessel disease are recommended to have heart bypass, better survival outcomes for diabetes. Angioplasty is often used for people with less-severe coronary artery disease.
PTCA
percutaneous transluminal coronary angioplasty D/C same day to following day.
Catheter inserted through the groin or the wrist
30 minutes to 2hrs .
CABG
A piece of blood vessel from elsewhere (saphenous vein, radial artery or mammary artery) is used to bypass around the narrowing or blockages in the coronary arteries.
Restores the blood supply to the heart.
Up to 2000 done in Ireland each year (2018).
5 cm incision anteriorly
3 half cm down pt side
D/C at 48 hrs
around 5.5 hours
open CABG sternotomy bypass machine D/C 5-10 days 4-5 hours duration
valve replacement
narrowing - stenosis
leakage - insufficiency or regurgitation of aortic valve or mitral valve
upper and lower chambers of heart
rheumatic fever
degenerative changes
certain systemic illnesses and disease contribute including auto immune disease - arhtritis, infection and kidney failure
congenital defect
aortic valve replacement
TAVR/I versus SAVR
Transcatheter aortic valve implantation versus surgical aortic valve replacement: TAVI reduces the risk of bleeding, atrial fibrillation and AKI, but has a higher incidence of permanent pacemaker implantation.
Need longer term outcomes
transcatheter mitral valve replacement
TMVR vs TAVR
to a preference for an MV repair rather than a replacement, thus contributing to the delay in the evolution of TMVR technology.
TMVR
Surgical mitral valve repair preferred to replacement
Percutaneous repair in high‐risk patients
TAVR
SAVR for aortic regurgitation and for bicuspid anatomy
TAVR in high‐ or intermediate‐risk patients
valve replacement
Mechanical replacement valves are constructed from very durable metals, polymers, and other materials.
Biological tissue valves consist of donated human tissue, animal tissue (pigs, cows) or the patient’s own valve (via the Ross Procedure).
Ross Procedure: In this unique form of aortic valve replacement surgery, the patient’s own pulmonary valve is used to replace the defective aortic valve. Then, the surgeon uses a homograft valve (from a human donor) and inserts it into the pulmonary position.
pre op
baseline Respiratory- sob/cough/sputum/wheeze/pain Smoking history Mobility- aids, distance, stairs Social support UL ROM – Thoracics/sternotomy
post op physio Ax
OP notes What was done? Why was it done? How long did it take? Any intra op events? Any post op instructions?
subjective objective resp Ax ABGs auscultation palpation CVS and vital signs Renal haematology
physio Rx
sternotomy
ACBT if needs airway clearance
Progressive Mobilisation
Education on pain control: supported cough.
Stair assessment
Provision of aids if required
Link with other AHP re discharge planning
Cardiac Rehab 10-12 weeks
Can take 12 weeks for breastbone to heal.
Commonly advised to avoid lifting more than 2 kg for 6 weeks after surgery and then gradually increase
UL AROM- bilateral activities
Driving at 6 weeks
post op pulmonary complications
Respiratory infection
Pneumonia
Pneumothorax
Bronchospasm
Pleural effusion
Respiratory failure
Wound disruption
evidence
Deep breathing and coughing (77%) and incentive spirometry (40%) continue to be widely used, despite literature consistently indicating no benefit in routine CABG patients (Brasher, McClelland, Denehy, and Story, 2003; Crowe and Bradley, 1997; Dull and Dull, 1983; Jenkins et al, 1990; Johnson et al, 1995; Savci et al, 2006; Stiller et al, 1994). Mobilisation was the most frequently implemented intervention (94% of respondents) and has sound evidence indicating benefits to this patient population (Hirschorn et al, 2008).
Philby
thoracic surgery
Wedge resection: removes lung cancer and small portion of healthy tissue
Lobectomy (removal of a lobe) +/- sleeve resection (Surgery to remove a lung tumour in a lobe of the lung and a part of the main bronchus (airway). The ends of the bronchus are rejoined and any remaining lobes are reattached to the bronchus.). Sleeve resections avoid the need for a pneumonectomy, resulting in lesser impact on pulmonary function and thus better quality of life
Pneumonectomy: removal of a lung
Pleurodesis (adhesion of pleurae) and pleurectomy (removal of part of pleura)
Lung cancer is the most frequent indication for surgery
chest drains
Chest drains remove air & fluid substances from the pleural space.
Inserted post cardiothoracic surgery
Always keep below the level of the patient.
Patients can be disconnected from suction for mobilisation (communicate with the team)
If the patient is not to be disconnected from suction, consider bedside exercises
enhanced recovery programme
To release resources to support the change of practice to an ERP a physiotherapy screening tool was developed to assess which patients would be the highest risk for developing PPC’s and which patients were low risk. The criteria patients are assessed against are:
- Has the patient had a thoracotomy?
- Has the patient had lung resection/chest wall/pectus correction or decortication surgery?
- Has the patient got a diagnosed lung disease? e.g., COPD.
- Is the patient a current smoker or stopped in the last 2months?
- Does the patient have a pre-existing mobility problem?
if yes to any Qs
screened pt in post op physio
otherwise pt = low risk - post and pre op info only
non -smoking patient with no history of lung disease
undering a talc pleurodesis for pneomothorax
