Chapter Eight - PT Management of the Surgical Patient: Complications Flashcards
What are some common cardiovascular post-op complications? What are the implications for PT?
Post‐operative Complications
Cardiovascular
Arrhythmias
Hyper/Hypotension:
- Hypotension: not enough pressure = the highest place to get pressure is your brain, so your system would not have adequate blood supply. Not enough to get you conscious or your muscles need more oxygen than they are getting.
- Hypertension: the heart has to push blood against a harder resistance, so if you’re having a heart attack, that is not a good situation for the heart. That is why we take blood pressure before mobilizing a patient post-op, to avoid complications due to an abnormal blood pressure
Myocardial infarction (heart attack)
Thrombosis
Pericarditis
Pericardial effusion
Implications:
How much activity is safe for the patient?
Post-heart attack: usually there are hospital protocoles
Gradual mobilization
What is thrombosis? What are the implications for PT?
Thrombosis: blood clot. Implications for PT: part of the clot could detach, travel elsewhere, through the circulation, and move to the pulmonary or cerebral circulation (pulmonary embolus or stroke)
We wait until they are anticoagulated before we mobilize the patient
What is DVT? What are the signs and symptoms?
Deep Vein Thrombosis (DVT)
Blood clot in the deep veins of the body
Typically in the legs (Always be aware of this in the hospital situation)
Signs and Symptoms
Leg swelling, warmth, pain, redness Usually calf
Usually unilateral
(Not always present)
Homan’s sign is unreliable (Pain during dorsiflexion with extended knee, but no longer reliable)
What are the risk factors associated with DVT?
Deep Vein Thrombosis (DVT)
Risk Factors
Surgery (put on anticoagulants during surgery, often)
Prolonged bed rest and immobility
History of previous venous thromboembolism
Oral contraceptives
Hormone replacement therapy
Pregnancy or post‐partum
Heart failure (blood not pumped out as briskly, so the chances of it coagulating is higher)
Stroke with hemiplegia
> 65 years old
Inflammatory bowel disease
Some types of cancer
*Hemiplegia: when one side of your body is paralyzed, so you don’t have the muscle pump moving the blood around
What is the diagnosis process for DVT?
Diagnosis (Series of events: we would be involved in the clinical suspicion)
Clinical suspicion (Wells score)
D‐dimer test (abN (abnormally) high levels of blood protein fragments) > 500 ng/ml (not to remember)
Ultrasound of the leg vessels (Based on these previous tests, used to visualize the veins)
What are the treatments for DVT?
Anti‐coagulants (3‐6 months)
Heparin: unfractionated heparin (constant infusion) (intraveinous = less expensive)
low molecular weight heparin (od or bid injection) (much simpler)
Oral agents:
rivaroxaban or apixaban (Direct oral anticoagulants [DOAC]) fairly new, they are expensive
Warfarin (Coumadin) (rat poison: cheaper
*Coumadin is volatile: if you change your diet, that changes your clotting time, so you don’t want to be too anticoagulated (bleed out), and you don’t want to be undercoagulated (clotting)
What are some pulmonary post-op complications? What can it lead to?
Post‐operative Complications
Pulmonary
Atelectasis
Retained secretions
Pneumonia
Pleural effusions
Pneumothorax Ex: can promote atelectasis, or the patient would have a chest tube, etc…
Pulmonary embolism
Pulmonary edema
What is a pneumothorax? What are its S&S?
Pneumothorax
Air in the pleural space Collapse of the lung
S&S of an Untreated Pneumothorax
Chest pain and shortness of breath
Rapid heart rate, respiratory rate
Cough
Subcutaneous Emphysema (+/‐)
Spontaneous pneumothorax is common in tall, skinny, young men: sudden pain, and get short of breath. Can be small, but it is still a pneumothorax. Depending on its size, it can compress the heart
The lung has blood vessels in it, which is healthy, so it will look a bit white on an x-ray. If it looks blacker, then that is a pneumothorax
We know that minute ventilation = tidal volume and respiratory rate. In the vascular system it is exactly the same thing. Cardiac input: stroke volume and heart rate. So when we compress the heart it can fill with blood and give us a good stroke volume, so the heart rate will go up.
What could an untreated pneumothorax possibly lead to?
Subcutaneous Emphysema
What does a pneumothorax look like in an x-ray?
What is a pulmonary embolism (PE)? What is an embolus?
Pulmonary Embolism (PE)
Blockage in one of the pulmonary arteries
Typically caused by blood clots that travel to the lungs
from the legs
Clots block blood flow to the lungs
Can be life‐threatening
We don’t get involved with this person: it’s not creating atelectasis
Embolus: when it breaks off and travels in the pulmonary circulation. It will block blood flow to the lungs. Can be life threatning
What are the S&S of pulmonary embolism?
Pulmonary Embolism (PE)
Signs and Symptoms
Depends on the size of the embolism, amount of lung affected, presence of underlying lung disease
Sudden SOB, worse with exertion
Chest pain/angina, not relieved by rest
Cough (+/‐ bloody or blood streaked sputum
Leg pain and/or swelling
Tachycardia, cyanosis, lightheaded, dizzy, xs sweating
* Lung tissue may become ischemic and die
What are the risk factors associated with pulmonary embolism?
Pulmonary Embolism (PE)
Risk Factors
DVT
Surgery
Prolonged bed rest and immobility
History of previous PE or clotting disorder
Supplemental estrogen
Pregnancy
Smoking
Some types of cancer
What is the diagnosis process for pulmonary embolism?
Diagnosis
D‐dimer test (abN high levels of blood protein fragments)
Ultrasound of the leg vessels
CT scan of the lung
What are the types of respiratory failure? How are they named?
Lung failure = type 1
Pump failure = type 2
Remember that either something goes wrong with the lungs, or with the heart, or sometimes even both. Type 1 and type 2 = not the most important part
What indicates hypoxemic respiratory failure? What can induce it?
Hypoxemic Respiratory Failure
PaO2< 60 mm Hg
Anatomical shunt: opening between the left and right side of the heart: blood comes into the right ventricle and goes into the left ventricle without being ventilated. Decreased blood oxygen: need for shunt
What indicates hypercapnic respiratory failure? What can induce it?
Hypercapnic Respiratory Failure
PaCO2> 45 mm Hg
(+/‐ hypoxemia)
What is the treatment for respiratory failure?
Treatment
Treat the underlying cause
Supplemental oxygen
variety of delivery devices
Enhance ventilation (mechanical ventilator)
invasive: endotracheal or tracheostomy tube
non‐invasive (NIV): mask ventilation (having tubes in your throat brings to a number of complication, + positive pressure working with your inspiration muscles)
*** IMPORTANT: Fraction of inspired oxygen: 21% (partial pressure of O2 in the air) WE HAVE TO KNOW THIS
What are the main complications associated with surgical patients? What is the significance to PT regarding them?
Complications Associated with Surgical Patients
(Any patient in the in/outpatient setting):
1) Deep Vein Thrombosis (potentially life threatening)
2) Pulmonary Embolism* (potentially life threatening)
Both of these ^ Significance to PT = awareness and reporting and activity restriction until effective anticoagulation
3) Respiratory Failure
Lung Failure
Pump Failure
For this one ^ Significance to PT = reduce V/Q mismatch and enhance respiratory muscle function, with or without activity
