Chapter Seven - Physiotherapy Management of the Surgical Patient

Question 1

Name four common cardiovascular surgical procedures by their acronyms, and say what it means.

Answer 1

Surgical Procedures

1. Cardiovascular

 CABG, PCI, AVR, MVR

‘Cabbage’: coronary artery bipass grafting

Percutaneous coronary intervention

Aortic valve replacement

Mitral valve replacement

Question 2

Name four common thoracic surgical procedures.

Answer 2

Surgical Procedures

2. Thoracic

 Lobectomy, Pneumonectomy, Thoracic Aortic Aneurysm Repair, LVRS

*wedge resection (compared to lobectomy): take out a small piece of the lung

AAA: abdominal aortic aneurysm

LVRS: lung volume reduction surgery = in COPD, parts of the lung become very useless because of V/Q mismatch, so they are ventilated without good blood supply, so you take those out (we will see this in second semester)

Question 3

Name two common peripheral vascular surgical procedures.

Answer 3

3. Peripheral vascular

 Peripheral Artery Bypass Graft, Amputations

Question 4

Name and explain five common general surgical procedures.

Answer 4

4. General

Resections

Transplants

Whipple -> Resection of part of the pancreas or liver

Nissan’s fundoplication -> Resection of part of the esophagus and wrapping it around the stomach

Sugarbaker’s procedure -> Take a body part and dip it in chemotherapy

Question 5

Name five common orthopedic surgical procedures.

Answer 5

3. Orthopedic
    THA, TKA, fractures, meniscus and ligament repairs

Total hip arthroplasty (replacement)

Total knee arthroplasty

* Orthopedic: we probably won’t see them for cardiopulmonary reasons, but as general physios yes

Question 6

Name the three thoracic incisions and where they are.

Answer 6

Thoracotomy (side), median sternotomy (sternum), clam shell (underboobs),

Question 7

Which thoracic incision is the most common for lung resection? Is it invasive?

Answer 7

This incision will induce pain, but… most common approach used on lung resection, we disrupt a lot of the muscles of the chest wall and shoulder complex

We can get away without it, using scopes

Question 8

What is a thoracotomy used for?

Answer 8

Most common approach used on lung resection

Question 9

What is a VATS? What does it allow to avoid? What is laparoscopic surgery?

Answer 9

VATS: Video‐Assisted Thoracoscopic Surgery

Avoids doing a thoracotomy.

Laproscopic surgery: similar as this, the three ports are in the abdomen

Question 10

What is a hemothorax? Where and how do you set up a chest tube? How can you enhance the drainage?

Answer 10

Hemothorax: blood in the pleural space

Attach chest tube to patient with a suture and some tape, then attach a drainage pump system to that tube, that also allows you to measure the volume of drained fluid and notice when it stops draining

You can increase the negative pressure and enhance the drainage

The function of the chest tube depends on the situation

Question 11

What are the functions of a chest tube drainage set?

Answer 11

Chest Tube Drainage Set

 Drain fluid or Air
 Quantify the amount of fluid drained

 Verify air leaks

Do not lift the chest tube above the level of the chest, especially if there is no suction (favorite thing to look at in an OSCE), don’t lower the bed on the chest tube, don’t sit on it

Question 12

Why would a chest tube create discomfort?

Answer 12

Pretty wide tube, in the pleural space, so it will create discomfort

Question 13

How and why would you use a median sternotomy?

Answer 13

Saw the chest open, crank it open with clamps, allows a good visualization for the heart, then you wire it shut

Question 14

Which incision would you use to get a good visualization of the heart?

Answer 14

Median sternotomy

Question 15

When would you use a clam shell incision?

Answer 15

Bilateral lung or heart/lung transplant

Question 16

Which incision would you use for a bilateral lung or heart/lung transplant

Answer 16

Clam shell incision

Question 17

What Puts Patients at Risk of Post‐op Pulmonary Complications?

Answer 17

Pre-op factors: pre-existing co-morbitities, smoking, age

Intra-op factors: intra-operative positioning, anaesthesia, mechanical ventilation

Ex: an arm dangling out of the table for 4 hours

Post-op factors: dehydration, pain, decreased mobility

Students: Pain, Non-sterile conditions, Comorbidities (ex: diabetes impacts healing, obesity: adipous tissue, restricting lung disease, they may start of with atelectasis, high blood pressure), Older age: lung function deteriorates with age, they tend to start off not as good, Smoking: damaged cilia, mucus/fluid clearance is impaired to begin with, may have COPD already

Question 18

What are the two main effects that are caused by anesthesia? For the second effect, give some examples. What is the position of cardiothoracic surgery? How can it affect consent? What are the factors that make you more or less affected by anesthesia? What does it do that positive pressure is used to push air into the lungs?

Answer 18

It is a drug and has many many effects, particularly in older people

Neurocognitive Disorders

Pulmonary Effects:

 Alters control of ventilation
 Rapid, shallow breathing (promotes atelectasis)
 Eliminates sighs (we take about 10 an hour, normally) (Sighing is helpful to replenish your surfactant, without it: atelectasis)
 ↓ response to hypercarbia, hypoxemia

 Decreases FRC and RV (affects your muscle tone)
 Decreases diaphragm movement  Changes bronchomotor tone
 Promotes V/Q mismatch
 Impairs ciliary clearance

** Cardiothoracic position for surgery: on your back, not ideal for your breathing, and you are on a ventilator (lifesaving but painful)

It can make people confused, delirious, combative, and that makes our job difficult because we can’t do anything without consent

Depending on your lung/general health, and on the duration of the procedure, will determine the important of the effect of anaesthesia

Lying supine, ventilated, mechanical ventilator = positive pressure (like a big pump), we squeeze the air in there

This positive pressure tends to preferentiate the NON-dependent areas, unlike with negative pressure, and the majority of your lung tissues are posteriorly (supine), so dependent. This affects the V/Q mismatch, because the air goes into the non-dependent areas, which causes a lot of atelectasis in the lower lobes

Question 19

What are some common pulmonary Postoperative Complications?

Answer 19

Atelectasis
Pleural effusions
Retained secretions
Pneumonia
Pneumothorax
Pulmonary edema
Pulmonary embolism
Respiratory failure뺭

Question 20

What are some common cardiovascular postop compliations?

Answer 20

Arrhythmias
Hyper/hypotension
Thrombosis
Pericarditis
Pericardial effusion
Myocardial infarction

Question 21

What are some common neurological postop complications?

Answer 21

Neurological
 Stroke
 Spinal cord ischemia

 Neuropraxia
 Delirium

Question 22

What are some common orthopedic postop complications?

Answer 22

 Loss of range of motion

 MSK pain
 Postural changes
 Muscle atrophy

Question 23

What are some common postop places where patients can go to recover?

Answer 23

Question 24

What is the Role of Physiotherapy Across the Surgical Continuum? What do you have to do to be eligible for a lung transplant?

Answer 24

These things will inform our discharge plan:

Pre‐operative (Pre-op clinic/prehab)

* 12 weeks exercise-education program to be ELIGIBLE for a lung transplant!!!

 Risk factor reduction

 Baseline status (What the person was like before surgery)
 Education (Reassure them, help them understand what they can do to improve their recovery after surgery)

Post‐operative

 Intra‐operative report

 Assessment
 Treatment

*All of that is for: discharge planning

Question 25

What is the Role of Physiotherapy post-op (with details)?

Answer 25

Post‐operative

 Intra‐operative report
 Blood & Fluid loss, cardiovascular function

 precautions

 Assessment
 LOC, orientation, patient engagement
 IPPA + cough + sputum
 Pain control/pain management

 Timing

 LOC, orientation, cooperation

RR
 Aspiration
 Mobility

 Complications: DVT, pulmonary embolus  Activity (orders)

 Treatment

 Deep breathing

 Sustained Maximal Inspiration (SMI)

 Stacked breathing
 Thoracic expansion exercises
 Incentive spirometry

 Coughing

 Huff

 Incisional support
 Thoracic expansion exercises & U/E range of motion

 Activity

*Do not start with the cough, it can be painful and scary for some people. Also, to cough, you need a deep breath first!

Question 26

What is the definition of collateral ventilation? What is the anatomy behind the concept?

Answer 26

It takes time for air to move through theses spaces, so a sustained deep inspiration can get the air to move into these and treat atelectasis

Question 27

Describe the mobilization progression (one role of physiotherapists). What does BUM stand for?

Answer 27

Question 28

Name some important parts of the environmental awareness, that is part of the mobilization process.

Answer 28

Question 29

What are the key components of discharge planning (one of the roles of physiotherapists)?

Answer 29

Question 30

Read-only: PHYSIOTHERAPY MANAGEMENT OF THE SURGICAL PATIENT (summary)

Answer 30

PHYSIOTHERAPY MANAGEMENT OF THE SURGICAL PATIENT

Summary

Anticipate Risks
Risk reduction: pre‐ & post‐op
Education: patient and their support network

Post‐op: Prevent & Manage Complications

 Assessment
 Neurological

 Pain control

 Pulmonary
 Mobility

 Treatment
 Pulmonary: DB & C
 Progressive Mobility: strength, endurance, ROM