CP LEC 5: SURGERY COPY Flashcards
An angioplasty is typically done following what?
Imaging like coronary-angiogram or MRI to confirm the location of the blockage
What is an angioplasty?
Balloon tipped catheter goes through femoral artery or radial artery
goal is to open up closed CAD artery and increase BF by pushing plaque against lumen
If you have an angioplasty what are your exercise precautions?
No vigourous exercise for 5-7 days
After they use the balloon in the angioplasty to push the plaque out of the way, what do they do next?
Put stent in to keep space open
What is the major risk involving angioplasty patients?
Bleeding
Any time we quickly re-establish blood supply the risk of _________ is increased
ventricular arythmias
This risk is present for about a day or 2
What is the problem with stents in coronary angioplasties?
Stents collect plaque and blockage can reappear
Drug eluting stents fix this problem by releasing drugs from the stent that stops blockages from occuring
How do hospitals manage the risk of bleeding for patients with angioplasty+stents
Continous pressure+ice pack for several hours to stop bleeding
Patient comes to you and says “I had an angioplasty 3-4 days ago!” in out patient, what do you say?
😡 GET OUT!!! GET OUT RIGHT NOW!!!!!!!! 😡
What is an arthectomy?
Simular to angioplasty. Now they have a drill that pushes through the plaque. For plaques that are thicker and larger
Note: still a risk of bleeding
True or false: Coronary Artery Bypass graph is a percutaneous surgery
False
Patient’s who have a coronary artery bypass graft have what precautions?
Sternal precautions
What are 3 places that surgeons can source a graft from for a CABG
Internal mammary artery
radial arteries
saphenous vein
NOTE: these locations must also heal before mobilizing patients
What are the complications of a CABG
2-4% of paients have heart attack
-myocardial stunning (low CO, can use inotropic meds or LVAD or balloon pump)
-arythmias, may need temporary pacing
- infection
- bleeding, 30% need blood transfusion after
- PLEURAL EFFUSIONS
- pericardial effusion
The longer the time the patient is on heart machine or under anesthesia….
the more deconditioned their respiratory function may be, and the longer it may take them to become active again
How can myocardial stunnng be managed after a CABG
Left ventricular Assistive Device
Inotropic medications
Intraaortic balloon pump
Pleural effusions occur in __% of patients with a CABG
90%
THIS IS WHY NEED FOR MOBILIZATION IS CRITICAL
the trauma of surgery causes an inflammation response that leads to fluid build up
How long do sternal precautions last? What are the precautions?
6-8weeks
stay in the tube - no lifting arms above the head or behind back, no pushing or pulling or lifting more than 5lbs, avoid excessive heat and cold
If sternal precautions are too restricting what can happen?
frozen shoulder/adhesive capsilitis
when inspecting a patient with sternal precautions surgical scar what should you be on the look out for?
drainage of wound/pus
make sure bandages are clean and dry
Prevent infections! Infections will be catastrophic
Note: they can get gentle scar massage after a couple of days
What is an intra-aortic balloon pump
a balloon inserted in heart used to restore cardiac output during severe HF, post-op cardiac surgery, cardiogenic shock
Typically inserted through femoral artery
Note: can increased CO up to 40%. a rate of 1:1 inflation is considered full assistance
can someone with a femoral intraortic balloon pump be ambulated?
hellllll nawwww
but maybe an axillary one can be ambulated, just maybe
Itra-aortic balloon pump inflates during _____
deflates during _________
inflates during diastole
deflates during systole
what are complications of an IABP?
the balloon goes through the aorta which can block BF to the extremities, so check capillary refill and pulses
can also cause damage to the vessel itself - cause arterial thrombus
What is an impella heart pump?
same precautions and complications as IABP, but it goes into left ventricle and sucks up blood and pushes it into aorta to decrease workload of heart
what is the purpose of percutaneous procedures?
reestablish blood supply!
what is the most commonly replaced valve?
aortic valve
true or false: most of the time physicians seek to repair the mitral valve instead of replace it
true
why? because then they wont need blood thinners for the rest of their life. They would if it was a replacement
the aortic valve cannot be repaired, its replaced by pulmomnary valve
What is the ross procedure?
using pulmonary valve to replace aortic valve
then pulmonary valve is replaced by donor
true or false: tricuspid and mitral valve rarely need to be replaced
true
What are the advantages of a bioproshesis instead of a mechanic valve?
reduces risk of stroke
Only patients with a mechanical valve will need blood thinners for rest of life!
why is it hard/impossible to repair the aortic valve
pressure is too high
what is the purpose of an annuloplasty?
flexible ring placed around mitral valve for support, reinforced annulus
prevents dilation of valve
valve repair procedures are usually done how?
minimally invasive percutaneous procedure where a catheter goes through femoral vein
what is the risk of catheter based valve repair procedures
risk of bleeding
fatigue may be issue
usually patients can go home from hospital after a day or 2
what is “something to think about” when a patient is coming off of a heart/lung machine
fatigue may be issue
True or false: Mitral valve repair typically does better than replacement
True
Also: Patients with repair dont have to use blood thinners for as long
what is the problem with anticoagulation medication for long periods of time?
bleeding
What is a cardiac ablation?
destroys ectopic cells in myocardium that cause arrhythmias
produces scar on myocardium using ablation catheter
typically radiofrequency or cryotherapy
note: very good for a-fib, can be used for v-fib too
What needs to happen before a cardiac ablation procedure
electrophysiological mapping to find the arrythmia
what is a risk of cardiac ablation?
it may end up causing another arrythmia because the inflammation response
Cardiac ablation patients typically need ____ days of rest
4-7 days of rest
what is a pace maker primarily for?
slow rhythm and heart blocks
OR
fast rhythm in UPPER chamber
whats the most important thing to know about a patients pacemaker
what their particular pace maker is for
- always works to maintain regular rate
- only works if rate is below certain amount
- or if they are used stop the atrias from going to fast
what are the 2 kinds of pace makers
Unipolar- one electrode (- at myocardium and + at pacemaker box)
bipolar (Biventricular) - 1 lead on right atrium, 2 at ventricles, (3 total leads)
pacemaker precautions for 4 weeks
no ROM of UE > 90 degrees, it might stretch the incinsion or move the lead
what is an Implantable cardioverter defibrillator for?
Used to correct life threatening arrythmias (designed for fast ventricular arrythmias)
What will you see on an ECG if the patient has a pacemaker?
Pacemaker spikes
if spike is infront of P-wave- the pace maker is working at atria
If spike is infront of QRS- pace maker is working at ventricles
If a patient comes to PT and says theyve recently been shocked by their ICD what do u say
go talk to your physician before PT
What is important to know for a patient with a pacemaker/ICD
Need to know at what heart rate their device is designed to deploy
stay 10-20 BPM below that
Endocardial vs epicardial pace makers
endocardial- inside the right atrium and ventricle via access through a large vein (transvenous)
epicardial- more often used in patients undergoing heart surgery often only used for temporary pacing
If a patient has a surgically placed pace maker what is a common precaution associated with this
no raising arm overhead no contact sports
no lifting more than 10lbs
incinsion is made in pec major and minor
What is a temporary ICD (vest)
patient who has had an MI in the past, there is a risk of arthmyias but as the heart heals the risk of arthymia drops
When looking at a ECG for someone with a pacemaker, what does it mean if you see the pacemaker spike before the p wave?
what about QRS?
Before Pwave- atrial pace maker
before QRS- ventricular pace maker
Abdominal aortic aneurysm repair is indicated for aneurysm’s larger than…
5cm or rapid enlargement or sudden change in characteristic of pain
If a patient get’s an abdominal aortic aneurysm repair where there is a midline incision at the xiphoid process, what is a common precaution youll see?
No thoracic extension 4-6 weeks
What are patients at high risk for following an AAA surgery?
Atelectasis! lung collapse
pulmonary complications because incisional pain limits inspiration
If a patient has an abdominal aortic aneurysm repair, what does PT need to teach them?
bronchiole hygene techniques. this patient cannot use their abdominals to huff or cough!!! no huffing or coughing!
note: you can teach them how to huff later on
what is a bronchoscopy?
procedure using endoscope to inspect airways of lung, remove obstructions or tumors, stop bleeding
What is a Lung resection? What are the three types?
surgical removal of all or part of lung due to diseases such as cancer - wedge, lobectomy and pneumonectomy
What vitals would you watch if your pt had a lung resection?
SpO2, RR, Swann catheter
What is a thoracocentesis?
drains excess fluid from pleural space
What should you as PT focus on following a thoractomy?
Proper positioning (semi fowler upright best for lung expansion)
breathing exercises, chest wall expansion exercises
Where is the incision for a posterolateral thoracotomy? what nerve is in this region?
T4 and scapula to 5-6th intercostal space
divides the serratus anterior (SALT)
makes it difficult to breathe
where is the incision for an anterolateral thoracotomy?
4-5th intercostal space to midaxillary line
(pec major is incised, serratus anterior fibers separated)
What is a very common complication following thoracic surgery, specifically the anterolateral approach?
damage to the phrenic nerve causes SHOULDER PAIN (ipsilateral)
position during AL surgery
shoulder stabilizers are cut (SA, pec major)
where is the incision for a lateral thoracotomy?
near nipple line extending toward scapula
where is the incision for a thoracoabdominal incision?
8th,9th IC space at post axillary line to midline of abdomen
transection of : lats, SA, External oblique, rectus abdominus
note: with this patient you cannot activate these muscles too aggressively at first allow them to heal
what are post-op difficulties for thoracoabdominal incision?
-coughing
-deep breathing
-thoracic extension
-80% experience ipsilateral shoulder pain, referred pain from phrenic nerve
NO AGGRESSIVE STRETCH OR STRENGTHENING
T/F: Chest tubes are portable and should be monitored before and after PT treatment
T
Chest tube PT precautions
do not tip the collection system = results in lung collapse!
treat them all as drainage tubes
encourage upright positioning, ambulation, deep breathing to aid in removal of secretions
A video assisted thorascopic surgery is less or more invasive, allowing for what?
less invasive, no rib spreading
allows for eariler mobilization, less pain, less blood loss
peripheral vascular procedures
used to remove plaque and reestablish BF to periphery
can be surgical or translumenal angioplasty
What is a carotid endarectomy?
the common and external carotid have plaque removed and then are surgically closed and a bypass shunt is inserted to make sure blood gets to the head
used when stenosis > 50% or 60% in asymptomatic patient
What is a common symptom for a patient who just had a carotid endarectomy?
the incision ins made at the SCM so they will get dizzy with head turns
What might you hear when auscultating the carotid artery is blocked?
brewy
True of false, peripheral vascular procedures and carotid endarectomies increase BP
FALSE, these open up the vessel so they dont increase BP
how does anesthesia affect pts respiratory fxn?
depresses breathing, alters tone and contractile patterns of the diaphragm and intercostal muscles
anesthesia can cause alveolar collapse which causes
intrapulmonary shunting
