ILP Wk 7 (8) Introduction to General Surgery

Question 1

What are 2 characteristics of PRE-OPERATIVE medication as 1. anaesthesia and pain management?

Answer 1

1. Some patients may be given medications before surgery, e.g. a sedative to calm the patient and reduce anxiety.
2. Other pre-medications may include prophylactic antibiotics, bronchodilators or deep venous thrombosis (DVT) prophylaxis.

Question 2

What are 3 implications for physiotherapy of pre-medication (eg sedative) as 1. anaesthesia and pain management?

Answer 2

1. Patient may be drowsy, may have impaired coordination, and impaired memory and learning.
2. This may impact the pre-operative assessment / treatment of this patient.
3. Patients should be assessed / treated prior to this pre-medication where possible.

Question 3

What are 4 PERI-OPERATIVE (during operation) medications in 1. anaesthesia and pain management?

Answer 3

1. General anaesthesia (GA)
2. Epidural anaesthesia
3. Spinal anaesthesia
4. Nerve block

Question 4

What are 3 characteristics of general anaesthetic as PERI-OPERATIVE (during operation) medications in 1. anaesthesia and pain management?

Answer 4

1. Used for the majority of surgical procedures, including head and neck surgery, cardiac, thoracic, and abdominal surgery.
2. Requires muscle paralysis, thus patients are intubated and mechanically ventilated.
3. Adverse effects of GA include:
   
   1. Impaired ventilation:
      
      1. Respiratory inhibition
      2. Reduced FRC
      3. Atelectasis
      4. V/Q mismatch → hypoxaemia
   2. Impaired airway clearance
      
      1. Loss of cough reflex
      2. Drying of cilia → impaired mucociliary function
      3. Secretion retention

Question 5

What are 2 main adverse effects(4/3) of general anaesthetic as PERI-OPERATIVE (during operation) medications in 1. anaesthesia and pain management?

Answer 5

1. Impaired ventilation:
   
   1. Respiratory inhibition
   2. Reduced FRC
   3. Atelectasis
   4. V/Q mismatch → hypoxaemia
2. Impaired airway clearance
   
   1. Loss of cough reflex
   2. Drying of cilia → impaired mucociliary function
   3. Secretion retention

Question 6

What are 4 implications for physiotherapy as general anaesthetic in PERI-OPERATIVE (during operation) medications as 1. anaesthesia and pain management?

Answer 6

1. GA has greater respiratory effects due to MV, intubation, and loss of cough
2. GA > 20 mins increases the risk of post operative hypoxaemia
3. GA > 30 mins increases the risk of DVTs
4. Patients may report a sore throat or have a hoarse voice following intubation.

Question 7

What are 4 characteristics of epidural anaesthesia as PERI-OPERATIVE (during operation) medications in 1. anaesthesia and pain management?

Answer 7

1. Commonly used for obstetric and lower limb surgery.
2. Catheter is placed into epidural space and injected with medication.
3. Blocks sensation (including pain) to the level below the epidural; but muscle power should remain intact (you will need to assess this prior to walking the patient).
4. The patient’s respiratory system is intact and thus no intubation or mechanical ventilation is needed (compared to GA)

Question 8

What are 4 implications for physiotherapy as PERI-OPERATIVE (during operation) medications in 1. anaesthesia and pain management?

Answer 8

1. Reduced risk of respiratory complications as intubation and mechanical ventilation not required.
2. The epidural catheter may be left in situ for post-operative pain management.

Question 9

What are 4 characteristics of spinal anaesthesia as PERI-OPERATIVE (during operation) medications in 1. anaesthesia and pain management?

Answer 9

1. Commonly used for orthopaedic surgery of the lower limb, or hernia repairs.
2. Catheter is placed into subarachnoid space in spinal canal and injected with a local anaesthetic infusion.
3. Blocks sensory, motor and pain input to the body parts innervated by this spinal level.
4. Similar to an epidural anaesthesia, there is no need for intubation or mechanical ventilation as the respiratory system is intact (compared to GA).

Question 10

What are 2 implications for physiotherapy of spinal anaesthesia as PERI-OPERATIVE (during operation) medications in 1. anaesthesia and pain management?

Answer 10

1. Reduced risk of respiratory complications as intubation and mechanical ventilation is not required.
2. As the dura is punctured, patients may report a headache following spinal anaesthesia. This is caused by cerebrospinal fluid leakage and patients should remain supine in bed until the symptoms resolve.

Question 11

What are 2 characteristics of nerve block as PERI-OPERATIVE (during operation) medications in 1. anaesthesia and pain management?

Answer 11

1. Injection of local anaesthetic close to the nerve.
2. Induces motor and sensory blockage, and pain relief.
3. Used for simple limb surgery or reduction of fractures.

Question 12

What are implications for physiotherapy of nerve block as PERI-OPERATIVE (during operation) medications in 1. anaesthesia and pain management?

Answer 12

1. Patients may have residual analgesia and loss of sensation and motor function in the innervated area.

Question 13

What are 6 POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 13

1. PCA
2. Epidural (+ PCEA)
3. NSAIDS
4. opioids
5. simple analgesics
6. nitrous oxide

Question 14

What are 5 characteristics of Patient Controlled Analgesia (PCA) as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 14

1. Analgesia delivered intravenously (PCA-IV), controlled partly by the patient by pushing a button to deliver additional analgesia as required.
2. Background Infusion rate: Constant rate delivered to the patient to provide a steady level of pain relief. Also minimises the adverse effects of large bolus doses.
3. Bolus dose: Additional amount of analgesia delivered when the patient requires it.
4. Lock out period: Time during which an additional bolus dose cannot be given. Usually 5 to 15 minutes for IV delivery. Used to prevent overdosing and excessive sedation.
5. Usually narcotic medications are used e.g. Morphine, Fentanyl in combination with adjuncts such as Ketamine and Clonidine.

Question 15

What are 7 characteristics of adverse effects of narcotics as Patient Controlled Analgesia (PCA) as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 15

1. Respiratory depression (RR<8bpm)
2. Postural hypotension, syncope
3. Drowsiness
4. Nausea, vomiting
5. Paralytic ileus
6. Pruritis / itchiness
7. Urinary retention

Question 16

What are 7 implications for physiotherapy as Patient Controlled Analgesia (PCA) as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 16

1. Consult the mediation chart for information regarding the type of narcotic used, base rate, bolus dose and lock out period.
2. Encourage patient to deliver some pain relief at the beginning of assessment and throughout management to ensure analgesia is optimised.
3. Monitor patient’s RR and SpO2 to ensure their breathing is not becoming depressed.
4. If patient reports nausea (e.g. due to narcotics), follow the Post-Operative Nausea and Vomiting (PONV) protocol to maximise the patient’s comfort prior to treatment. Have a vomit bag handy throughout assessment and treatment.
5. Commonly used drugs are Metoclopromide (Maxolon), Tropisetron, Dropisetron.
6. Some patients may not be able to mobilise due to severe nausea.
7. Monitor patient’s responsiveness, by using a sedation scale. If they are very drowsy and unable to participate in your physiotherapy treatment, notify nursing and medical staff as the patient’s medications may need to be reviewed.

Question 17

What are 6 characteristics of epidural analgesia as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 17

1. Catheter is placed in epidural space in spinal canal and injected with a local anaesthetic and/or a narcotic infusion.
   
   1. May be either:
      
      1. a constant infusion determined by the anaesthetist, or
      2. a bolus as controlled by the patient (Patient Controlled Epidural Analgesia PCEA).
   2. This blocks pain impulses primarily in sensory nerves before they enter the spinal cord; effects are determined by the volume and concentration of the local anaesthetic solution.
   3. Enables analgesia without loss of motor function.
   4. Using an opiate in combination with local anaesthetic enables a similar level of pain relief with less concentration than when each drug is used individually. This reduces the side effects of both drugs.
2. A PCEA usually incorporates a background rate, patient controlled bolus and a nurse controlled bolus. The lock out period is usually a minimum of 20 minutes.

Question 18

What are 7 side effects of epidural analgesia as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 18

1. Hypotension (SBP <90 mmHg)
2. Sedation
3. Respiratory depression (RR<8bpm)
4. Motor and sensory loss of upper and lower limbs
5. Bowel and bladder disturbance (urinary retention)
6. Infection, haemorrhage, inflammation, displacement of the epidural catheter
7. Epidural haematoma

Question 19

What are 2 implications for physiotherapy of epidural analgesia as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 19

1. Ensure effective pain relief is achieved, using a pain scale (eg. VAS) to establish pain at rest and with movement (i.e. on deep breathing/coughing/bed mobility).
2. For optimal effectiveness the patient-controlled bolus should be initiated at least 20 minutes prior to the commencement of physiotherapy.

Question 20

What are 7 safety requirements of epidural analgesia as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 20

1. Pain over the epidural site, sensori-motor changes in limbs and changes in bladder and bowel function could be signs of an epidural haematoma or infection and requires immediate notification to the medical officer; there is an ~8 hour window to surgically prevent long-term neurological consequences. P/I: pins and needles, numbness, weakness or heaviness, new backache especially over the epidural site, or headache.
2. P/E: observe epidural site for signs of leaking, redness, swelling, hematoma; muscle strength in lower limbs prior to mobilisation;
3. If numbness or P&N are present an objective assessment of light touch in a dermatomal distribution must be undertaken to define the level involved
4. A thorough evaluation of muscle strength must be performed:
   
   1. Static quads and inner range knee extension (isometric hold): quality of movement, range, ability to maintain anti-gravity eccentric control.
   2. Ankle dorsi-flexion and plantar flexion
   3. Hip (if possible) and knee flexion - assist in supporting the limb initially; quality of movement, range and eccentric control.
5. Report any new muscle strength loss to the Medical Team
6. Numbness may not prevent the patient from mobilising, but the effect of weakness on movement control and thus safety may delay mobilisation
7. Hypotension may be an adverse effect. Check BP prior to mobilising. Check sitting BP if able, to see if postural hypotension is present. Care with mobilisation if Systolic pressure 30 mmHg. Defer mobilising patient away from bedside until corrected.
8. If there is a progressive loss of motor function report to medical staff immediately as this may indicate inflammation of the epidural site and compression of the spinal cord.

Question 21

What are 2 characteristics of non steroidal anti-inflammatory drugs (NSAIDs) as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 21

1. Reduce inflammation and thus limit mild and moderate levels of pain and fever.
2. Administered orally, intramuscular (IM) injection, or via suppository.

Question 22

What are 4 side effects of non steroidal anti-inflammatory drugs (NSAIDs) as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 22

1. Bronchospasm
2. Peptic ulcer
3. Renal impairment
4. Reduced platelets

Question 23

What are 4 characteristics of Opioids as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 23

eg. Morphine, Endone, MS contin, Oxycontin, Oxycodone

1. Provide relief for moderate to severe pain.
2. These have similar side effects to IV narcotics.
3. In addition to the IV route, opioids can be administered orally or via intramuscular injection.
4. Usually administered together in slow release and short acting doses. Timing of treatment should be considered around short acting dose.

Question 24

What are 2 characteristics of simple analgesics as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 24

Eg. Aspirin, Paracetamol

1. Provide analgesia for mild levels of pain and also assist in reducing body temperature.
2. Often used in conjunction with the above medications.

Question 25

What are 3 characteristics of **nitrous oxide** as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 25

1. Provides analgesia for a short period. 2. Inhaled via a mask. 3. Used in removal of painful dressings, or painful physiotherapy treatment e.g. stretching post burns grafting, or in labour

Question 26

What are 6 roles of this team (APU) to optimise the pain relief for patients and you may need to liaise with them with any problems as POST-OPERATIVE medications in 1. anaesthesia and pain management?

Answer 26

Pain management following surgery is usually monitored by a central multidisciplinary team (Acute Pain Service) 1. Effectiveness of pain relief in enabling adequate chest expansion and cough 2. Progressive loss of sensation or motor function in a patient with an epidural. 3. Persistent pain which is limiting treatment 4. Very drowsy patient (on narcotics) 5. Ability of the patient to participate in treatment as assessed by a sedation scale 6. Signs of adverse side effects e.g. respiratory depression, hypotension, neurological changes, new back pain.

Question 27

What are 2. surgical incisions?

Answer 27

Incisions are made along the lines of least tissue tension to promote tissue healing but still allow optimal access to the required area.

Question 28

What are 3 implications for physiotherapy (considerations) in 2. surgical incisions?

Answer 28

1. Which muscle/s will be transected? 2. How will this affect the patient? 3. How will you modify any movement / intervention and your handling / support to minimise discomfort?

Question 29

What are 3. surgical procedures?

Answer 29

The general pre- and post-operative physiotherapy management for many surgical procedures is similar. There are specific differences with implications for physiotherapy management that will be highlighted for the relevant operations.

Question 30

What are 2 main 3. surgical procedures?

Answer 30

1. Abdominal surgery 2. Vascular surgery

Question 31

What are 6 different types of 3A. abdominal surgical procedures?

Answer 31

1. OESOPHAGECTOMY 2. GASTRIC / DUODENAL SURGERY 3. CHOLECYSTECTOMY 4. WHIPPLE'S PROCEDURE / PANCREATICODUODENECTOMY 5. SEGMENTAL / PARTIAL COLECTOMY 6. TOTAL COLECTOMY AND PROCTOCOLECTOMY (with ILEOSTOMY)

Question 32

What are indications of **Oesophagectomy** in 3A. abdominal surgical procedures?

Answer 32

Oesophageal carcinoma or perforation. Removal of part or all of the oesophagus; the stomach is then pulled up and reanastomosed to the end of the oesophagus. When an Ivor Lewis procedure is performed two incisions are made – an upper abdominal to mobilise the stomach and a R) postero-lateral thoracotomy for resection of the lesion and construction of the anastomosis. Thorascopic-assisted oesophagectomies = only one abdominal incision and 4 or 5 port incisions posteriorly for dissection of the oesophagus.

Question 33

What are 4 specific implications for physiotherapy management of **Oesophagectomy** in 3A. abdominal surgical procedures?

Answer 33

1. Head down tilt should be avoided to prevent gastric reflux which may lead to aspiration or infection of the wound site. 2. Care with nasopharyngeal suction, as the anastomosis may be damaged with insertion of the catheter. 3. Neck motion may be limited to prevent stress on the anastomosis. 4. Present post-operatively with intercostal catheter (ICC)

Question 34

What are 3 types of gastric/duodenal surgery in 3A. abdominal surgical procedures?

Answer 34

most commonly performed for complications arising from gastric or duodenal ulcers or gastric carcinoma. 1. Pyloroplasty 2. Nissen Fundoplication 3. Gastrectomy

Question 35

What is pyloroplasty as gastric/duodenal surgery in 3A. abdominal surgical procedures?

Answer 35

The pyloric muscle is divided and the defect is sutured transversely leaving a larger gastric outlet. First, a trunkal or selective vagotomy is performed; this paralyses the stomach muscles and defective gastric emptying occurs.

Question 36

What is Nissen Fundoplication as gastric/duodenal surgery in 3A. abdominal surgical procedures?

Answer 36

performed when anti-reflux surgery is indicated. The gastric fundus is mobilised and loosely wrapped around the lower oesophagus and sutured, preserving the vagus nerve. The “wrap” returns a portion of the lower oesophagus to the abdomen. This eliminates acid reflux and heals oesophagitis. This procedure is now often laparoscopic. The post operative protocol may dictate that no nausea or vomiting is allowed, so physiotherapy intervention must not induce this.

Question 37

What is Gastrectomy as gastric/duodenal surgery in 3A. abdominal surgical procedures?

Answer 37

removal of all or part of the stomach, closure of the duodenum & anastomosis of the oesophagus to the jejunum (Roux-en-yoesophagojejunostomy)

Question 38

What is cholectystectomy in 3A. abdominal surgical procedures?

Answer 38

removal of the gallbladder from the liver bed.

Question 39

What are 2 types of cholectystectomy in 3A. abdominal surgical procedures?

Answer 39

1. Open cholecystectomy - performed via a Kocher's incision or (R) paramedian incision. * The cystic duct is catheterised with a T-tube; this may be left in for 10 days to prevent stenosis of the common bile duct, to drain any remaining gallstones and to prevent inadvertent biliary leakage into the peritoneal cavity. 2. Laparoscopic cholecystectomy now common.

Question 40

What is Whipple's procedure/Pancreaticoduodenectomy in 3A. abdominal surgical procedures?

Answer 40

usually performed for cancer of the head of the pancreas. This is a long procedure involving a large incision and removal of the pancreas, common bile duct, part of the stomach and duodenum with re-anastomosis of the remaining portions.

Question 41

What are 2 implications of physiotherapy of Whipple's procedure/Pancreaticoduodenectomy in 3A. abdominal surgical procedures?

Answer 41

1. The condition is difficult to diagnose and therefore the patient may be very malnourished as a result of cancer spread. 2. Often have obstructive jaundice prior to surgery and are at a high risk of postoperative complications.

Question 42

What is segmental/partial colectomy in 3A. abdominal surgical procedures?

Answer 42

removal of part of the colon (large intestine), commonly for treatment of carcinoma, ulcerative colitis, Crohn’s disease and diverticular disease of the colon.

Question 43

What are 3 types of segmental/partial colectomy in 3A. abdominal surgical procedures?

Answer 43

1. Hemicolectomy (TRANSVERSE, RIGHT or LEFT) 2. Anterior resection 3. Abdominoperineal resection

Question 44

What is Hemicolectomy (TRANSVERSE, RIGHT or LEFT) of segmental/partial colectomy in 3A. abdominal surgical procedures?

Answer 44

is a resection of a segment of colon with an end to end anastomosis. There is no stoma formed.

Question 45

What is Anterior resection of segmental/partial colectomy of of segmental/partial colectomy in 3A. abdominal surgical procedures?

Answer 45

Anterior resection with anastomosis, is usually used for the resection of rectal malignancy via a low midline incision. It involves removal of the sigmoid colon and upper rectum with an end to end anastomosis and is performed for lesions in the upper rectum and lower sigmoid colon. * High Anterior Resection (HAR) - involves sigmoid colon and upper rectum; * Low Anterior Resection (LAR) and Ultra Low Anterior Resection (ULAR) for malignancy of the lower rectum in which the anal sphincters are preserved. These usually involve the refashioning of the rectum with a section of the Jejunum called a J pouch to overcome post-operative faecal urgency. A temporary loop ileostomy is often formed to enable sound healing of the anastamosis.

Question 46

What is Abdominoperineal resection of of segmental/partial colectomy in 3A. abdominal surgical procedures?

Answer 46

Abdominoperineal resection (APR) removal of the rectum and anus for malignancy within 5 cm of the anal verge via low mid-line and perineal incisions. Patients usually have a permanent colostomy. There is a significant risk of perineal wound breakdown associated with the wound’s location, the common use of neo-adjuvant therapy (pre-operative chemotherapy and radiotherapy) and the increased risk associated with malignancy.

Question 47

What are 4 specific implications for physiotherapy managements of Abdominoperineal resection (APR) of of segmental/partial colectomy in 3A. abdominal surgical procedures?

Answer 47

1. Patients are nursed in supine, side lying or high side lying 2. Patients must avoid sitting in bed, sitting over edge of bed to avoid pressure on the perineal wound site; perform physiotherapy in high side-lying alternatively 3. Patients need to be encouraged to mobilise Day1 and transfer from supine to standing by avoiding symmetrical sitting positions 4. Patients are allowed to sit out of bed in a chair only with a customised sitting cushion which is ordered pre-operatively

Question 48

What is Hartman’s procedure of segmental/partial colectomy in 3A. abdominal surgical procedures?

Answer 48

is usually performed for Diverticular Disease of the sigmoid colon. The proximal colon is externalised through the formation of a colostomy. The distal end of the rectum is oversewn to form a rectal stump. This rectum and colon may be rejoined and the colostomy reversed at a later date via a Reversal of Hartman’s procedure.

Question 49

What is total colectomy and proctocolectomy (with ileostomy) in 3A. abdominal surgical procedures?

Answer 49

involves excision of the whole colon, either alone or in conjunction with the rectum (proctocolectomy). The procedure is indicated in the treatment of ulcerative colitis and malignant changes in polyps. A one-stage proctocolectomy is an extension of an APR involving excision of the rectum and entire colon via abdominal and perineal approaches. The patient has a permanent ileostomy. In a two-stage procedure the total colectomy is performed first, an ileostomy is formed and the proximal cut end of the rectum is closed. In the next stage the rectum and anus are removed. Occasionally, if the rectum is relatively free of disease, the ileum may be anastomosed to the rectum.

Question 50

What is stoma in 3A. abdominal surgical procedures?

Answer 50

artificial opening between the colon or ileum and the skin of the abdominal wall. The mucosa of the colon is stitched to the cut edges of the skin in the opening in the abdominal wall that has been made to receive it. Flatus and faeces are then discharged through the opening onto the surface of the abdomen and collected into a plastic (coloplast) bag.

Question 51

What are 5 types of stoma in 3A. abdominal surgical procedures?

Answer 51

1. **Terminal colostomy** - a permanent colostomy, formed when the divided end of the colon is brought out to the surface of the abdomen eg following APR 2. **Side colostomy** - formed when the anterior wall of the colon is sutured to the abdominal wall via a small hole made in the colon. Used for relief of distal colonic obstruction and to ‘protect’ an anastomosis initially post-operatively, to ensure it is not placed under any pressure and cause leakage; eg following anterior resection. 3. **Loop colostomy** - created by exteriorising a loop of colon and passing it over a glass rod. The glass rod is withdrawn after 5-7 days and the externalised colon falls back into the abdomen. A variation of the loop colostomy is the double-barrel colostomy. 4. **Defunctioning colostomy** - sometimes necessary to ensure that no faeces can pass into the distal colon. In this case, the colon is transected and the two ends, proximal and distal, are brought out through separate openings in the abdominal wall. 5. **Ileostomy** - a procedure which creates a cutaneous fistula from the lower part of the ileum.

Question 52

What are 3 specific implications for physiotherapy management of stoma in 3A. abdominal surgical procedures?

Answer 52

1. Check the level of fluid or gas in the colostomy bag prior to mobilising 2. If full, notify nursing staff to empty the contents prior to mobilising 3. When teaching patient to perform a supported cough ensure pillow or folded towel is placed over the wound only and doesn’t externally compress on the stoma and bag

Question 53

What are 7 general implications of vascular conditions for physiotherapy management in 3B. vascular surgical procedures?

Answer 53

1. Assess circulation and pulses as part of physiotherapy assessment; monitor for signs of acute ischaemia 2. Care during treatment with regard to exercises (avoid scraping heel) 3. Adhere to any ROM limitations 4. Use correct footwear when walking 5. Mobilise with reference to post-op claudication distance 6. Make sure a patient with PVD has sheepskin or bootees during their stay in hospital 7. Complications include: post-op infection, aneurysm and thrombotic occlusion

Question 54

What is femoral-popliteal bypass in 3B. vascular surgical procedures?

Answer 54

Femoral-popliteal bypass is performed for acute or chronic ischaemia and the treatment of non-healing arterial ulcers in patients with superficial femoral or popliteal artery occlusion with a patent popliteal arterial system distal to the occlusion.

Question 55

What are 6 characteristics of femoral-popliteal bypass in 3B. vascular surgical procedures?

Answer 55

1. Procedure involves a Xeno graft (Dacron, Gortex) or autograft (saphenous vein) from the femoral artery to the popliteal via a long incision or 3 small graft incisions on the medial aspect of the leg. The graft is attached distally to the anterior or posterior tibial artery and passes behind the knee and popliteal muscle and along the medial thigh to attach proximally to the common femoral or superficial femoral artery. 2. Patients are usually seen Day 1 for chest care and mobilised Day 1 or Day 2 depending on swelling, graft integrity/stability. 3. Ensure hip does not exceed 60° flexion when knee is extended (as this risks stretching the graft) – consider this when positioning the patient in bed, and when moving from supine to sitting and standing (and vice-versa). 4. Care when handling the limb to avoid pressure over incision and graft sites. 5. Inform the patient that they may experience the sensation of blood ‘rushing’ through the graft when they first sit on the edge of the bed, and allow them to rest until this sensation settles. 6. When mobilising, encourage a ‘normal’ gait pattern.

Question 56

What is Aorto-bifemoral bypass in 3B. vascular surgical procedures?

Answer 56

Aorto-bifemoral bypass involves a Y-shaped Dacron graft from the aorta to two femoral arteries via midline abdominal incision and uni/bilateral groin incisions. Procedure is usually performed for patients with symptomatic aorto-iliac occlusive disease.

Question 57

What is Aorto-Iliac bypass in 3B. vascular surgical procedures?

Answer 57

Aorto-Iliac bypass involves a Y-shaped Dacron graft from aorta to iliac arteries via abdominal incision.

Question 58

What is Femoro-femoral crossover in 3B. vascular surgical procedures?

Answer 58

Femoro-femoral crossover involves Dacron graft from one femoral artery to the other via a C shaped graft. It involves two small vertical groin incisions. It is used for a unilateral iliac artery occlusion and is a low risk procedure which can be done under spinal or epidural anaesthesia.

Question 59

What is Axillo-femoral bypass in 3B. vascular surgical procedures?

Answer 59

Axillo-femoral bypass involves a Dacron graft from the axillary artery to the ipsilateral femoral artery with an additional side limb grafted to attach to the common femoral artery on the contra-lateral side. This forms an axillary – femoro femoral crossover. It is a subcutaneous graft involving a unilateral subclavicular incision dividing Pectoralis Major and Minor and two vertical groin incisions. This procedure is often performed in patients with severe cardiac or respiratory disease who would not tolerate a lengthy general anaesthetic or patients who have extensive atherosclerotic disease of the aorta. It is an alternative to aorto-bifemoral bypass. It requires a shorter anaesthesia and a less invasive dissection and less pain post-op. Incisions are a unilateral subclavicular incision dividing Pectoralis Major and Minor and bilateral groin incisions.

Question 60

What are 5 specific implications for physiotherapy of Axillo-femoral bypass in 3B. vascular surgical procedures? What should be avoided?

Answer 60

1. Avoid pressure on graft from hand placement during chest palpation, deep breathing exercises, percussion and vibrations 2. Avoid use of overhead ring when moving in bed 3. Advice re belts and bras not to constrict the flow in the graft 4. Avoid constrictive clothing 5. Avoid using axillary crutches with mobilisation

Question 61

What is Abdominal Aortic Aneurysm Repair in 3B. vascular surgical procedures? What should be avoided?

Answer 61

An abdominal aortic aneurysm is an abnormal, weakened dilatation in the aorta which is usually located in the infra renal part of the aorta. It can be up to 10cm in size but will usually rupture when it gets to this size.

Question 62

What are 4 causes of Abdominal Aortic Aneurysm Repair in 3B. vascular surgical procedures?

Answer 62

1. atherosclerosis 2. trauma 3. congenital weakness 4. post-op. complications

Question 63

What are the co-morbidities of Abdominal Aortic Aneurysm (AAA) Repair in 3B. vascular surgical procedures?

Answer 63

A patient with an AAA may also present with other comorbidities, such as coronary artery disease, diabetes, COPD, HT, PVD, renal disease, liver disease and/or obesity.

Question 64

What are the 2 presentations of Abdominal Aortic Aneurysm (AAA) Repair in 3B. vascular surgical procedures?

Answer 64

1. an acute rupture, severe back and abdominal pain, shock, comatose, low BP. This is an emergency situation and carries greater risk for the patient. 2. a slow leak or unruptured - slight back or abdominal pain, often found on routine examination of abdomen or lumbar x-ray. The elective repair procedure is to minimise the risk of rupturing. The operation involves the aorta being clamped above the aneurysm. The aneurysm is cut open and a graft sewn from one end of the aneurysm to the other. The aneurysm is then wrapped around it. If the aneurysm is suprarenal there is a high incidence of renal failure post-operatively due to occlusion of the renal arteries during the procedure.

Question 65

What are the 2 specific implications for PRE OPERATIVE physiotherapy of Abdominal Aortic Aneurysm (AAA) Repair in 3B. vascular surgical procedures?

Answer 65

Whether or not you should cough the patient depends on whether there has been a leak or the size of the aneurysm 1. \< 6 cm - limit cough / FET; depends on chest condition and indication for coughing 2. \> 6 cm - risk of rupture therefore no cough preoperatively

Question 66

What are the 5 specific implications for POST OPERATIVE physiotherapy of Abdominal Aortic Aneurysm (AAA) Repair in 3B. vascular surgical procedures?

Answer 66

1. At a high risk due to severity of surgery and concomitant diseases 2. Potential to develop respiratory failure so require intensive treatment for at least 5 days with appropriate techniques directed by assessment 3. Effective pain relief and wound support are essential 4. No head-down tilt 5. Mobilise once CV stable, dependent on patient's condition

Question 67

What are 4. patient attachment?

Answer 67

Following an operation, patients may present with many attachments. The function and implications to physiotherapy of some common attachments are included below. The golden rule for all attachments is “Do not dislodge”.

Question 68

What are 5 functions of 4A. Naso-Gastric Tube (NGT) for patient attachment?

Answer 68

1. A flexible tube used to drain bile and gastric contents from the stomach when the gastrointestinal tract is inactive. 2. Used pre-op in patients with gastrointestinal obstruction to prevent aspiration or regurgitation 3. Used post-op in patients with marked ileus to decompress the gut; unconscious / semi conscious patients to prevent aspiration; and in those with marked abdominal distension and vomiting post-op. 4. The tube is either on free drainage, regular aspiration, or low pressure suction. 5. Can also be used for enteral feeding - a narrow, softer feeding tube can be inserted for this purpose.

Question 69

What are 4 implications for physiotherapy of 4A. Naso-Gastric Tube (NGT) for patient attachment?

Answer 69

1. Often pinned to pillow – ensure NGT is not dislodged when sitting patient forward 2. Ensure tube is well secured to patient’s nose with appropriate tape, and will not slip out when mobilising 3. Switch off NG feeds when suctioning the patient or when in HDT to avoid aspiration 4. NG feeds can often be disconnected to mobilise the patient. This should be done by nursing staff as flushing of line required prior to reconnection

Question 70

What are 3 functions of 4B. Oxygen device for patient attachment?

Answer 70

1. Nasal prongs or face mask attached for delivery of supplemental oxygen. 2. Patients on a narcotic infusion post-op will routinely receive supplemental O2 to help overcome the effects of respiratory depression. 3. Can be used to improve PaO2.

Question 71

What are 3 implications for physiotherapy of 4B. Oxygen device for patient attachment?

Answer 71

1. Check the device is worn correctly (ie, not dislodged) and that the correct concentration is being delivered to the patient 2. Monitor SpO2 with pulse oximeter 3. Mobilise post-op patients with portable O2 (if appropriate), or if removed use portable pulse oximeter, and ensure oxygen device replaced when returned to bed / chair.

Question 72

What are 3 functions of 4C. Urinary catheter (indwelling catheter IDC) for patient attachment?

Answer 72

1. Remove urine from bladder into an external bag 2. Used when patients cannot mobilise to toilet 3. Monitors urinary output, important when narcotic analgesia is used, and post-op to help gauge fluid balance (ie, amount of fluid IN via IV / drink etc vs OUT via urine etc)

Question 73

What are 3 implications for physiotherapy of 4C. Urinary catheter (indwelling catheter IDC) for patient attachment?

Answer 73

1. Ensure bag is not too full prior to mobilising 2. Do not dislodge catheter during your interaction, take special care when mobilising 3. Keep bag below level of the catheter

Question 74

What is the function of 4D. Intravenous (IV) drip / line for patient attachment?

Answer 74

Peripheral venous line inserted for post-op administration of maintenance / replacement fluids and medications. Following abdominal surgery, most patients remain NBM until normal gastrointestinal function has re-appeared (usually 2 - 4 days).

Question 75

What are 3 implications for physiotherapy of 4D. Intravenous (IV) drip / line for patient attachment?

Answer 75

1. Care with arm exercises; do not dislodge IV line 2. Care with bed mobility - limit movements of joints close to insertion of IV as there is an increased risk of tissuing (rupture vein wall) 3. If patients c/o pain at drip site report to medical team as thrombophlebitis may occur.

Question 76

What are 4 functions of 4E. Intercostal catheter for patient attachment?

Answer 76

1. A flexible tube inserted into the pleural space, connected to a system of underwater seals and suction. 2. Removes fluid or air from pleural space 3. Re-establishes normal negative pressure within the pleural space 4. Promotes re-expansion of the lung

Question 77

What are 3 implications for physiotherapy of 4E. Intercostal catheter for patient attachment?

Answer 77

1. Do not dislodge during the course of your management 2. Check whether the fluid is swinging, draining or bubbling (see lecture) 3. Keep bottle system below level of insertion into patient’s chest wall so no danger of fluid entering pleural cavity 4. If the bottle breaks: if previously no bubbling – double clamp, quickly change bottles; if previously bubbling – do not clamp, quickly change the bottle 5. If chest tube accidentally disconnected, reconnect and assess system

Question 78

What is the function of 4F. Wound drain for patient attachment?

Answer 78

Provides a channel of exit from a wound, to prevent accumulation of post-op fluid

Question 79

What are 3 steps of 4F. Wound drain for patient attachment?

Answer 79

1. Open drain: passive drains that drain fluid into an overlying bag (such as a colostomy bag) or gauze. Eg “Penrose” and “Yeates” drains. 2. Closed drain: bag attached to the draining tube but does not have suction pressure. Eg IDC 3. Closed suction drain: draining tube, bag and a closed suction reservoir which generates vacuum when air is expelled from it by squeezing. They have a one-way valve to prevent reflux of drainage fluid back into the wound from the collection bag. Eg. Bellovac. These drains are common in post-surgical patients.

Question 80

What are 3 implications for physiotherapy of 4F. Wound drain for patient attachment?

Answer 80

1. Do not dislodge during the course of your management 2. Infection can be a problem; ensure safe, appropriate handling of this equipment 3. Can mobilise patients with drainage bag - keep below level of wound

Question 81

What is the function of 4G. Vacuum assisted closure (VAC) system for patient attachment?

Answer 81

A non-invasive technique where negative pressure is delivered in a uniform manner to the wound. The wound is sealed over by a plastic film which prevents entry of bacteria and the vacuum removes secretions from the wound and reduces infection. This system is used in the management of large wounds to facilitate tissue healing.

Question 82

What are 4 implications for physiotherapy of 4G. Vacuum assisted closure (VAC) system for patient attachment?

Answer 82

1. Do not dislodge during your interaction 2. Check with medical/nursing staff whether suction can be removed prior to mobilisation 3. Ensure the VAC unit is below the level of the wound to avoid reflux of drainage 4. Beware of hissing noise, as this may indicate the dressing is leaking

Question 83

What is 4H. Thromboembolic Deterrent (TED) stockings / socks for patient attachment?

Answer 83

Question 84

What are 3 implications for physiotherapy of 4H. Thromboembolic Deterrent (TED) stockings / socks for patient attachment?

Answer 84

1. Remove to expose legs for assessment of DVT and circulation 2. Do not leave rolled around ankle as this can create a tourniquet and impair circulation 3. Patient can ambulate in TEDs as long as shoes are worn (ie, not just TEDs without shoes)

Question 85

What are 6 post operative complications?

Answer 85

1. Atelectasis 1. Collapse of alveoli, usually affects the basal segments following surgery 2. Pneumonia 1. Respiratory infection 3. Pulmonary oedema * Increased fluid administration may lead to increased fluid in the interstitial space 4. Nausea and vomiting * This can be a result of pain relief medication, especially narcotics 5. Deep venous thrombosis * Blood clot formed in large veins due to immobility. May dislodge and occlude the pulmonary vessels. 6. Acute ischaemia * Impaired circulation to limb, possible following vascular surgery

Question 86

What is Atelectasis as a post operative complications?

Answer 86

Collapse of alveoli, usually affects the basal segments following surgery

Question 87

What is Pneumonia as a post operative complications?

Answer 87

Respiratory infection

Question 88

What is Pulmonary oedema as a post operative complications?

Answer 88

Increased fluid administration may lead to increased fluid in the interstitial space

Question 89

What is Nausea and vomiting as a post operative complications?

Answer 89

This can be a result of pain relief medication, especially narcotics

Question 90

What is Deep venous thrombosis as a post operative complications?

Answer 90

Blood clot formed in large veins due to immobility. May dislodge and occlude the pulmonary vessels.

Question 91

What is Acute ischaemia as a post operative complications?

Answer 91

Impaired circulation to limb, possible following vascular surgery

Question 92

What are 3 signs and symptoms of Atelectasis as a post operative complications?

Answer 92

1. Ausc: ↓BS, fine end inspiratory crackles 2. SOB 3. May result from poor pain control

Question 93

What are 3 signs and symptoms of Pneumonia as a post operative complications?

Answer 93

1. Increased secretion production; 2. Moist/productive cough 3. SOB 4. Changes on chest X-ray

Question 94

What are 2 signs and symptoms of Pulmonary oedema as a post operative complications?

Answer 94

1. Fine inspiratory crackles 2. “Wet” chest X-ray

Question 95

What are signs and symptoms of Nausea and vomiting as a post operative complications?

Answer 95

Patient c/o nausea / vomiting

Question 96

What are signs and symptoms of Deep venous thrombosis as a post operative complications?

Answer 96

1. Increased temperature of calf 2. Redder appearance of calf 3. Calf tender on palpation 4. Positive Homan’s sign (passive dorsiflexion)

Question 97

What are 6 signs and symptoms "P" of Acute ischaemia as a post operative complications?

Answer 97

Signs of Acute Ischaemia - The “6” P’s 1. Pallor 2. Polar 3. Pulseless 4. Paralysis 5. Paraesthesia 6. Pain

Question 98

What are 3 physiotherapy implications of Acute ischaemia as a post operative complications?

Answer 98

1. Monitor and maintain circulation (circ. ex) 2. Notify Nursing Staff and Medical Staff immediately as the ischaemia needs to be reversed to preserve the limb. 3. Document findings in patient’s medical chart.

Question 99

What are 2 physiotherapy implications of Deep venous thrombosis as a post operative complications?

Answer 99

1. Prevent DVTs with circulatory exercise and early ambulation 2. If present, rest in bed, consult medical staff prior to commencing ambulation

Question 100

What are 3 physiotherapy implications of Nausea and vomiting as a post operative complications?

Answer 100

1. Time session wrt optimal anti-emetic medication 2. Ensure vomit bag handy at all times 3. If severe, do not mobilise

Question 101

What are physiotherapy implications of Pulmonary oedema as a post operative complications?

Answer 101

No role for physiotherapy if there are no secretions present

Question 102

What are 4 physiotherapy implications of Pneumonia as a post operative complications?

Answer 102

1. Optimise positioning 2. Techniques to mobilise and remove secretions 3. Supported cough 4. Encourage bed mobility and ambulation

Question 103

What are 4 physiotherapy implications of Atelectasis as a post operative complications?

Answer 103

1. Optimise pain relief 2. Techniques to improve ventilation 3. Encourage bed mobility and ambulation

Question 104

What is Wound Dehiscence as a post operative complications?

Answer 104

Partial or total disruption of any or all of the layers of the operative wound. Usually occurs around end of week 1.

Question 105

What are 7 signs and symptoms of Wound Dehiscence as a post operative complications?

Answer 105

1. Discharge of sero-sanguineous peritoneal fluid (fluid composed of serum and blood) 2. Dry dressings suddenly become wet 3. Patient reports feeling of something ‘giving way’ at wound site 4. Pain 5. Bleeding from wound with coughing or movement 6. Increased HR 7. Hypotension

Question 106

What are 5 physiotherapy implications of Wound Dehiscence as a post operative complications?

Answer 106

1. Always check wound prior to sitting / moving patient In an emergency 1. Lie patient flat, elevate feet if necessary 2. Hold patient’s wound using clean sheet, towel or pillow case 3. Summon help 4. Patient is usually returned to theatre ASAP to have the whole wound repaired

Question 107

What are 2 physiotherapy implications of Paralytic Ileus as a post operative complications?

Answer 107

1. Encourage standing or high sitting 2. Encourage mobility to decrease collapse and start bowels moving

Question 108

What are 5 signs and symptoms of Paralytic Ileus as a post operative complications?

Answer 108

1. No bowel sounds, flatus / faeces 2. Vomiting, hiccups 3. Abdo distension ++ 4. Severe abdo pain ++ 5. Tendency towards bi-basal collapse

Question 109

What is Paralytic Ileus as a post operative complications?

Answer 109

Cessation of movement of the gut, or peristalsis not regained for a prolonged post-operative period

Question 110

What are 4 physiotherapy implications of Post-operative Haemorrhage (internal) as a post operative complications?

Answer 110

In an emergency: 1. Lie patient flat 2. Elevate patient’s feet if necessary 3. Summon help 4. Remain with patient until help arrives

Question 111

What are 7 signs and symptoms of Post-operative Haemorrhage (internal) as a post operative complications?

Answer 111

1. Decreased BP 2. Increased HR 3. Pallor and sweating 4. Dizziness and thirst 5. Pain ++ 6. Increased abdo girth 7. Increased drainage in bag

Question 112

What are 3 associations of Post-operative Haemorrhage (internal) as a post operative complications?

Answer 112

Associated with: 1. Organ removal 2. Resection of part of the GIT 3. Vascular surgery

Question 113

What is Peritonitis as a post operative complications?

Answer 113

Inflammation or irritation of the peritoneal cavity - with associated infection

Question 114

What are 8 signs and symptoms of Peritonitis as a post operative complications?

Answer 114

1. Severe abdo pain +++ 2. Nausea and vomiting 3. Fever 4. Abdominal rigidity 5. Tendency towards bi-basal collapse 6. Tendency towards paralytic ileus 7. Increased HR 8. Increased white cell count (WCC).

Question 115

What are 5 physiotherapy implications of Peritonitis as a post operative complications?

Answer 115

1. Time Rx with pain relief 2. Maintain pulmonary function / prevent complications. 3. Short, frequent Rx 4. Positioning patients in high sitting may be difficult - consider standing 5. Consider long term re-conditioning program

Question 116

What are 2 physiotherapy implications of Ascites as a post operative complications?

Answer 116

1. Maintain the patient’s pulmonary function / prevent collapse 2. Short, frequent Rx

Question 117

What are 3 signs and symptoms of Ascites as a post operative complications?

Answer 117

1. Large abdomen 2. SOB 3. Tendency towards bi-basal collapse

Question 118

What is Ascites as a post operative complications?

Answer 118

Increase in non-infective peritoneal fluid in the peritoneal cavity.

Question 119

What is post operative complications?

Answer 119

Question 120

Answer 120

Question 121

Answer 121