Management of a surgical patient Flashcards
What are some key respiratory problems?
- Dyspnoea
- Secretion retention
- Loss of lung volume
- Respiratory failure
What are some general Sternotomy precautions for 4-12 weeks post-op?
- No pushing through arms (including sit -> stand)
- No pulling (including banister upstairs, dog on lead)
- No lifting heavy weights
- Some may restrict arm movements (e.g. overhead, behind back, unilateral movements vs bilateral movements)
What does PPC stand for?
Post-op Pulmonary Complications
What can happen to the length of hospital stay (LOS) when a patient has PPC (Post-op Pulmonary Complications)?
Prolonged by 13-17 days
How does mortality rate differ after Post-op pulmonary complications (PPC)?
Mortality rate after 1 year:
- 45.9% (8.7% without)
Mortality rate after 5 years:
- 71.4% (41.1% without)
1/5 die within 30 days of major surgery (0.2-3% without)
What are risk factors of age in pre-op?
- Reduced physiological reserve
- Decreased elastic recoil
- Decreased chest wall compliance
- Decreased respiratory muscle strength
- Increased alveolar collapse
- > 70 y.o 3x risk
What can happen if the patient has lung disease pre-op?
- Increased reduction in FRC
- Potential cilia dysfunction
- Potential dysfunction of lung tissue/impaired gas exchange
- Potential existing retained secretions
- Severe COPD FEV<40% has 6x more complications
What can happen if the patient has heart failure pre-op?
- Potential worsening VQ mismatch
- Potential worsening hypoxaemia
What can happen if the patient has a neurological disorder pre-op?
- Increased risk respiratory failure
- Increased risk aspiration
What can happen if the patient has functional status pre-op?
- Lower functional reserves
- Further reduced mobility post-op increased risk VTE, pneumonia, etc.
What can happen if the patient has obesity pre-op?
- Increased reduction in FRC perioperatively
- Potential mobility issues post-op
What can happen if the patient has a smoking status pre-op?
- Cilia dysfunction
- Potential underlying lung disease
- 2x increased risk complications
What can happen if the patient has mechanical ventilation peri-op?
- Aspiration
- VQ mismatch
- Lack of independent airway protection/secretion clearance
- Ventilator-Induced Lung Injury (VILI)
What can happen if the patient has anaesthesia peri-op?
- Cilia impairment
- Risk bronchoconstriction
- Reduced surfactant production
- Reduced FRC (muscle tone, chest wall deformation)
What can happen if the patient has opioids in peri-op?
- Respiratory depression
- Hypoventilation
- Aspiration risk
What can happen in peri-op if the patient has emergency surgery?
- Lack of fasting - risk of aspiration
- Higher risk patient cohort
What can happen if the patient has lung deflation peri-op?
- Atelectasis of deflated lung
- Barotrauma of reinflation
What are the most important predictors of risk in a surgical site peri-op?
Most important predictor of risk:
- Aortic
- Thoracic
- Upper abdominal surgeries are high-risk
What can happen if the patient has surgical site peri-op?
- Distance of incision from diaphragm inversely proportional to the incidence of complications
- Intercostal muscle involvement
- Positions/restrictions
- Site of pain/inflammation
What can happen if the patient has pain post-op?
- Reduced thoracic expansion
- V/Q mismatch
- Reduced cough-risk retained secretions
- Reduced mobility
What can happen if the patient has reduced mobility in post-op?
Reduced FRC
What can happen if the patient has dehydration post-op?
- Increased viscosity of secretions
- Reduced sputum clearance
- Reduced mobility/repositioning
What are the aims of post-op physio management?
- Improve V/Q matching
- Restore FRC
- Maintain sputum clearance
- Restore mobility
What are some physio treatment options for post-op?
- Positioning
- Mobilise
- ACBT (splinted cough)
- Humidification
- Incentive spirometry, flutter devices
- Intermittent Positive Pressure Breathing (IPPB)
- CPAP –> BiPAP
- Manual hyperinflation, Suctioning
What can positioning allow?
Positioning can re-expand atelectatic lung, but regular position change is needed to prevent atelectasis reappearing in dependent zones.
- Patients are encourage high sitting and to sit out of bed ASAP, and avoid slumping.
What assists in the decision about positioning?
- Clinical assessment
- X-ray
What does positioning supine to upright increase?
- Tidal volume
- Total lung capacity
- Vital capacity
- FRC
- Residual volume
- AP diameter of chest
- Diaphragmatic excursion
- Mobilisation of secretions
What is an Incentive Spirometry device?
A device which provides visual feedback on inspiratory effort and volume
What must be encouraged when using incentive spirometer?
Diaphragmatic excursion
What must the patient do when using an incentive spirometer?
The patient should take a slow deep breath in watching the indicator and aiming to achieve a set target
What are the indications for Intermittent Positive Pressure Breathing (IPPB)?
- Increased work of breathing
- Atelectasis
- Low tidal volumes
- Sputum retention
What are the contraindications & precautions for Intermittent Positive Pressure Breathing (IPPB), CPAP, MI-E?
- Vomiting
- Facial trauma / surgery
- Raised intracranial pressure
- Recent upper GI surgery (D/W consultant)
- Recent thoracic surgery (D/W consultant)
- Low GCS/impaired consciousness
- Undrained pneumothorax
- Large emphysematous bullae
- Open bronchopleural fistula
- Lung abscess
- Severe haemoptysis
- Ca Bronchus
- Active pulmonary tuberculosis
- Frank haemoptysis
What are the (3) main ways suction can be carried out on non-intubated patients?
- Nasopharyngeal (NP)
- Oropharyngeal
- Tracheostomy
What is the indication for airway suction use?
An inability to cough effectively and expectorate when airway secretions are retained
What must be considered with suctioning?
- Very unpleasant for the patient when alert
- Can cause trauma to the epithelium
- Catheter may not be inserted into the trachea
- Infection risk
- Desaturation during procedure
Name some surgical incisions.
- Median sternotomy
- Right subcostal (open cholecystectomy)
- Horizontal transabdominal
- Appendicectomy
- Right inguinal (hernia repair)
- Bilateral subcostal with median extension (liver transplant)
- Left paramedian (laparotomy)
- Lower midline
- Suprapubic
- Lateral thoracotomy
- Limited thoracotomy
- Left transverse lumbar (nephrectomy)
What problems may post-op patients have that we can address?
- Atelectasis
- Sputum retention
- Decreased mobility
What are pre-op risk factors?
- Age
- Lung disease
- Heart failure
- Neurological disorder
- Functional status
- Obesity
- Smoking
What are peri-op risk factors?
- Mechanical ventilation
- Anaesthesia
- Opioids
- Emergency surgery
- Length of surgery
- Lung deflation
- Surgical site
What are post-op risk factors?
- Pain
- Reduced mobility
- Dehydration
- Altered mental state
- Recumbancy
What should be avoided in the early post-op physiotherapy management of a patient after a lobectomy surgery? (or any lung resection)
Supine positioning for prolonged periods
How does functional residual capacity (FRC) change postoperatively following major thoracic or abdominal surgery?
It decreases due to diaphragmatic dysfunction and shallow breathing
Which breathing technique is most appropriate to prevent postoperative atelectasis?
Diaphragmatic breathing with inspiratory hold
What is the primary goal of physiotherapy in the immediate post-op period for a patient following major thoracic surgery?
Early mobilisation and reducing/preventing respiratory complications
When should a post-thoracic surgery patient begin ambulation as part of the physiotherapy program?
As early as possible, within 24 hours post-surgery if stable
What is the most effective physiotherapy technique to facilitate sputum clearance in a post-op patient who has pain on coughing?
Huffing technique with wound support/splinting
What is the recommended home physiotherapy program for a patient recovering from major abdominal surgery? (eg: hysterectomy, colectomy/hemicolectomy etc)
Progressive ambulation, deep breathing exercises, and supported coughing
What is the most common complication of major thoracic and abdominal surgery?
Pneumonia
What is a primary effect of general anaesthesia on the respiratory system?
Reduced ciliary clearance and atelectasis
What is a key precaution when prescribing chest physiotherapy for a post-op patient with an epidural catheter?
Avoiding excessive spinal flexion or extension during exercises or mobilsation
