Period Cardioresp

Question 1

Cardioresp

1. What is atelectasis
2. Pathophysiology
3. Risk factors in the surgical patient
4. Clinical Features
5. Ix
6. Management
7. Prevention

Answer 1

1. partial collapse of the small airways

majority of post-op patients will develop some degree of atelectasis, resulting in abnormal alterations in lung function or compromise to the lung’s immune defences.

2. Suggested airway compression + alveolar gas resorption intra-operatively + impairment of surfactant production.

The reduced airway expansion and subsequent accumulation of pulmonary secretions -> pulmonary complications e.g. hypoxaemia, reduced lung compliance, pulmonary infections, and acute respiratory failure.

The degree of lung tissue involved is variable, depending on the underlying cause. Most cases seen are in the post-operative period, typically developing within 24 hours of surgical intervention.

3. Age, Smoking, general anaesthesia, Duration of surgery, Pre-existing lung or neuromuscular disease, Prolonged bed rest (especially with limited position changes), Poor post-op pain control (resulting in shallow breathing)
4. most common clinical features are increased RR and reduced O2 sats

O/e: may have fine crackles over the affected pulmonary tissue and a reduced oxygen saturation; some cases can also produce a low-grade fever.

5. typically clinical,

within 24hrs of surgery

CXR can show small airway collapse

6.

• deep breathing exercises and chest PT -> airways are opened maximally and coughing can be performed effectively.
• Adequate pain control -> deep breathe
• no significant improvement is seen following physiotherapy, bronchoscopy may be required to aid in suctioning out pulmonary secretions, however is not routinely performed

7. chest physio

Question 2

1. Pneumonia is defined as a LRTI with accompanying consolidation visible on CXR. There are four main types of pneumonia:
2. Surgical patients are predisposed to developing LRTI due to a combination of:
3. Risk factors for developing HAP include:
4. Clinical Features
5. DD
6. Ix
7. Management
8. Complications
9. What is aspiration pneumonia, ~ effects?

In surgical patients, the main risk factors for an aspiration are:

Answer 2

1.

• Community-acquired pneumonia (CAP)
• Hospital-acquired pneumonia (HAP) onset >48hrs since hospital admission
• Aspiration pneumonia
• Immunocompromised pneumonia

2.

• Reduced chest ventilation – reduced mobility in bedridden patients results in an inability to fully ventilate their lungs, leading to accumulation of fluid secretions which subsequently become infected
• Change in commensals – E. coli, S. aureus (including MRSA), S. pneumoniae, and Pseudomonas
• Debilitation – many patients undergoing surgery are likely to be sick or have several co-morbidities, compromising their immune systems and predisposing to pulmonary infections
• Intubation – patients undergoing major surgery may need a stay in ICU and require intubation and ventilation, a major risk factor for a HAP

3.

• Age
• Smoking (current or previous)
• Known respiratory disease or recent viral illness
• Poor mobility (either baseline or post-operatively)
• Mechanical ventilation
• Immunosuppression
• Underlying co-morbidities, such as diabetes mellitus or cardiac disease

4. cough (productive or non-productive), dyspnoea, or chest pain, malaise, pyrexia, impaired cognition, or changes in physiological parameters.

O/e: reduced oxygen saturation, increased RR or HR, pyrexial, or with features of a septic response.

Bronchial breath sounds (localised or diffuse) and inspiratory crackles may be heard on auscultation, dull percussion note.

5. acute HF or ACS, PE, asthma or COPD exacerbation, pleural effusion or empyema, and psychological (e.g. anxiety disorder).

6.

• Lab: routine bloods (FBC, CRP, and U&Es)
• ABG: type 1 respiratory failure, or a type 2 failure
• sputum sample +/- blood culture
• Imaging: CXR -> consolidation*, either lobar or bronchopneumonia

7. Mild: Co-amoxiclav 625mg oral TDS

Moderate: Co-amoxiclav 625mg oral TDS

Severe: Tazocin 4.5g TDS IV

chest physio

8. Pleural effusion, Empyema, Respiratory failure, Sepsis
9. Chemical pneumonitis, only an infection if orophargeal bacteria in the lung

right middle or lower lung lobes

• Reduced GCS (e.g. secondary to anaesthesia)
• Iatrogenic interventions (e.g. misplaced NG tube)
• Prolonged vomiting without NG tube insertion
• Underlying neurological disease
• Oesophageal strictures or fistula
• Post-abdominal surgery

Mainly preventative, identifying the patients who are at an increased risk:

• (e.g. NG tube feeding), this will require involvement from both the nursing staff and the Speech and Language Therapists (SALT).
• Any pneumonitis only supportive, but aspiration pneumonia will need Abx therapy, similar to that of HAP. Suction of any aspirated contents is rarely performed as has no real benefit to overall outcomes.

Question 3

1. Two level DVT wells score

Answer 3

Question 4

Two-level PE Wells Score (explain)

1. Clinical Features

Answer 4

1. unilateral leg pain and swelling. Other symptoms include low-grade pyrexia, pitting oedema, tenderness or prominent superficial veins. Importantly, 65% of DVTs are asymptomatic.

Question 5

What tests would you order? (DVT)

Answer 5

Question 6

What treatments are available for this patient? How soon should it be started?

What preventative measures are you aware of to try to prevent this problem?

Answer 6

DVT first line now DOACs (direct factor Xa inhibitors)

e.g. apixaban, rivaroxaban, and edoxaban

Direct thrombin inhibitor, dabigatran

Dabigatran and edoxaban require initial treatment with LMWH (>5 days) before commencement of the DOAC, whereas rivaroxaban and apixaban do not

Anticoagulation treatment should be continued for:

3 months in those with a provoked DVT

Proximal DVT and a persistent risk factor or high risk of DVT recurrence may require lifelong anticoagulation

Question 7

a. Complications of a DVT
b. Clinical Features
c. Investigation and Management

Answer 7

a. image
b. sudden onset dyspnoea, pleuritic chest pain, cough, or (rarely) haemoptysis. Clinically, a patient may have tachycardia, tachypnoea, pyrexia, a raised JVP (rare), or pleural rub or pleural effusion (rare). Remember to examine for any signs of DVT in any patient with suspected PE.

c.

• Score less than or equal to 4 – PE clinically unlikely, requires a further D-dimer test to exclude*
• Score greater than 4 – PE clinically likely and a PE diagnosis should be confirmed with a CT Pulmonary Angiography (CTPA) scan (or V/Q scan in those with poor renal function).

*A D-dimer test is sensitive but not specific; a D-dimer may also be raised following recent surgery or trauma, with ongoing infection or inflammation, concurrent liver disease, or pregnancy, and indeed in any patient with a prolonged hospital stay.

An ECG should be performed due to the differential diagnosis of MI, however this most commonly shows no abnormalities or a sinus tachycardia*.

*Less commonly, a PE may present on ECG with a right bundle branch block (RBBB), RV strain (inverted T waves in V1-V4 and / or leads AvF-III), or a rare S1Q3T3 (deep S wave in Lead I, pathological Q wave in Lead III, and inverted T wave in Lead III)

For haemodynamically stable PEs, management is much the same as for DVTs, as discussed above. For those with suspected PEs causing haemodynamic compromise, thrombolysis may be warranted however will require input from medical and intensive care teams.

Recurrent PEs known secondary to recurrent DVTs, despite pharmacological management, should be considered for IVC filter.

Question 8

1. Acute respiratory distress syndrome (ARDS) is?
2. Pathophysiology: The causes of acute respiratory distress syndrome can be divided into direct and indirect:
3. Clinical Features
4. Investigations
5. The management of ARDs is twofold; (i) supportive treatment with ventilation, and; (ii) focused treatment of the underlying cause. It is highly likely that patients will require emergency intubation and ITU admission for respiratory and circulatory support.

The specific goals of ITU management of ARDS are complex, focusing on limiting the inflammatory cascade and alveolar oedema. However, the main aspects of management involve:

Answer 8

1. A form of acute lung injury: severe hypoxemia in the absence of a cardiogenic cause.
2. Direct: Pneumonia, Smoke inhalation, Aspiration, Fat embolus

Indirect: Sepsis, Acute pancreatitis, Polytrauma

3.

• ARDs presents with (worsening) dyspnoea, usually in the presence of a related risk factor or underlying cause.
• This then rapidly leads to hypoxia, tachycardia, and tachypneoa, with inspiratory crackles on auscultation.

4.

• Routine bloods (including full blood count, urea and electrolyte, amylase, and C-reactive protein)
• Blood cultures
• Arterial blood gas
• Chest radiograph (CXR)
• Classically shows diffuse bilateral infiltrates, similar to that of pulmonary oedema.

5.

• Maintaining the minimum intravascular volume required to ensure adequate tissue perfusion, thus limiting excess oedema
• Lower tidal volumes used in ventilation, reducing shear forces from over-distension and ventilator-associated lung injury
• Positive end-expiratory pressure, splinting airways and avoids the damage caused by the cyclical opening of alveoli