Problems and Physiotherapy Management of the General Surgical Patient

Question 1

Aims

Answer 1

• Describe impairments and the underlying pathophysiology of common cardiorespiratory
  issues following general surgery

• Describe possible physiotherapy problems following general surgery

• Justify an evidence-based physiotherapy treatment plan for managing a patient
following upper abdominal surgery

• Select and critically evaluate appropriate research evidence that explore the
physiotherapy management in the general surgical patient

Question 2

How much does sputum does the average person produce in a day?
(in mls)

Answer 2

100mls

Question 3

What is the effect of anaesthesia on the CNS?

Answer 3

• Reduced consciousness/ Drowsiness.

Question 4

What is the effect of anaesthesia on the CVS?

Answer 4

• Reduced BP (blood PA)
• Shock
• Cardiac arrest

Question 5

What is the effect of anaesthesia on the Urinary system?

Answer 5

• Acute renal failure
• Urinary retention
• Dehydration –> less fluid —> infection.

(Due to lower blood pa, renal arteries will be impacted and have a consequence to your urinary system )

Question 6

What is the effect of anaesthesia on the GI?

Answer 6

• Slows/stops peristalsis —> constipation

- N+V (Nausea and vomiting)

Question 7

What is the effect of anaesthesia on the Respiratory system?

Answer 7

• Impaired mucociliary clearance
• Reduced lung volumes
• Loss of diaphragm tone.

Question 8

What is the effect of anaesthesia on Cilia function?

Answer 8

• Dry O₂ –> dehydration peri-ciliary and mucus layer.
• Reduced ciliary beat frequency after 60mins of anaesthetic which is restored after 60-90 mins.
• Mucociliary clearance stops after 90minutes.
• Secretion retention –> Infection

Question 9

What is the effect of anaesthesia on the FRC?

Answer 9

Reduced by 15-20%

Question 10

What is the effect on the lungs if FRC drops below “closing volume”?

Answer 10

• Lungs collapse.

aka Atelectasis

Question 11

What can cause Atelectasis?

= lung collapse partial or total

Answer 11

• Compression atelectasis; Chest geometry and diaphragm position and movement.
• Absorption Atelectasis: High FiO2 –> reduced nitrogen.
• Loss of surfactant atelectasis: Impede surfactant function, predisposing to repeated collapse.

Question 12

Reminder

Answer 12

• Major surgery results in large volume fluid/blood loss.
• Important to be aware of fluid balance as part
  of multi-systems assessment. Consider impact
  of fluid overload and dehydration. e.g., peripheral oedema.

Question 13

Reminder

Answer 13

Impaired Cough Mechanism

• Restrictive pattern of vent - incision, oedema.
• Reduced Tidal Volumes and Vital Capacity
• Impaired contraction and co-ordination of
expiratory mm.
• Pain - Anxiety / Fear!!
Potential secretion retention.

Question 14

What problems do we often see/expect from post-op patients?

Answer 14

• Pain
• Reduced FRC
• Reduced TV
• Poor cough
• Secretion retention (affecting gas exchange and possibly leading to infection)
• Reduced mobility
• MSKK problems; e.g., long term LBP

Question 15

Post-op Pulmonary Complications (PPC):

• What is the definition?
• How common is it in post-op patients?
• What is its mortality rate?

Answer 15

• No one definition is used
• PPC incidence post major surgery = 1-23%
• Mortality rate = 14-30%

Question 16

What are the outcome measures for PPC?

Answer 16

Some include;

• Respiratory infection
• Respiratory failure
• Pleural effusion
• Atelectasis
• Pneumothorax
• Bronchospasm
• Pneumonia

Question 17

What are the modifiable risk factors for PPC?

Answer 17

- Smoking
• Co-morbidity: COPD, CHF, CLD.
• Pre-op Anaemia
• General anaesthesia
• Intra-op ventilation strategies.
• Duration of procedure / anaesthetic.

Question 18

What are the non-modifiable risk factors for PPC?

Answer 18

• Age
• Surgery type
• Investigations – SpO2

Question 19

What common types of Upper abdominal surgery (UAS)/ Lower GI and surgical incisions?

Answer 19

• Cholecystectomy – Gall
bladder
• Whipples -
Pancreaticoduodenectomy
• Hepatectomy
• Liver transplant
• Hemi-colectomy
• Nephrectomy
• Bariatric surgery

(Google to find out what these are, DO IT NOW)

Question 20

What treatment techniques are available for physios to use for post-op patients?

Answer 20

• Positioning
• Thoracic expansion exercises (TEE’s)
• Incentive spirometry
• Intermittent Positive Pressure Breathing
(IPPB)
• Forced Expiratory Technique (FET)
• Supported cough
• Early mobilisation
• Ensure adequate pain relief/analgesia

Question 21

What is the effect of positioning on a patient, who is put into an upright posture?

Answer 21

• In supine FRC is reduced up to 40%.

So in an upright position:
- ↑FRC, TV and TLC.
• Improved V/Q matching in upright posture.
• ↑ oxygenation (PaO2).
• ↑ diaphragm excursion.
• ↑ expiratory flow rates.
• ↑ cough and clearance of secretions.

Question 22

Which patient would be more suited to Thoracic expansion exercises?

Answer 22

Those who:

• Can listen and follow instructions.
• Are able to take deeper breaths.

Question 23

How would you carry out/ what instructions would you give to a person when doing thoracic expansion exercises.

Answer 23

• Slow deep breath in.
• Lower ribs – bucket handle
movement (give some proprioceptive
input – hands on)
• Inspiratory hold and sniff - collateral
ventilation.
• 3-4 breaths

Question 24

What is the purpose of an incentive spirometer?

Answer 24

• Encourages slow deep inspiration
• Provides visual feedback to patient
• Can be useful for patients struggling with thoracic
expansion exercises.

Question 25

What is the purpose of using Intermittent Positive Pressure Breathing (IPPB)?

Answer 25

• ↑VT
• Mobilise secretions - collateral
ventilation.
• Improved cough strength as ↑
inspiratory volume.
• Can use with drowsy patient (face
mask).

Question 26

Reminder for FET

Answer 26

Supported Huff / Cough
• Support for abdominal muscles.
• Place towel / pillow over incision site. helps give them more confidence too.
• Reduces anxiety.
• FET more comfortable than coughing.
• Equal pressure point changes with
differing lung volumes, moving
secretions mouth wards (see previous
lecture for more detail on EPP)

Ensure you have a good FET instructions, need to practice this!!!!!!!!

Question 27

Reminder for posture and abdominal support

Answer 27

• Wound pain, anxiety → flexed, antalgic posture.
• Restricts bucket handle movement.
• May affect scar healing and cause contracture
• Surgery dissects deep stabilising abdominal
mms.
• ? Development of LBP in longer term.

So ensure you remind them that when they’re not doing the exercises that they ensure their posture correct and not hunched.

Question 28

Summary

Answer 28

• Surgery alters normal mechanics of breathing and mucociliary clearance
mechanisms
• Anaesthesia results in disruption of cilia function and reduced FRC
• Atelectasis common problem post abdominal surgery - diaphragm dysfunction,
secretion retention
• Abdominal wound impairs cough mechanism
• Multiple attachments often limit mobility post-op
• Pain can significantly impair function and status post op
• PPC delay recovery, cause of mortality and morbidity post op
• Physio aims to improve respiratory function
• Positioning useful tool to enhance lung volumes and secretion clearance
• Early mobilisation addresses all components of O2 transport pathway