Problems and Physiotherapy Management of the General Surgical Patient Flashcards
Aims
- 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
How much does sputum does the average person produce in a day?
(in mls)
100mls
What is the effect of anaesthesia on the CNS?
- Reduced consciousness/ Drowsiness.
What is the effect of anaesthesia on the CVS?
- Reduced BP (blood PA)
- Shock
- Cardiac arrest
What is the effect of anaesthesia on the Urinary system?
- 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 )
What is the effect of anaesthesia on the GI?
- Slows/stops peristalsis —> constipation
- N+V (Nausea and vomiting)
What is the effect of anaesthesia on the Respiratory system?
- Impaired mucociliary clearance
- Reduced lung volumes
- Loss of diaphragm tone.
What is the effect of anaesthesia on Cilia function?
- 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
What is the effect of anaesthesia on the FRC?
Reduced by 15-20%
What is the effect on the lungs if FRC drops below “closing volume”?
- Lungs collapse.
aka Atelectasis
What can cause Atelectasis?
= lung collapse partial or total
- 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.
Reminder
- 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.
Reminder
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.
What problems do we often see/expect from post-op patients?
- 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
Post-op Pulmonary Complications (PPC):
- What is the definition?
- How common is it in post-op patients?
- What is its mortality rate?
- No one definition is used
- PPC incidence post major surgery = 1-23%
- Mortality rate = 14-30%
What are the outcome measures for PPC?
Some include;
- Respiratory infection
- Respiratory failure
- Pleural effusion
- Atelectasis
- Pneumothorax
- Bronchospasm
- Pneumonia
What are the modifiable risk factors for PPC?
- Smoking • Co-morbidity: COPD, CHF, CLD. • Pre-op Anaemia • General anaesthesia • Intra-op ventilation strategies. • Duration of procedure / anaesthetic.
What are the non-modifiable risk factors for PPC?
- Age
- Surgery type
- Investigations – SpO2
What common types of Upper abdominal surgery (UAS)/ Lower GI and surgical incisions?
• Cholecystectomy – Gall bladder • Whipples - Pancreaticoduodenectomy • Hepatectomy • Liver transplant • Hemi-colectomy • Nephrectomy • Bariatric surgery
(Google to find out what these are, DO IT NOW)
What treatment techniques are available for physios to use for post-op patients?
• 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
What is the effect of positioning on a patient, who is put into an upright posture?
- 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.
Which patient would be more suited to Thoracic expansion exercises?
Those who:
- Can listen and follow instructions.
- Are able to take deeper breaths.
How would you carry out/ what instructions would you give to a person when doing thoracic expansion exercises.
• Slow deep breath in. • Lower ribs – bucket handle movement (give some proprioceptive input – hands on) • Inspiratory hold and sniff - collateral ventilation. • 3-4 breaths
What is the purpose of an incentive spirometer?
• Encourages slow deep inspiration
• Provides visual feedback to patient
• Can be useful for patients struggling with thoracic
expansion exercises.
What is the purpose of using Intermittent Positive Pressure Breathing (IPPB)?
• ↑VT • Mobilise secretions - collateral ventilation. • Improved cough strength as ↑ inspiratory volume. • Can use with drowsy patient (face mask).
Reminder for FET
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!!!!!!!!
Reminder for posture and abdominal support
• 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.
Summary
• 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
