Surgery - Cardiopulmonary Flashcards
S/p CABG a few days
+ fever, tachy, CP, leukocytosis, purulent wound discharge
Acute mediastinitis
- complication of cardiac surgery
Need drainage/debridement + prolonged abx
What post op days is atelectasis most common?
day 2 and 3
Preventing atelectasis…
pain control
deep breathing exercises
early mobilization
incentive spirometry
Reason for atelectasis post-op
Pain and changes in lung compliance post op can cause impaired cough and shallow breathing
Shallow breaths:
decrease recruitment of alveoli at lung bases
Weak cough:
causes small airway mucous plugging
Results in hypoxia –> increase RR –> blow off CO2
How do you get hematuria with AAA?
hematuria in AA rupture –> aortocaval fistula w/ IVC –> venous congesion in retroperiteoneal structures (eg bladder) –> fragile and distended veins in bladder can rupture –> gross hematuria
Which diaphragm is more prone to injury?
Left
- congenital weakness in diaphragm’s left posterolateral region
- also liver protective effects on R side
Can have late presentation of diaphragm injury
Use CT to diagnose diaphragmatic injury
How much circulating blood vol can a hemithorax hold?
How much blood is a massive hemothorax?
50% of circulating blood vol
Massive > 1.5 L
Will have FLAT NECK VEINS
Characteristics of hemothorax
tracheal deviation
Reduced breath sounds
dullness to percussion over involved side
flat neck veins (if hypovolemic)
Takotsubo’s cardiomyopathy
is a type of non-ischaemic cardiomyopathy in which there is a sudden temporary weakening of the myocardium (the muscle of the heart). Because this weakening can be triggered by emotional stress, such as the death of a loved one, a break-up, or constant anxiety, it is also known as broken heart syndrome
What kind of heart attack is perioperative MI?
NSTEMI
O2 demand > delivery
Will have increased HR w/ pain, anxiety and also increased contractility –> need more O2 demand but not enough delivery
How do you handle MI sx post-op?
EKG before, 1 day post op, 2 day post op, 7 day post op
Troponins day 1, 2, 7
How can you try and ppx against NSTEMI peri-op?
+ Beta blocker
How do you avoid pulm complications post-op?
Incentive spirometer before and after surgery
DO NOT need PFTs
Cardiac cath MAJOR complications
MDS
MI
Death
Stroke/TIA
Cardiac cath MINOR complications
CHHAAP
Contrast allergy Hemostasis @ access site Hematoma formation (retroperitoneal) AV fistula Arterial thrombosis AKI Pseudoaneurysm Perforation of heart or great vessels
Which bronchus is more commonly injured w/ tracheobronchial perforation 2/2 to blunt thoracic trauma?
Right main bronchus
Confirm w/ CT scan or surgical exploration
Pneumomediastinum causes
Tracheal rupture
Esophageal rupture
ARDS vs. pulmonary contusion
Pulmonary contusion usually within first 24 hrs
ARDS usually 24-48 hrs from trauma
- also, b/l lung involvement usually
Tension pnsumothorax
Life threatening
Air w/in pleural space displacing mediastinal structures
- air can enter pleural space but cannot excape naturally
Findings:
- SOB
- tachycardia
- tachypnea
- HYPOtn
- distension of neck veins (b/c SVC compression)
1/4 of these in hospital caused by placement of subclavian central venous catheters
Tx: needle thoracostomy + emergency tube thoracostomy
When ok to give heparin for aortic dissection?
DO NOT GIVE if it’s ruptured
Give if not ruptured
How high can diaphragm be?
4th thoracic dermatome on R
5th thoracic dermatome on L (nipples)
Cx negative infective endocarditis
HACEK
Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella
UTI associated endocarditis
Enterococci (esp fecalis)
How much blood needed to cause sudden rise in intrapericardial pressure that compresses cardiac chambers and compromises both venous return and CO?
100-200mL
Respiratory quotient
- what is it?
- different values = what?
= Steady state CO2 produced : O2 consumed / unit time
Can be used to make assessments of metabolism in particular organs or in body as whole
RQ = 1 = carbs major nutrient oxidized RW = 0.8 = protein metabolism only RW = 0.7 = fatty acid metabolism only
Ppx for bacterial endocarditis for these procedures:
- dental/oral
- GI/GU
Dental/oral/resp/esoph: - give 1 hr before procedure
- amoxicillin
- clindamycin / cephalosporin / clarithromycin
GI/GU high risk
- ampicillin + gentamicin before and after
- vanco + gentamicin before ONLY
GI/GU mod risk
- amoxicillin / ampicillin before ONLY
- Vanco before ONLY
Cardiac index =
CO / body surface area
CO = SV x HR
What does PCWP via swann ganz catheter represent?
L atrial P
L ventricular EDP
Pulm vasc disease can increase PCWP independent of LAP or LVEDP
Mitral stenosis and regug increase LAP and PCWP and falsely elevated LVEDP in swann ganz catheter reading
PEEP/CAP can alter PCWP on SG catheter
Tx gastric aspiration into tracheal tree
Tracheal intubation and suctioning
Tracheostomy - tips
Trachea should be entered at 2nd or 3rd cartilaginous ring
Central venous pressure
- increasors
- decreasors
Increase
- vasoconstrictor
- PEEP
- mediastinal compression
- hypervolemia
- acute PE (RV overload –> increase RAP0
Decrease
- sepsis
1st branch of ascending aorta
Coronary A
1st branch off internal carotid A
Ophthalmic A
Internal and external carotid relationship
Internal carotid is always posterior
Internal carotid is lower resistance b/c it perfuses the brain
A-a gradient
= PAO2 - PaO2
PAO2 = 150 - PaCO2 / 0.8
Tx hemothorax
Chest tube
Don’t need surgery to stop bleeding usually - will stop by itself if it is the lung bleeding
Need thoracotomy if systemic vessel (intercostal A) is bleeding
Surgery if:
- > 1500 mL blood when chest tube put in
- > 600 mL blood / 6 hrs with CT
Danger of pulmonary contusion and how that plays for tx
Very sensitive to fluid overload
Tx = fluid restriction + diuretics
Can happen from flail chest
Tx myocardial contusion
Troponins are specific - get when sternal fracture
Tx focuses on complications (like arrhythmias)
Ddx subQ emphysema
Rupture of trachea
Rupture of esophagus (usually w/ endoscopy or vomiting)
Tension pneumo
Sudden death in chest trauma pt who is intubated + on respirator
Tx?
Prevent?
Air embolism
also happens when subclavian opened to air (eg central line placement, supraclavicular node bx)
Tx:
- cardiac massage w/ pt L side down
Prevent:
- Trendenlenburg if putting in central line
Vascular ring
congenital defect in which there is an abnormal formation of the aorta and/or its surrounding blood vessels.
The trachea and esophagus are completely encircled and sometimes compressed by a “ring” formed by these vessels, which can lead to breathing and digestive difficulties.
1d old child w/ cyanosis - what do they have? What do you do next? what keeps them alive?
Transposition of great vessels
Echo next
ASD, VSD, or PDA keeps them alive
When do you do a valve replacement for aortic stenosis?
Gradient > 50 mm Hg
1st indication of CHF, angina or syncope
Repair for chronic vs acute aortic regurg?
Chronic - repair when see signs of LV dilatation
Acute - immediate repair! Long term abx needed. Usually 2/2 endocarditis via drugs
What’s the best surgery for mitral regurg?
Valve annuloplasty (preferred over prosthetic replacement)
CAD intervention indication?
If >=1 vessles have > 70% stenosis and the distal vessel is still ok
–> do angioplasty + stent
Triple vessel disease - best to use bypass via internal mammary
Post op care of cardiac pt - if the CO is low, what do you do next?
Find out the PCWP
If it is low, then need more IVF
If it is high, then you have ventricular failure
1st thing you do after pt has a coin lesion on CXR?
Find old xray and compare to see if it was there before, got bigger, etc
Tx central vs peripheral lung cancer.
Indications?
Central = pneumectomy
Peripheral = lobectomy
A minimum of FEV1 = 800 mL is needed post op. Tx w/ chemo and radiation if pt is not a surgical candidate
Subclavian steal syndrome
- pathophys
- signs
- dx
- tx
Arteriosclerosis plaque at origin of subclavian (before vertebrals branch off) lets arm have enough blood at rest but not w/ activity
Arm will try to steal enough to meet higher demands
–> arm will steal blood from brain by reversing flow in vertebral
Signs:
- claudication of arm
- posterior neuro signs (visual sx, equilibrium problems) when arm exercised
Dx:
Duplex scanning when it shows reversal of flow
Tx:
Bypass
When repair AAA?
> 5-6 cm –> elective repair
If grow 1cm/year or faster –> elective repair
Tender AAA (impending rupture)
Back pain in AAA pt (aneurysm is already leaking, rupture is imminent)
Best way to dx thoracic aortic dissection
spiral CT scan
Will have wide mediastinum on CXR
Manage ascending surgically
Descending –> medically w/ HTN control in ICU
Pulmonary contusion
Can be caused by severe blunt chest trauma
Dyspnea
Tachypnea
Chest pain
Hypoxemia WORSENED by intravascular volume explansion
Patchy, irregular alveolar infiltrates in CXR
Square root sign
Constrictive pericarditis
Equalization of pressures in RA, RV, LA, LV
The deep sulcus sign
is when one costophrenic angle appears much ‘deeper’ and more lucent than the other. Additionally, that hemidiaphragm or the adjacent cardiac border may appear much crisper (clearly defined) than the other. It can be confirmed by performing a decubitus film on which air should ascend to the abnormal side.
When a patient is supine, the air rises to the highest part of the thorax, namely the anterior costophrenic sulcus. Instead of seeing the typical lucency around the lung apex, as with an upright CXR, you see it at the base.
Pt has a fall and suspected rib fx. What imaging do you get?
You can just get CXR to r/o any hemithorax, pneumothorax.
You will most likely know it is rib fx so no need for imaging
ONly get rib fractures in:
- children w/ suspected hcild abuse + possible posterior rib fx
- patients w/ cancer
Pneumomediastinum causes
Spontaneous - usually young, fit, skinny men
Related to high inspiratory or expiratory pressures - asthma, intubated patients (often with high PEEP settings such as acute respiratory distress syndrome)
Secondary to a pneumothorax or pneumoperitoneum (e.g. laparoscopy)
Secondary to esophageal perforation (vomiting, instrumentation, tumor)
Traumatic from a tracheal or bronchial rupture
Complication of free basing cocaine
Coin lesions on CXR in lung common in…
areas where fungal disease is prevalent
Coccidio, histo
CXR has coin lesion - what is next step?
CT
- defines lesion
- examines if lymph nodes present
Needle aspiration w/ CT
If CT guided needle aspiration of coin lesion is malignant or indeterminate on needle bx, what do you do?
What is complicatino of needle bx
Resection
complication - PTX
Use of the following in examining lung lesions:
- bronchoscopy
- mediastinoscopy
Bronch = obtain tissue diagnosis and determine location of lesion
Mediastinoscopy = determines state of mediastinal lymph nodes
Tx small cell carcinoma of lung
Chemo b/c usually systemic spread
Most common non-small cell carcinomas
Tx
adenocarcionma
SCC
Stage 1 + 2: Should resect + radiation + chemo - exploratory thoracotomy - lobectomy OR - pneumonectomy (removal of all of lung)
Stage 3
- chemo + radiation
How can you assess percentage of functioning lung tissue pre-pneumectomy?
How about mechanics of respiration?
Percentage - V/Q perfusion scan
Mechanics - spirometry
Suspect pancoast tumor - workup?
CT
Bronchoscopy
Mediastinoscopy
Needle bx of mass
Pancoast tumor
lung cancer in extreme apex of lung in the groove produced by subclavian artery
Invades:
- chest wall
- lower cords of brachial plexus
- subclavian A
- sympathetic ganglia
Results:
- brachial plexopathy
- horner’s syndrome
Tx pancoast tumor
Irradiation for 6 weeks
Surgical resection of invlved chest wall and lung
Pts usually do pretty well
Bronchial adenomas
Types:
- carcionid tumor
- adenocystic carcionmas
Can be malignant!
Often cause atelectasis b/c blcok bronchus
Bronch for definitive diagnosis
Tx: lobectomy
Pleural effusion in older person - work up?
Thoracentesis + pleural bx
Suspicious for malignancy/mesothelioma!
Tx mesothelioma
Very bad prognosis
Extrapleural pneumonectomy
What does it mean when you see air bubbles in the water or PleurVac fo PTX?
There is still an air leak in the patient / the patient still has air in his pleura.
Tx spontaneous ptx
Thorascopic excision of blebs adn pleural abrasion (pleurodesis)
Tx empyema
Abx
Evacuate pus via cehst tube drainage - otherwise risk empyema to become loculated and thoracotomy and decortication is needed to reexpand lung
Reexpand lung
Iatrogenic causes of afib
hypokalemia
fluid overload
esophageal cancer tx
- cervical +upper 1/3
- middle 1/3
- distal 1/3
Cervical - chemo + radiation, resection
Middle - chemo + radiation, resection
Distal - esophagectomy + proximal gastrectomy
Why would someone with suspected esophageal cancer cough constantly?
Could be 2/2 to chronic aspiration from tracheoesophageal fistula b/c tumor erodes into trachea
Anterior mediastinum masses
Teratoma
Thymoma
Thyroid cancer
Hodgkin’s lymphoma
Middle mediastinum masses
Lymphatic tumors Various cysts (Bronchiogenic)
Posterior mediastinum masses
Neurogenic tumos (from nerves and nerve sheaths in the area) - ex: neurilemoma
Who benefits the most from CABG?
3 vessel disease + reduced EF
Best gract patency rate for CABG
Internal mammary A graf
1st step in management for massive hemoptysis
Worry about asphyxiation, not exsanguination
Patent airway asap!
Bronchoscopy is initial procedure b/c can localize bleeding site
Pt w/ recent MI –> EKG later on shows persisten ST elevation and deep Q waves in same leads
SOB – what happened?
LV aneurysm
Systolic diastolic abdominal bruit + HTN + atherosclerosis - what is it?
Renal artery stenosis
NOT ab aorta aneurysm (would maybe have systolic bruit, but not systolic, diastolic)
Tx symptomatic sinus bradycardia
IV atropine + transcutaneous pacing
Pneumonitis (patchy diffuse infiltrates) + colitis in post-bone marrow transplant pt - what is organism?
CMV
Diarrhea suggests CMV! Can be P jiroveci but does not cause diarrhea
Dx pericardial tamponade
US
Tx torsades de pointes
Stop offending agents
+ Mg SO4
