Surgical Interventions

Question 1

Besides technical success what are measures of successful surgeries?

Answer 1

Individuals complete return to full participation in life
Capacity to perform activities
Avoidance of recurrence of problem for which surgery was indicated
Reduced subsequent doctor and hospital based care: readmissions
Lifelong health: annual PT exam for function, risk factor management

Question 2

What is role of PT in acute surgical conditions?

Answer 2

Primary role in identifying individuals at risk of complications
Need for PT indicated by need not condition: restricted mobility, decreased strength, balance, extrinsic factors related to pt care, intrinsic factors related to pt

Question 3

What is effect of thoracic and cardiovascular surgery on cardiopulmonary function?

Answer 3

Invasive and lengthy: 10-15 hours
Require heavy and prolonged anesthesia/sedation
Typically performed on older adults
Generally associated with increased risk

Question 4

What are factors contributing to increased cardiopulm risk?

Answer 4

Type of surgery, anesthetics, procedures involved
Duration of surgery, incisions, body positioning
Lines, leads, tubes, catheters, monitoring devices
Perioperative anxiety, discomfort, pain
Perioperative fluid balance, blood and plasma transfusion

Question 5

What is effect of anesthesia on the body?

Answer 5

Results in depression of breathing
Thoracic respiratory excursion is significantly reduced
Tone and pattern of contraction of respiratory muscles change: diaphragm ascends into chest by 2 cm, decreased TLC, supine procedures have greatest effect
Airway closure occurs with anesthesia and contributes to intra pulmonary shunting
Compression atelectasis occurs when lung tissue and surrounding structures are being physically manipulated
Airway resistance increased with breathing circuits, valves and tracheal tubes
Airways can be obstructed with: blood, fluid, bronchospasm d/t irritation of airways
WOB is increased

Question 6

What is role of PT in perioperative care?

Answer 6

Assess pre surgical hemodynamic response
Premorbid cardiopulmonary fitness, cardiac dysfunction
Lung dysfunction, smoking history
Neuromuscular dysfunction
Effects of age, obesity, diabetes, compromised systems
Body position, transfers, bed mobility, ther ex

Question 7

What are the different surgical procedures?

Answer 7

Thoracotomy
Posterolateral thoracotomy
Anterolateral thoracotomy
Lateral thoracotomy
Median sternotomy
Thoracoabdominal incisions

Question 8

What are characteristics of thoracotomy’s?

Answer 8

Surgeon preference for approach to lung resection

Diaphragmatic procedures performed through lateral or thoracoabdomoinal incision

Question 9

What are characteristics for posterolateral thoracotomy?

Answer 9

Operative side elevated (1/4 turn from prone)
Uppermost arm elevated forward and flexed at elbow and behind head
Incision downward between 4th thoracic vertebrae and the scapula: serratus anterior divided close to origin to preserve function, avoid long thoracic nerve

Question 10

What is position for anteroloateral thoracotomy? Lateral?

Answer 10

Anterior: operative side elevated 1/4 turn from supine, uppermost arm elevated forward and placed beneath back, retracts latissimus dorsi
Lateral: side lying, operative side up, arm abducted flexed at elbow and rotated, latissimus is not incised but moved ant/post and fibers of serratus anterior incised, careful to preserve long thoracic nerve

Question 11

What are characteristics of median sternotomy?

Answer 11

Frequently used incision for cardiothoracic surgery
Patient is supine
Extends below xiphoid process, sternum divided along midline, sternal retractor holds incision open, sternum closed with stainless steel sutures, incision closed in layers

Question 12

T/F: thoracoabdominal incisions allow for procedures on diaphragm, esophagus, biliary tract, right lobe of liver and kidneys

Answer 12

True

Question 13

what are coronary artery revascularization procedures?

Answer 13

Use an inflatable device to increase lumen size
Use peripheral access site into coronary arteries to site of lesion
Contrast dye to assess blood flow
Risk associated with these procedures
Short length of stay

Question 14

What is PCTA and when is it used?

Answer 14

Percutaneous transluminal coronary angioplasty
Used when lesion does not completely occlude lumen on coronary artery
Lesion penetrated, balloon placed at distal aspect of catheter and inflated: presses central portion outward against wall of artery, can start with small catheters and progress to larger ones to increase lumen size

Question 15

What are endoluminal stents?

Answer 15

Tiny spring like devices placed into stenotic lesion
Once positioned they are inflated and remain in place
Increase luminal diameter to restore blood flow
40% reduction in coronary bypass surgery within 1 year follow up

Question 16

When is a CABG used and what is the procedure?

Answer 16

Used when artery becomes completely occluded
Venous grafts come from either or both saphenous veins
Median sternotomy performed, pt on heart/lung machine
Graft placed above and below lesion site
Chest wall closed and recovery process begins

Question 17

What are CABG patients at risk for?

Answer 17

Pulmonary infection
Chest wall soreness
Leg discomfort/infection

Question 18

What is function of cardiac pacemakers? Considerations for PT?

Answer 18

Used to eliminate hemodynamic compromise d/t inadequate cardiac output
Electronic pulse generator: creates artificial action potential, electrical voltage difference between the two electrodes, controls some arrhythmias (2 or 3 degree heart block, tachycardia, bradycardia)
Considerations: any precautions associated with exercise

Question 19

What is function of implantable cardioverter defibrillator and who benefits from it?

Answer 19

Similar to pacemaker but designed to correct life threatening arrhythmias
Detects and corrects all tachycardias, bradycardias, and v fib
ICD implanted into the pt and a separate programmer used to change the function of the ICD
Benefits: individuals for LVEF less than 30%, reduced risk for sudden death d/t arrhythmias (ie frequent or complex PVCs or non sustained ventricular tachycardia)

Question 20

What is purpose of carotid endarterectomy and who are candidates for it?

Answer 20

Prevent stroke caused by atherosclerotic plaques
Procedure: surgical incision along anterior border of SCM, pt left with incision on lateral aspect of neck
Candidates: symptomatic pt with carotid stenosis greater than 70%, symptomatic pt with stenosis of 50-69% of carotid artery, asymptomatic pt with stenosis of 60% or greater

Question 21

What’s possible supplemental O2 after post op?

Answer 21

Low flow oxygen delivery (fiO2): delivered via nasal cannula, reduces hypoxemia and intrapulmonary shunting
High flow oxygen delivery (fiO2): delivered via oxygen masks

Question 22

What happens to breathing after surgery?

Answer 22

Shallow monotonous tidal ventilation: reduced normal occasional spontaneous deep breaths, can cause alveolar collapse within one hour
Tachypnea with gross atelectasis d/t hypoventilation
Decreased breath sounds at bases, coarse wheezes with mucus obstructing flow
Left lower lobe atelectasis is common after cardiac surgery

Question 23

Why is rest prescribed during post op period?

Answer 23

healing, repair, recovery
Night sleep more biologically restorative than day sleep
Prolonged periods of rest can be deleterious: rest periods during day and in between sessions, monitor physiological signs, bed positioning changes, transfer, sit in chair and ambulate

Question 24

What is systematic sequence for mobilization post op? What are considerations for pt progress?

Answer 24

Supine to turning in bed, sitting over bed, standing, sitting in chair, walking
Patients progress at different rates: encourage body positioning otherwise pts will assume supine position for extending periods of time

Question 25

What are goals of PT in post op period?

Answer 25

Maximize pt ability to perform ADLs
General muscle strength and endurance
Maximize muscle and soft tissue length and ligament integrity
Normal arousal and neurological function
Skin integrity
Prescribe secondary prevention

Question 26

What is role of PT in post op care?

Answer 26

Coordinate mobilization and body position with deep breathing and supported coughing maneuvers
Know precautions (movement restrictions) associated with surgical procedures
Early mobilization beneficial for pt s/p surgery
Cardiac revascularization procedures are most common: short LOS, OP cardiac rehab