Thoracic Surgery Flashcards
What are the typical clinical signs of thoracic conditions?
Tachypnoea
Orthopnoea/hyperpnoea/dyspnoea/abdominal breathing
Cough?
Pale MMs (cyanosis)
Exercise intolerance, collapse
Injuries? Systemic illness?
What initial management can be given to thoracic patients?
Oxygen therapy
Wound management - assess, flush, protect
Temperament - mild sedation?
What samples can we initially take from thoracic patients?
Bloods
Thoracocentesis for cytology and culture
How can we decide between using radiography and ultrasonography for thoracic patients?
Restraint for radiography can be life-threatening in dyspnoeic patients
Nurses can use TFAST scan for triaging
What are the surgical thoracic conditions?
Pneumothorax
Chest and lung trauma
Pulmonary blebs or bullae
Diaphragmatic rupture (abdominal approach!)
Pleural effusion
Pyothorax
Pericardial effusion
Pulmonary neoplasia
Describe an internal/closed pneumothorax.
More life-threatening!
Oesophagus/respiratory tract (trachea/small airways)
Describe an external/open pneumothorax.
Hole in the chest
Chest trauma e.g. dog attack
Iatrogenic e.g. post-lung lobectomy, diaphragmatic rupture, complications of thoracocentesis/thoracostomy
What are the clinical signs of pneumothorax?
Dyspnoea!
Lethargy
Cough
Exercise intolerance
How can we diagnose pneumothorax?
Unilateral/bilateral
Thoracocentesis
How can we treat pneumothorax?
Chest drain (may need bilateral drains if mediastinum intact)
Thoracotomy - massive air leak/ongoing and not sealing itself
How can patients get chest and lung trauma?
Accidents e.g. RTA/train, fall of cliff, impaling injury
Attack e.g. big dog, human, accidental vs deliberate
What are the clinical signs of chest and lung trauma?
Shock!
Dyspnoea
Soft tissue damage (extensive open wounds / progressive bruising/crushing wounds)
Ortho damage (rib fractures e.g. flail chest, other parts of skeleton)
What complications can we see with chest and lung trauma patients?
Infection/inflammation - depends on cause of trauma/degree of contamination
Healing - can be delayed/breakdown common depending on degree of tissue loss
Ongoing effusion/pneumothorax - depends on amount of trauma/tissue injury
What is the difference between pulmonary blebs and pulmonary bullae?
Blebs = on edges of lobes
Bullae = within lobes
What is the typical signalment for pulmonary blebs/bullae?
Large-breed, deep-chested dogs
What are the clinical signs of pulmonary blebs/bullae?
None if not ruptured!
Non-specific e.g. lethargy, anorexia, exercise intolerance
Respiratory - progressive e.g. sudden onset dyspnoea, tachypnoea/orthopnoea/coughing OR peracute e.g. spontaneous closed tension pneumothorax (if ruptured!)
How can we diagnose pulmonary blebs/bullae?
Radiography (diagnose pneumothorax but cannot localise affected lobes)
CT (assess which lobes affected, needed before surgery)
How can we surgically treat pulmonary blebs/bullae?
Thoracotomy and lung lobectomy (depending on how many lobes affected)
How can we conservatively manage pulmonary blebs/bullae?
Intermittent thoracocentesis / indwelling chest drain
How do patients get diaphragmatic rupture?
Blunt force trauma e.g. RTA, fall
What are the clinical signs of diaphragmatic rupture?
Can be peracute, acute or chronic
Can have no signs or just vague ill health
Dyspnoea, shock
Tachypnoea, orthopnoea
What affects severity of clinical signs of diaphragmatic rupture?
Herniation (what organs? How much torsion? Compressed thoracic contents?)
Size of tear
How can we initially stabilise diaphragmatic rupture patients?
Oxygen therapy
Analgesia
IVFT
How can we surgically treat a diaphragmatic rupture?
Explore chest and abdomen
Reposition abdo contents/remove if devitalised
Repair and debride as necessary
Chest drain due to iatrogenic pneumothorax
What are the clinical signs of a pleural effusion?
Dyspnoea!
Lethargy
Cough
Exercise intolerance
How can we diagnose a pleural effusion?
Unilateral / bilateral
Imaging
Thoracocentesis - SG, cytology, culture and sensitivity
Which conditions causing pleural effusion are medical?
CHF
Pyothorax (cat)
Which conditions causing pleural effusion are surgical?
Pyothorax (dog)
Diaphragmatic rupture
What is typical canine and feline aetiology of pyothorax?
Bacterial infection - E. coli in dogs / Pasteurella in cats
Cats - idiopathic e.g. bites, extensions from pulmonary abscesses
Dogs - FBs, oesophageal tears, pulmonary infections
What are the clinical signs of pyothorax?
Lethargy, inappetence, pyrexia
Dyspnoea due to effusion
How can we diagnose pyothorax?
Imaging e.g. radiographs, ultrasound
Cytology and culture of effusion
How can we conservatively manage pyothorax in cats?
Systemic antibiotics
Chest drain +/- lavage
How can we surgically treat pyothorax?
Typically done early in dogs due to high % of FBs
Sternotomy - explore, remove, debride, flush THEN post-op medical management
What are the typical aetiologies of pericardial effusion?
Idiopathic
Neoplastic
What are the clinical signs of pericardial effusion?
Cardiac tamponade
Depends on how quickly fluid forms - does pericardium have time to stretch?
How can we diagnose pericardial effusion?
Imaging e.g. radiography, echocardiography, advanced
Cytology to rule in/out neoplasia
How can we treat pericardial effusion?
Repeated pericardiocentesis
Surgery - pericardiectomy (does not prevent effusion forming! Prevents cardiac tamponade and converts into pleural effusion)
Chest drain
What are the possible complications of pericardial effusion treatment?
Recurrence after draining/surgery
Long-standing effusion causes adhesions
Describe which aetiologies of pulmonary neoplasia are most common.
Malignant more common than benign - benign is very rare!
Secondary metastases far more common than primaries
What are the clinical signs of pulmonary neoplasia?
None!
Non-specific e.g. non-productive cough, haemoptysis, dyspnoea, weight loss, exercise intolerance, anorexia
Hypertrophic pulmonary osteopathy (paraneoplastic syndrome) - very painful!
How can we diagnose pulmonary neoplasia?
Biochem, haematology, urinalysis +/- cytology
Imaging - inflated radiographs / advanced imaging
How can we treat pulmonary neoplasia?
Palliative
Surgery - thoracoscopy / thoracotomy
What affects the prognosis of pulmonary neoplasia patients?
Presence of mets
Histopathology
Clean/dirty surgical margins
What considerations should we have for nursing thoracotomy patients?
Analgesia, hypothermia, IPPV once thorax open
Monitoring - pain score, TPR
Appropriate drug regime
Surgical site/wound management
Body bandages
IVFT, urinary catheters, feeding tubes
Chest drains
Define thoracocentesis.
Procedure involving the puncture of the pleural space for diagnostic and/or therapeutic purposes
What equipment do we need for thoracocentesis?
Oxygen
Local anaesthetic
Sterile prep + gloves/drape
Needle / IV catheter / butterfly catheter
+/- extension set
Assistant
3-way tap
20ml syringe
Kidney dish/jug
What samples can we collect from thoracocentesis?
EDTA, heparin, plain tubes - cytology, biochem, culture
Smear for cytology
Check specific gravity bed-side
+/- Diffquik staining
Define chest drain.
A tube placed into the pleural space to allow ongoing, continuous or intermittent therapeutic drainage
What does the decision to place a chest drain usually depend on?
Underlying disease (if fluid/air continuing to be produced)
Quantity of fluid/air being produced
Patient temperament
Treatment plan (if going to thoracotomy)
When is a chest drain usually placed?
Intermittent thoracocentesis not working - too much fluid/air being produced/fluid too thick/causing lung trauma
Following thoracotomy - remove fluid/air introduced during surgery/produced due to underlying condition/due to complications of surgery
Long-term pleural drainage e.g. pneumothorax due to underlying disease, pleural effusion
Instillation of medication e.g. LAs, saline for lavage of pyothorax, antibiotics, chemotherapy
What are the types of chest drain?
Size - large bore / narrow bore
Placement - trocar / Seldinger technique
What factors affect which chest drain is selected for placement?
Type e.g. trocar/narrow bore/PleuraPort
Size (6Fr to 20Fr)
Placement method e.g. open/closed chest
Site (unilateral vs bilateral)
Connectors
Securing e.g. roman sandal sutures/anchor flanges with simple sutures
Protecting e.g. body bandages, buster collars
Describe trocar-style chest drains.
Fenestrated with or without stylet
Commonly placed under GA
Subcut tunnel required as air leaks common
Rigid so easy to place where wanted
What are the pros of trocar-style chest drains?
Lots of different sizes available
Versatile, larger bore so less likely to block
Robust/do not collapse
Transparent so can monitor for clogs in tube
What are the cons of trocar-style chest drains?
Need GA to place
Higher complication rate than narrow bore
Need careful training to place
Need good suture technique for anchoring
Less comfy than narrow bore
Describe a narrow bore/Seldinger technique chest drain.
More expensive tube than trocar, but cheaper to place as no GA needed
Less need for subcut tunnel as air leaks less likely
Easy to place
What are the pros of narrow bore chest drains?
No GA
Easy to place
Easy to secure
Versatile
More comfy
What are the cons of narrow bore chest drains?
May not cope with pleural fluid / pyothorax
Not as rigid so can be more difficult to place cranioventrally
When would we use a PleuraPort chest drain?
Palliative care where long-term drainage required
What equipment do we need to place a chest drain in a closed chest?
Sterile prep + gloves
Anaesthetic e.g. GA/LA
Assistant
Chest drain pre-measured for length
Scalpel and blade
Basic instrument kit
Fenestrated drape
3-way tap
Syringes
Extension set
Kidney dish/jug
Suture
Describe intermittent drainage of a chest drain.
Care of connectors particularly important!
Typically every 4-8hrs and/or determined by resp rate/dyspnoea
Describe continuous drainage of a chest drain.
E.g. Heimlich valve/commercial drainage unit
Used most often with large air-leak pneumothorax cases
Care with suction level as can collapse tube/aspirate tissue
What analgesia can we consider for chest drains?
Local e.g. lidocaine / bupivacaine down the drain
Opioids e.g. methadone/buprenorphine
CRIs e.g. ketamine/lidocaine (no lido in cats)
Paracetamol in dogs
NSAIDs to go home
What issues with placement can we see with chest drains?
Unable to place
Incorrect placement (went caudal, stuck in mediastinum)
Use X-ray to check placement!
What can lead to chest drains failing to drain?
Accidental removal
Tube disconnection/obstruction/kinking
Patient interference!
What iatrogenic complications can we see with chest drains?
Haemorrhage/haemothorax
Heart/lung damage
Premature removal leading to recurrence
Nerve damage
Pneumothorax (check connectors/fenestrations)
Pyothorax (aseptic technique)
Seroma (self-resolving)
Subcutaneous emphysema (around skin incision, self-resolving once tube removed)
List the four options for thoracic surgery.
Left lateral intercostal thoracotomy
Right lateral intercostal thoracotomy
Ventral sternal thoracotomy / sternotomy
Thoracoscopy
Describe an intercostal thoracotomy.
Less painful than sternotomy
Unilateral surgery - correct side to approach? Correct intercostal space?
Describe a sternotomy.
More painful
Better for exploratory thoracotomy
Better for bilateral conditions
Describe thoracoscopy.
Least painful
Steep learning curve
Specialised equipment
Some limitations in which procedures appropriate
What groups of instruments do we need for thoracic surgery?
Long-handled basics e.g. tissue forceps/scissors/needleholders
Retractors
Tissue forceps
Sternotomy instruments (to break bone)
What miscellaneous items might we need for thoracic surgery?
Lap swabs
Wire/thick suture
Suction
Pre-selected chest drain and connectors
Tourniquet
Pledget sutures
Vessel loops
What are the basic electrosurgery types?
Monopolar (need earthing pad to prevent patient burns)
Bipolar
What is a pneumonectomy?
Removal of one half of the lungs!
Cope surprisingly well - expands to fill the chest
Describe sutures vs staplers for lung lobectomy.
Sutures = slow, challenging, higher risk of leakage
Staples = quick, lower risk of leakage, more expensive, steep learning curve
Describe leak testing.
Should always be done after a lung lobectomy!
Fill chest with warm saline
IPPV - check for air bubbles
Suction fluid back out once happy no leaks
