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Applied Clinical Veterinary Nursing > Thoracic Surgery > Flashcards

Thoracic Surgery Flashcards

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1
Q

What are the typical clinical signs of thoracic conditions?

A

Tachypnoea
Orthopnoea/hyperpnoea/dyspnoea/abdominal breathing
Cough?
Pale MMs (cyanosis)
Exercise intolerance, collapse
Injuries? Systemic illness?

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2
Q

What initial management can be given to thoracic patients?

A

Oxygen therapy
Wound management - assess, flush, protect
Temperament - mild sedation?

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3
Q

What samples can we initially take from thoracic patients?

A

Bloods
Thoracocentesis for cytology and culture

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4
Q

How can we decide between using radiography and ultrasonography for thoracic patients?

A

Restraint for radiography can be life-threatening in dyspnoeic patients
Nurses can use TFAST scan for triaging

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5
Q

What are the surgical thoracic conditions?

A

Pneumothorax
Chest and lung trauma
Pulmonary blebs or bullae
Diaphragmatic rupture (abdominal approach!)
Pleural effusion
Pyothorax
Pericardial effusion
Pulmonary neoplasia

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6
Q

Describe an internal/closed pneumothorax.

A

More life-threatening!
Oesophagus/respiratory tract (trachea/small airways)

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7
Q

Describe an external/open pneumothorax.

A

Hole in the chest
Chest trauma e.g. dog attack
Iatrogenic e.g. post-lung lobectomy, diaphragmatic rupture, complications of thoracocentesis/thoracostomy

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8
Q

What are the clinical signs of pneumothorax?

A

Dyspnoea!
Lethargy
Cough
Exercise intolerance

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9
Q

How can we diagnose pneumothorax?

A

Unilateral/bilateral
Thoracocentesis

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10
Q

How can we treat pneumothorax?

A

Chest drain (may need bilateral drains if mediastinum intact)
Thoracotomy - massive air leak/ongoing and not sealing itself

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11
Q

How can patients get chest and lung trauma?

A

Accidents e.g. RTA/train, fall of cliff, impaling injury
Attack e.g. big dog, human, accidental vs deliberate

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12
Q

What are the clinical signs of chest and lung trauma?

A

Shock!
Dyspnoea
Soft tissue damage (extensive open wounds / progressive bruising/crushing wounds)
Ortho damage (rib fractures e.g. flail chest, other parts of skeleton)

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13
Q

What complications can we see with chest and lung trauma patients?

A

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

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14
Q

What is the difference between pulmonary blebs and pulmonary bullae?

A

Blebs = on edges of lobes
Bullae = within lobes

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15
Q

What is the typical signalment for pulmonary blebs/bullae?

A

Large-breed, deep-chested dogs

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16
Q

What are the clinical signs of pulmonary blebs/bullae?

A

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!)

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17
Q

How can we diagnose pulmonary blebs/bullae?

A

Radiography (diagnose pneumothorax but cannot localise affected lobes)
CT (assess which lobes affected, needed before surgery)

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17
Q

How can we surgically treat pulmonary blebs/bullae?

A

Thoracotomy and lung lobectomy (depending on how many lobes affected)

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18
Q

How can we conservatively manage pulmonary blebs/bullae?

A

Intermittent thoracocentesis / indwelling chest drain

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19
Q

How do patients get diaphragmatic rupture?

A

Blunt force trauma e.g. RTA, fall

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20
Q

What are the clinical signs of diaphragmatic rupture?

A

Can be peracute, acute or chronic
Can have no signs or just vague ill health
Dyspnoea, shock
Tachypnoea, orthopnoea

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21
Q

What affects severity of clinical signs of diaphragmatic rupture?

A

Herniation (what organs? How much torsion? Compressed thoracic contents?)
Size of tear

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22
Q

How can we initially stabilise diaphragmatic rupture patients?

A

Oxygen therapy
Analgesia
IVFT

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23
Q

How can we surgically treat a diaphragmatic rupture?

A

Explore chest and abdomen
Reposition abdo contents/remove if devitalised
Repair and debride as necessary
Chest drain due to iatrogenic pneumothorax

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24
Q

What are the clinical signs of a pleural effusion?

A

Dyspnoea!
Lethargy
Cough
Exercise intolerance

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25
Q

How can we diagnose a pleural effusion?

A

Unilateral / bilateral
Imaging
Thoracocentesis - SG, cytology, culture and sensitivity

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26
Q

Which conditions causing pleural effusion are medical?

A

CHF
Pyothorax (cat)

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27
Q

Which conditions causing pleural effusion are surgical?

A

Pyothorax (dog)
Diaphragmatic rupture

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28
Q

What is typical canine and feline aetiology of pyothorax?

A

Bacterial infection - E. coli in dogs / Pasteurella in cats
Cats - idiopathic e.g. bites, extensions from pulmonary abscesses
Dogs - FBs, oesophageal tears, pulmonary infections

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29
Q

What are the clinical signs of pyothorax?

A

Lethargy, inappetence, pyrexia
Dyspnoea due to effusion

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30
Q

How can we diagnose pyothorax?

A

Imaging e.g. radiographs, ultrasound
Cytology and culture of effusion

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31
Q

How can we conservatively manage pyothorax in cats?

A

Systemic antibiotics
Chest drain +/- lavage

32
Q

How can we surgically treat pyothorax?

A

Typically done early in dogs due to high % of FBs
Sternotomy - explore, remove, debride, flush THEN post-op medical management

33
Q

What are the typical aetiologies of pericardial effusion?

A

Idiopathic
Neoplastic

34
Q

What are the clinical signs of pericardial effusion?

A

Cardiac tamponade
Depends on how quickly fluid forms - does pericardium have time to stretch?

35
Q

How can we diagnose pericardial effusion?

A

Imaging e.g. radiography, echocardiography, advanced
Cytology to rule in/out neoplasia

36
Q

How can we treat pericardial effusion?

A

Repeated pericardiocentesis
Surgery - pericardiectomy (does not prevent effusion forming! Prevents cardiac tamponade and converts into pleural effusion)
Chest drain

37
Q

What are the possible complications of pericardial effusion treatment?

A

Recurrence after draining/surgery
Long-standing effusion causes adhesions

38
Q

Describe which aetiologies of pulmonary neoplasia are most common.

A

Malignant more common than benign - benign is very rare!
Secondary metastases far more common than primaries

39
Q

What are the clinical signs of pulmonary neoplasia?

A

None!
Non-specific e.g. non-productive cough, haemoptysis, dyspnoea, weight loss, exercise intolerance, anorexia
Hypertrophic pulmonary osteopathy (paraneoplastic syndrome) - very painful!

40
Q

How can we diagnose pulmonary neoplasia?

A

Biochem, haematology, urinalysis +/- cytology
Imaging - inflated radiographs / advanced imaging

41
Q

How can we treat pulmonary neoplasia?

A

Palliative
Surgery - thoracoscopy / thoracotomy

42
Q

What affects the prognosis of pulmonary neoplasia patients?

A

Presence of mets
Histopathology
Clean/dirty surgical margins

43
Q

What considerations should we have for nursing thoracotomy patients?

A

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

44
Q

Define thoracocentesis.

A

Procedure involving the puncture of the pleural space for diagnostic and/or therapeutic purposes

45
Q

What equipment do we need for thoracocentesis?

A

Oxygen
Local anaesthetic
Sterile prep + gloves/drape
Needle / IV catheter / butterfly catheter
+/- extension set
Assistant
3-way tap
20ml syringe
Kidney dish/jug

46
Q

What samples can we collect from thoracocentesis?

A

EDTA, heparin, plain tubes - cytology, biochem, culture
Smear for cytology
Check specific gravity bed-side
+/- Diffquik staining

47
Q

Define chest drain.

A

A tube placed into the pleural space to allow ongoing, continuous or intermittent therapeutic drainage

48
Q

What does the decision to place a chest drain usually depend on?

A

Underlying disease (if fluid/air continuing to be produced)
Quantity of fluid/air being produced
Patient temperament
Treatment plan (if going to thoracotomy)

49
Q

When is a chest drain usually placed?

A

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

50
Q

What are the types of chest drain?

A

Size - large bore / narrow bore
Placement - trocar / Seldinger technique

51
Q

What factors affect which chest drain is selected for placement?

A

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

52
Q

Describe trocar-style chest drains.

A

Fenestrated with or without stylet
Commonly placed under GA
Subcut tunnel required as air leaks common
Rigid so easy to place where wanted

53
Q

What are the pros of trocar-style chest drains?

A

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

54
Q

What are the cons of trocar-style chest drains?

A

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

55
Q

Describe a narrow bore/Seldinger technique chest drain.

A

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

56
Q

What are the pros of narrow bore chest drains?

A

No GA
Easy to place
Easy to secure
Versatile
More comfy

57
Q

What are the cons of narrow bore chest drains?

A

May not cope with pleural fluid / pyothorax
Not as rigid so can be more difficult to place cranioventrally

58
Q

When would we use a PleuraPort chest drain?

A

Palliative care where long-term drainage required

59
Q

What equipment do we need to place a chest drain in a closed chest?

A

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

60
Q

Describe intermittent drainage of a chest drain.

A

Care of connectors particularly important!
Typically every 4-8hrs and/or determined by resp rate/dyspnoea

61
Q

Describe continuous drainage of a chest drain.

A

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

62
Q

What analgesia can we consider for chest drains?

A

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

63
Q
A
64
Q

What issues with placement can we see with chest drains?

A

Unable to place
Incorrect placement (went caudal, stuck in mediastinum)
Use X-ray to check placement!

64
Q

What can lead to chest drains failing to drain?

A

Accidental removal
Tube disconnection/obstruction/kinking
Patient interference!

65
Q

What iatrogenic complications can we see with chest drains?

A

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)

66
Q

List the four options for thoracic surgery.

A

Left lateral intercostal thoracotomy
Right lateral intercostal thoracotomy
Ventral sternal thoracotomy / sternotomy
Thoracoscopy

67
Q

Describe an intercostal thoracotomy.

A

Less painful than sternotomy
Unilateral surgery - correct side to approach? Correct intercostal space?

68
Q

Describe a sternotomy.

A

More painful
Better for exploratory thoracotomy
Better for bilateral conditions

69
Q

Describe thoracoscopy.

A

Least painful
Steep learning curve
Specialised equipment
Some limitations in which procedures appropriate

70
Q

What groups of instruments do we need for thoracic surgery?

A

Long-handled basics e.g. tissue forceps/scissors/needleholders
Retractors
Tissue forceps
Sternotomy instruments (to break bone)

71
Q

What miscellaneous items might we need for thoracic surgery?

A

Lap swabs
Wire/thick suture
Suction
Pre-selected chest drain and connectors
Tourniquet
Pledget sutures
Vessel loops

72
Q

What are the basic electrosurgery types?

A

Monopolar (need earthing pad to prevent patient burns)
Bipolar

73
Q

What is a pneumonectomy?

A

Removal of one half of the lungs!
Cope surprisingly well - expands to fill the chest

74
Q

Describe sutures vs staplers for lung lobectomy.

A

Sutures = slow, challenging, higher risk of leakage
Staples = quick, lower risk of leakage, more expensive, steep learning curve

75
Q

Describe leak testing.

A

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

76
Q
A

Applied Clinical Veterinary Nursing (40 decks)

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