Thoracic Surgical Treatments Flashcards
(51 cards)
1
Q
what is a thoracocentesis?
A
procedure involving the puncture of the pleural space for diagnostic and/or therapeutic purposes
2
Q
what should you prioritise when performing a thoracocentesis?
A
- safety
- sterile skin prep
- gloves
- sterile drape
3
Q
what equipment do you need for a thoracentesis?
A
- Oxygen
- Short-acting local anaesthetic +/- anxiolytic
- Sterile prep (clippers, scrub, surgical spirit, sterile gloves +/- drape)
- Needle / IV catheter / butterfly catheter. Butterfly catheters available 20/22g for cats/small dogs &
18/20g for larger dogs - IV catheters
- Needles / Butterflies
- Assistant
- 3-way tap
- 20ml syringe – size determined by volume expected
- +/- Extension set
- Kidney dish / jug
4
Q
what is a chest drain?
A
A tube placed into the
pleural space to allow
ongoing, continuous or
intermittent therapeutic
drainage
5
Q
When is a chest drain usually placed?
A
➢ Intermittent thoracocentesis not working
➢ Following thoracotomy
➢ Long term pleural drainage required
➢ Instillation of medication
6
Q
why might an intermitten thoracentesis not work?
A
- Too much air/fluid being produced
- Fluid too thick to come through butterfly
- Proving too risky – causing lung trauma
7
Q
why might you place a chest drain after thoracotomy?
A
- Remove fluid/air introduced during surgery
- Detect fluid/air being produced due to the underlying condition
- Detect fluid/air being produced due to complications of surgery
8
Q
what medication can be put through a chest drain?
A
- Local anaesthetics
- Saline for lavage of pyo
- Antibiotics
- Chemotherapy
9
Q
what types of chest drain are there?
A
- Large bore
- Narrow bore
10
Q
what techniques are there to place a chest drain?
A
- Trocar
- Seldinger technique
11
Q
how would you select a chest drain?
A
- Type
- Size - 6Fr - 20Fr
- Placement method - closed or open chest
- Site - unilateral or bilateral? fenestrations all in chest?
- Connectors -
- Securing & protecting
12
Q
what are trochar style chest drains?
A
- Fenestrated with/without stylet. Stylets blunt or sharp.
- Most commonly placed under GA
- Need a subcutaneous tunnel as air leaks common
- Rigidity means easy to place where you want them
- Higher risk of tube-associated complications such as lung damage on insertion / pneumothorax»
complication rates up to 58%
13
Q
what are the benefits of a trochar sytle chest drain?
A
- lots of different sizes available
- Versatile, good for air or fluid, large bore means less likely to block
- Robust / don’t collapse
- Once learned, easy to place
- Most transparent so easy to monitor for stuff that could clog the tube
14
Q
what are the disadvantages of trochar style chest drains?
A
- Typically need a GA to place
- Likely to have higher complication rate than narrow bore though published evidence minimal
- Needs careful training
- Need to learn a good suture technique for anchoring (2nd technique to learn)
- Less comfy than narrow-bore
15
Q
what are narrow bore/seldinger technique chest drains?
A
- May cost more for the actual tube than a trocar , but may be cheaper to place as no GA
- Not as important to have a subcutaneous tunnel as placement technique less invasive / air leaks less likely
- Lots of fiddly bits in the packet
16
Q
what are the advantages of using narrow bore / Seldinger technique chest drains?
A
- No GA
- Easy to place
- Easy to secure
- Versatile
- More comfy
17
Q
what are the disadvantages of using narrow bore/seldinger technique chest drains?
A
- May not cope with pleural fluid / block e.g. pyothorax
- Smaller sizes difficult in our patients as can be overlong meaning either too much inside the chest (prone to
kinking) or too much outside (vulnerable to patient interference) - Not as rigid can end up in weird placement: can be difficult to position cranioventrally as not as rigid as the trocar drains
- May not be able to do the normal SQ tunnel in a large patient as introducer catheters not that long
18
Q
what are pleuralport chest drains?
A
the ones that look a bit like a stethoscope, used for palliatve care
19
Q
what equipment will you need for closed chest placcement of a drain?
A
- Sterile prep (clippers, scrub, surgical spirit, sterile gloves +/- drape)
- Anaesthetic kit and monitoring as appropriate
- Local for narrow bore
- General for trocar
- Assistant
- Chosen chest drain, pre-measured for length
- Scalpel & blade
- Basic instrumentation (Rat-toothed forceps, needle holders, scissors, sterile swabs)
- Fenestrated drape
- 3-way tap
- Syringes (size depends on volume to be drained)
- Extension set
- Kidney dish / jug
- Suture
20
Q
how do you secure a chest drain?
A
in-built anchor flanges and simple interrupted sutures
external drain-securing sutures
21
Q
how do you manage a chest drain?
A
- Nursing
- Drainage
- Infection
- Analgesia
22
Q
what types of drainage is there for chest drains?
A
intermittent and continuous
23
Q
what is intermitten drainage of the chest?
A
drained usually every 4-6 hours depending on RR/dysponoea
24
Q
what is continuous drainage of chest drains?
A
drain is continously draining
25
how do youreudce the risk of infection for a patient with a chest drain?
* Aseptic technique at all times
* Good bandage hygiene
* Early identification for culture rather than just giving antibiotics
26
what analgesia can be given for a hospitalised patient with a chest drain?
* Local e.g. lidocaine
* Systemic opioids e.g. methadone / buprenorphine
* Local down the chest drain e.g. bupivacaine
* CRIs e.g ketamine / lidocaine (no lidocaine in cats)
* Paracetamol injection (dog only)
27
what analgesia can you give to a patient who has gone home with a chest drain?
NSAID or oral paracetamol for dogs
28
what are there complications that can arise from a patient with a chest drain?
* Failure to place
* Failure to drain
* Patient
* Iatrogenic
* Introduction of infection
29
why might a drain failure to drain after placement?
* Inadvertent /accidental removal (kennel door, stood on by patient)
* Tube disconnection
* Tube obstruction (e.g. pleural, mediastinum, clots, pus)
* Tube kinking
* Tube slipped out a little. care not to break sterility
30
what issues can arise with placement of a drain?
* Unable to place
* Incorrect placement (went caudal not cranial; didn’t enter the thorax; stuck in mediastinum)
* Logical to check X-Ray post placement
31
what patient interference can cause a drain not to drain properly?
* Removal / chewing!
* Whole thing or part? Foreign Body? Chewing a hole in it?
32
what iatrogenic reasons might there be if a drain isnt draining properly?
* Haemorrhage / Haemothorax check PCV & look for a difference
* Heart / lung damage
* Inappropriate / premature removal >> recurrence
* Nerve damage – Phrenic / Horners
* Pneumothorax
* check connectors
* check fenestration
* Pyothorax - aseptic technique
* Seroma
* Subcutaneous emphysema
* Often around skin incision, can use antibiotic ointment to plug! Care with size of incision, should be snug
* Check position of fenestrations
* Self-resolves once tube removed (air reabsorbed)
33
why might you keep a chest drain in?
* Ongoing treatment via the drain
* Clinically significant production of fluid/air
34
why might you remove a chest drain?
* Complications
* Resolution of issue
* Ongoing need for drainage
35
what are the four main options for thoracic surgery?
* Left, lateral, intercostal thoracotomy
* Right, lateral, intercostal thoracotomy
* Ventral, sternal thoracotomy / sternotomy
* Thoracoscopy
36
what are the important notes to rememebr with a intercostal thoracotomy?
- defined next by numbered rib space
* Less painful than sternotomy
* Need to be sure that condition can be treated with unilateral surgery
* Need to be sure of the correct side to approach
* Need to be sure of the correct intercostal space to use
* Left vs right
* Where the organ is more accessible e.g. distal oesophagus (FB) => left side; PDA => left side
37
what are the things to rememeber with a sternotomy?
* More painful
* Better for exploratory thoracotomy
* Better for bilateral conditions
* Not so good for if the problem is in dorsal thorax
38
what are the things to remember with a thoracoscopy?
* Least painful
* Steep learning curve
* Specialised equipment
* Some limitations in which procedures can be safely completed using a scope.
- rapid recovery
- reduced visualisation
39
how would a sternotomy be performed?
* Dorsal recumbency
* Midline approach
* Osteotomy with saw blade
* Exploration of left and right sides
* Place chest drain under visual guidance
* Closure with metal wire or sutures
40
how would you lcip for a lateral thoracotomy?
* Clip correct side of chest
* Wide clip, long cranial –caudal
41
how would you clip for a sternotomy?
from thoracic inlet to mid abdomen
42
how would you clip for a thoracoscopy?
fully clipped in case have to convert to open
43
how would you position for lateral thoracotomy?
* Front legs +/- back legs loosely tied out of the way
* +/- sandbag under chest
44
how would you position for a sternotomy?
* Dorsal recumbency
* Legs tied loosely out of the way
* May need cradle and/or sandbags to stabilise if narrow chested
45
how would you position for a thoracoscopy?
* Can be done in both lateral and dorsal recumbency depending on the procedure
46
what are sternotomy instruments used for?
breaking through bone
47
what are tissue forceps used for?
* For atraumatic tissue handling
* For atraumatic, fine dissection
* For clamping vessels prior to ligation
48
what types of retractors are there?
handheld or self-retaining
49
what miscellaneous equipment would you need for thoracic surgery?
▪ Laparotomy swabs
▪ Wire or thick suture (1 PDS, 0 PDS)
▪ Suction
▪ Pre-selected chest drain & connectors
▪ Tourniquet
▪ Pledget sutures
▪ Vessel loops
50
what types of lung lebectomies can be done?
* Partial lobectomy (part of a lobe)
* Total lobectomy (one entire lobe)
* Pneumonectomy (one half of the lungs) = surprising how well they manage with only half a lung > expands to
fill the chest
51
how would you leak test a lung during surgery?
* Fill the chest with warm saline
* Suction on standby
* IPPV
* Check for air bubbles
* Suction fluid back out once happy
