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General Surgery 2 > Vascular/Cardio > Flashcards

Vascular/Cardio Flashcards

1
Q

peripheral arterial disease

A
  • When a patient comes in with PAD, you need to be able to figure out where on this spectrum they lie.
  • You can almost always do this with just a good H&P and then use imaging to confirm your suspicion and plan treatment
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2
Q

claudication

A
  • Cramping/tiredness in the calves or thighs that comes on with ambulation and is relieved with rest.
  • Classic definition. Where the pain is located helps to differentiate where the disease is. Symptoms tend to be just distal to the lesion is. Pain in the thighs/buttocks corrolates with aortio-iliac disease.
  • Non-Disabling
    • H&P
      • Does not interfere with desired activities
      • Symptoms have been present for months to years
      • Pulse exam - Typically palpable pulses, may be diminished
      • No wounds/gangrene
  • Treatment
    • Baseline ABI/TBI
    • Smoking cessation, ASA, statin, Beta blocker, control DM
    • Exercise Regimen
    • Consider Pletal (anti-platelet)
  • Claudication can be split into non-disabling and disabling based on your H&P
  • PULSE EXAM: Every patient Femoral, popliteal, DP.PT
  • A baseline AbI is helpful because most of these patients will progress and you can follow them with quantitative data especially if they are in a monitored exercise program
  • Pletal (Cilostazol) relaxes muscles in your blood vessels to help them dilate as well as keep platelets from sticking together. Can help patients walk longer without pain
  • Every Patient with PAD is typically followed with ABI’s
  • ABI’s above 1.3 are falsely elevated due to calcified vessels. This is seen in diabetics
  • Disabling
    • H&P
    • Symptoms interfering with activities and ADL’s
    • Denies pain at rest
    • No wounds or gangrene
  • Treatment
    • Smoking cessation, ASA, statin, Beta blocker, control DM
    • Arterial Duplex with an ABI – take the highest on the arm and the highest on the leg to use for the ABI
    • CT Angiogram
    • Angiogram
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3
Q

post angiogram considerations

A
  • Patient to remain flat with the treated leg straight for 6 hours.
  • Monitor for hematoma, distal perfusion
  • Check Cr due to the contrast given
  • If a stent is placed – Plavix load 300mg and then daily Plavix 75 mg for at least three months
  • Post op check and new baseline ABI/TBI
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4
Q

chronic limb ischemia

A
  • H&P
    • Unable to walk short distances without pain
    • Forefoot pain that wakes them up at night (Rest Pain)
    • Cyanosis, dependent rubor, elevation pallor
    • Decreased pulses, doppler signals
    • Ulceration, gangrene
  • Patients with rest pain will often sleep with their leg dangling off the bed to get the help of gravity bringing blood to the foot.
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5
Q

diagnostics/treatment of limb ischemia

A
  • Diagnostics
    • Arterial Duplex with ABI
    • Vein mapping
    • CT Angiogram – surgical planning
  • Treatment
    • Endovascular Intervention – Angiogram with PTA/stent
    • Femoral Endarterectomy
    • Lower Extremity Bypass
  • Endovascular repair for iliac disease, SFA, tibialperoneal lesions
  • Common femoral disease – femoral enarterectomy
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6
Q

femoral endarterectomy

A
  • An incision is made over the femoral artery and a longitudinal incision is made over the artery. The artery is opened and the plaque is removed. A bovine patch is used to close the artery so that it has a larger diameter once we finish.
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7
Q

lower extremity bypass

A
  • Indications are for a total occlusion we can’t get through during an angio
  • distal target to sew to
  • The type of bypass depends on where the lesion is
  • Preference is to use a reversed greater saphenous vein.
  • Fem Pop is pretty common bypass that is done
    • You don’t want to use prosthetic material around the knee
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8
Q

acute limb ischemia

A
  • Sudden onset of severe lower extremity pain
  • Irreversible tissue damage within 6 hours
  • H&P
    • 5 P’s – pain, pulselessness, pallor, parasthesias, paralysis
    • Compare exam to the contralateral leg
    • 60% caused by a thrombosis – hx of PAD
    • 30% caused by an embolic source – A. fib, recent MI, proximal aneurysm
    • 5 P’s – painful early but as nerves die, they develop sensory loss and impaired dorsiflexion.
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9
Q

clinical classification of acute limb ischemia

A
  • Class one and two you’ve got some time – not a lot of time, but some time
  • Cat I and IIa you can start a heparin gtt to buy you some time to get more imaging with a CTA.
    • Can be a candidate for thrombolysis – place catheter through clot and slowly drip TPA
  • Cat IIb is immediate surgery
  • Cat III go immediately to surgery as well but may be well beyond the 6 hours and will have a worse outcome with amputation likely
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10
Q

surgical options for acute limb ischemia

A
  • Thrombolysis
  • Thrombectomy/Angioplasty
  • Embolectomy
  • May need 4 compartment fasciotomies
  • Thrombolyisis CAT I and IIa
  • Typically done with each other where we will pull out the major clot and leave a catheter in place overnight dripping TPA to break up any little emboli that have traveled distally.
  • Need to treat the underlying PAD to prevent reoccurance
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11
Q

arterial and venous ulcers

A
  • Arterial Ulcers
    • Located on the outer ankles, feet, toes
    • Painful
    • Irregularly shaped, punched out appearance
    • Necrotic tissue present - black
    • Little to no bleeding
      • Management
        • Treat underlying PAD to improve blood flow
        • Ulcers – debride necrotic tissue
        • Dry Gangrene – stable, can wait.
          • Painted with betadine daily – can be reversed (not 100% but can reduce amount of amputation)
        • Wet Gangrene – infected and needs amputation
          • Toe amputation, transmetatarsal amputation
          • Wet gangrene is foul smelling, erythema, drainage
    • Even amputations need adequate blood flow to heal
  • Venous Ulcers
    • Located on the ankles, calf
    • Shallow with flat margins
    • Slough at the base and moderate to heavy exudate
    • Swelling of the lower extremity
    • Stasis dermatitis
    • Management
      • Debridement to clean wound bed
      • Manage drainage
      • Compression therapy
      • Treat underlying venous insufficiency to decrease healing time and prevent reoccurrence
    • Manage drainage with foam dressings
    • Unna boots, circ aids, stockings for compression
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12
Q

venous insufficiency/varicose veins

A
  • The valves within the veins have become weak or damaged, allowing the blood to flow backwards.
  • This backward flow is called reflux. This enlarges the veins and causes pain and swelling.
  • Pregnancy, jobs where you sit or stand all day
  • Patients present with swelling, heaviness, itchy or painful varicose veins.
    • Genetic, pregnancy, weight gain, excessive sitting or standing, DVT
  • H&P
    • Hx of DVT, previous vein surgery, family hx of VV, occupation, hx of bleeding veins.
    • Have them stand while you examine them
    • Document location and size of the veins
    • Pulse exam
    • Hemosiderin staining
    • Ulcers
  • Evaluates the superficial and deep system as well as perforators.
  • Rules Out DVT
  • Directs our treatment
  • Non-Surgical Treatment
    • Compression stockings (20-30mm Hg )
    • Leg elevation
    • Calf exercises
  • Surgical Treatment
    • Vein Ligation/stripping – Treats GSV, not done as frequently due to newer techniques
    • Endovenous Ablation – Treats GSV, SSV
    • Phlebectomy
    • Sclerotherapy – treats small reticular veins and telangiectasias.
  • Endovenous ablation – table on next slide
  • Sclerotherapy – usually considered cosmetic except for treating bleeding veins
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13
Q

when do people need heart surgery

A
  • VERY BROAD indications:
    • Symptoms not controlled with medication
    • Worsening heart function
    • Area of ischemia
    • Multi-vessel CAD (more later)
  • A patient even considering surgery often has an established relationship with a cardiologist
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14
Q

common cardiac sxs

A
  • Chest pain/pressure
  • Shortness of breath
  • Exertional dyspnea or SOB
  • Exercise intolerance / unexplained fatigue
  • Radiating chest pain/”GERD”
  • Claudication → more vascular, but important
  • Pre-syncope or syncope
    • Unexplained falls
  • Palpitations
  • Lower extremity swelling
  • Orthopnea
  • PND
  • ….or NOTHING… but all leads to a cardiac work-up
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15
Q

cardiac history and PE

A
  • Good history!
    • Affecting ADLs?
    • Can tell a lot about if they’d be a good surgical candidate or if they’d really benefit
  • Prior surgeries, cancer, radiation (particularly mediastinal), a-fib/rhythm/pacemaker, OSA, CVA/TIA, kidney problems, lung disease, liver problems, prior cardiac history or MI, DM, HTN, HLD
  • Family history - we log data about sudden cardiac death or h/o early onset CAD (<55y)
  • What is their functional baseline prior to surgery?
  • General assessment of overall condition
  • Skin: open sores/rashes (any infection source)
  • Mouth/teeth (again infection source)
  • Lungs - esp if suspected heart failure
  • Swelling/ulcers in extremities
  • Pulses
  • Varicosities (particularly legs for conduit)
  • Cardiac exam: JVD, rub, murmur, S3 or S4
  • Scars on chest/legs
  • Swelling in extremities
  • Basic abdominal/neuro exam
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16
Q

diagnostics and pre-op for cardiac surgery

A
  • (Stress) Echocardiogram
  • Transesophageal echo (valves)
  • Cardiac catheterization/angiogram
  • CTA Chest/Abd/Pelvis
  • Carotid US
  • Pulmonary Function Testing
  • ABIs
  • Chest x-ray
  • Labs: CBC, BMP, troponin, BNP, coags, platelet function assay, UA, LFTs
  • EKG
  • MRSA screening (nasal swab)
  • Others depending on history…
  • Don’t need to memorize this
17
Q

CABG

A
  • Coronary Artery Bypass Grafting (CABG) indications (stents don’t last as long as grafts
    • Class I indications from the American College of Cardiology (ACC) and the American Heart Association (AHA):
      • >50% left main stenosis (sometimes can do high-risk PCI)
      • >70% proximal LAD and Cx stenosis
      • Multi-vessel disease in asymptomatic patient, or mild/stable angina
      • 3v disease with proximal LAD stenosis in patient with poor LV function
      • 1 or 2 vessel disease and a large area of viable myocardium in high-risk area in patients with stable angina
      • >70% proximal LAD stenosis with either EF < 50% or demonstrable ischemia on noninvasive testing (stress test, myocardial perfusion imaging)
  • Determine vessel conduit
  • Median sternotomy
  • Heparinization and cardiopulmonary bypass cannulation/initiation
  • Myocardial arrest
  • Distal anastomosis(es)
  • Proximal anastomosis(es)
  • CPB wean
  • Sternal drainage and closure
  • Conduit:
    • L internal mammary (thoracic) artery:
    • Right IMA
    • Saphenous veins
    • Radial artery
  • Intra-aortic balloon pump
    • Indicated in surgery if difficulty separating from CPB usually due to ongoing ischemia or low EF
    • Works by increasing blood flow to proximal aorta (and therefore coronary arteries)
    • Also works by creating a vacuum on quick deflation to help improve cardiac output and reduce afterload
    • Indications:
      • Cardiogenic shock (esp. after MI)
      • Low cardiac output after CPB
      • Sometimes used for high-risk angioplasty or prophylaxis until surgery (especially left main dz)
      • Ongoing ischemia or angina
      • Often used as a bridge to other therapy or surgery
18
Q

Risk stratification - cardiac

A
  • Several risk models exist, but most commonly used is the Society of Thoracic Surgeons (STS) risk calculator
  • Takes into account many risk factors
    • Age, gender, race
    • Creatinine/dialysis, DM, cerebrovascular dz
    • Chronic lung dz
    • Prior MI or surgery, NYHA Class symptoms classification
    • CHF or Cardiogenic shock
    • A-fib
    • Valve problems, LVEF, left main stenosis
19
Q

surgery time - cardiac

A
  • Continue ASA, beta-blockers, non-nephrotoxic meds until surgery
    • Stop ACE/ARB/metformin ~48h prior
  • Stop anticoagulation - many kinds!
    • Each one is different for how long, usually 2-7 days
    • Sometimes need a heparin drip if critical stenosis which is stopped right before surgery
20
Q

post-operative care/complications - CABG

A
  • Myocardial dysfunction
    • Ischemia-reperfusion injury, myocardial edema
    • Low output - may need IABP
    • Post-op arrhythmias in 30% of patients
      • Usually atrial fibrillation, peak on POD #2
  • Cerebrovascular complications (stroke)
    • About 3%, most recover within 3-12 months
  • Acute kidney injury
  • Cardiac tamponade
  • Post-pericardiotomy syndrome (aka Dressler syndrome) 2-4 weeks after
    • Delayed inflammatory reaction
    • Fever, friction rub, pleuritis, chest pain
    • NSAIDs controversial postoperatively
    • Usually give colchicine
  • Surgical wound infections
  • Anemia
  • DVT
  • Respiratory tract infections
  • Aortic dissection
21
Q

post-op management - CABG

A
  • Typically manage patient care once transferred out of cardiopulmonary ICU
  • Motivate/educate patients on life after surgery, restrictions
  • Check labs, CXR
  • Monitor incisions
  • DVT prophylaxis
  • Medication management - GDMT
    • ASA, statin, and beta-blocker
  • Typically discharge patients on POD #4 or 5 barring complications
  • Most common thing I see is post-op a-fib, and patient’s anxiety around discharge
  • Wound healing issues generally arise later on, seen at 2 week post-op appt
22
Q

aortic valve disease - stenosis

A
  • Usually due to degeneration and calcification with age in bicuspid but also tricuspid valve (still common)
  • Monitored with echo
  • Severe: valve area ≤1.0 cm2, an aortic velocity 4.0 m/s or higher, and/or a mean transvalvular gradient ≥40 mmHg
  • Common sxs:
    • Syncope or exertional syncope/presyncope
    • Dyspnea on exertion
    • Exertional angina
    • Increasing fatigue or reduced exercise tolerance
    • Murmur: systolic crescendo-decrescendo vs holosystolic at right upper sternal border
  • Average survival without valve replacement is 2-3 years once severe
23
Q

Aortic valve replacement

A
  • Anyone considered for surgery needs cardiac catheterization/coronary angiogram if they have CAD risk factors or symptoms
  • Should have AVR if severe and undergoing other cardiac surgery
  • Similar pre-op workup as CABG
  • Sometimes exercise testing for severe AS when asymptomatic
  • Similar operative steps as CABG of median sternotomy with CPB and post-op complications
  • Bioprosthetic vs mechanical valve
    • Mechanical valve requires lifelong anticoagulation vs prosthetic doesn’t, but also doesn’t last as long
  • Transcatheter AVR (TAVR)
    • Newer, less invasive intervention to replace AV
    • Team approach with interventional cardiology
    • Many ongoing trials, estimated 20% reduction in mortality at 1 year vs SAVR
    • Need cardiac surgeon present, and two different cardiac surgery consults
    • Medicare now covering TAVR in intermediate and high-risk patients
    • Recommended for all patients not deemed suitable for SAVR by heart team (high risk STS PROM is >8%)
    • Or for intermediate risk (4-8% STS PROM)
    • At Summit, Medicare is allowing TAVR in low-risk patients as part of special registry/trial
  • TAVR
    • Paravalvular regurgitation and need for pacemaker significantly higher in TAVR vs SAVR
    • New onset a-fib, kidney injury, and bleeding lower in SAVR vs TAVR
24
Q

Aortic insufficiency

A
  • Caused by myxomatous degeneration, endocarditis, rheumatic heart disease, bicuspid valve, or other rheumatic or connective tissue disorders (see table)
  • Measured by echo: left ventricular end systolic dimension (LVESD)
  • Mortality rate per year in patients with severe AR is 25% in patients with NYHA Class III/IV, and 6% if NYHA Class II
  • Usually have heart failure symptoms
  • Early diastolic murmur
  • Surgical indications:
    • Chronic moderate to severe AI with LVEF <50%
    • Chronic AI undergoing other cardiac surgery
25
Q

mitral regurgitation

A
  • Caused by abnormality of any component of the mitral valve apparatus
  • Most commonly caused by degenerative mitral valve dz (including prolapse)
  • Rheumatic heart disease still a common cause elsewhere in the world
  • Also infective endocarditis, trauma (including MI), congenital, or annular calcification
  • Surgical indications for repair/replacement:
    • Moderate to severe (grade >3) MR in symptomatic patients or those with left ventricular (LV) dysfunction
    • Consider if severe LV dysfunction refractory to medical therapy with low likelihood of durable repair and low comorbidity
    • Asymptomatic patients with preserved LV function, high likelihood of durable repair, low surgical risk, and left atrial dilatation and sinus rhythm or pulmonary HTN on exercise
26
Q

mitral valve repair/replacement

A
  • Delaying surgery until moderate to severe symptoms occur is associated with increased perioperative and long-term mortality
  • MitraClip for severe MR in high-risk pts
  • TMVR is on the way…
27
Q

mitral valve stenosis

A
  • Almost always from rheumatic fever
  • Need aggressive rheumatic fever prevention/treatment
  • LV dilatation >45mm associated with high incidence of atrial fibrillation
  • Often managed by Interventional Cardiology with percutaneous mitral balloon commissurotomy
28
Q

pericardial effusion

A
  • Risk of tamponade (emergency)
  • Typically pericardiocentesis preferred, but must have >1 cm anterior effusion on echo
  • If not, then surgery indicated (for safety)
    • Small, organized, or loculated effusions (cannot tap)
    • Malignant, traumatic, or purulent pericardial effusions → pericardial window preferred for longer term tx
  • Typically surgical approach is subxiphoid pericardial window
  • Leave pericardial drain in place until drainage slows
  • Repeat echo or CT scan, monitor drainage
29
Q

aortic dissection

A
  • Type A involves ascending aorta - a true emergency
    • Wall rupture
    • Hemopericardium or tamponade
    • Occlusion of coronary arteries with MI
    • Severe aortic insufficiency
  • Typically Type B can be managed medically (beta-blockers; keep BP low) and then evaluated by vascular surgery
  • Mediastinal widening present in 80% CXR
  • Typically following by CTA per protocol in a stable enough patient, otherwise TTE can work
  • Most commonly:
    • ~2.2 cm above the aortic root
    • Distal to the left subclavian artery
    • Aortic arch
  • Etiology:
    • HTN
    • Pregnancy
    • Cocaine
    • Chest trauma
    • Iatrogenic
    • Syphilitic aortitis
    • Arteriosclerosis
    • HLD
    • Smoking
    • Many congenital factors, including connective tissue disorders
  • High morbidity and mortality for acute dissection (<2 weeks). 1-2% die per hour for the first 24-48 hours
  • Better prognosis if chronic dissection (>2 weeks old; more stable)
30
Q

pneumomediastinum (or mediastinal emphysema)

A
  • Not common, but good to recognize
  • “Spontaneous” (forceful coughing) vs
    • Blunt force
    • Penetrating chest trauma
    • Esophageal tear/rupture
    • Iatrogenic (esophageal or endobronchial procedures, chest surgery)
    • Lung disease
    • Mechanical ventilation
  • Not really well understood, thought that air from ruptured alveoli tracks along peribronchial vascular sheaths to the hilum of lungs, then into the mediastinum
  • Also connects with submandibular space, retropharyngeal space, and vascular sheaths in the neck
  • Free air can cause pneumopericardium, pneumothorax, subcutaneous emphysema pneumoperitoneum, or pneumoretroperitoneum
  • Treatment is usually observation
  • Esophageal injuries more commonly require intervention or close following
  • Chest tube indicated only if concurrent pneumothorax
  • Avoid strenuous physical activity until resolved
  • Avoidance of coughing/vomiting, addressing whatever led to the condition
31
Q

Thoracic imaging

A
  • CXR: standard imaging study to evaluate chest pathology: pneumothorax, pleural effusion, lung tumors
  • CT scan of chest: very frequently used imaging modality to evaluate intrathoracic pathology
  • PET/CT scan: standard test for lung cancer evaluation
  • CT-guided biopsy
32
Q

cervical mediastinoscopy

A
  • Evaluation of paratracheal space for biopsy of lymph nodes: lung cancer, lymphoma, sarcoidosis
  • Outpatient procedure, general anesthesia
  • Risks: injury to great vessels, bronchus, recurrent laryngeal nerve, pleura, lung
  • In my practice, usually reserved for lung cancer staging via biopsy to guide treatment
33
Q

lung cancer pre-op evaluation

A
  • The treatment for lung cancer is stage-dependent (TNM linked below)
  • Preop evaluation:
    • imaging studies
    • PFT (FEV1/DLCO) and estimation of postoperative FEV1/DLCO
    • Cardiac evaluation
    • Management of co-morbidities
  • Stages I/II: lobectomy & mediastinal lymph node dissection/biopsy
    • Sublobar resection for high-risk limited lung reserve
  • Stage IIIA: potentially resectable disease: multimodality (induction chemo/SX/PORT or chemoXRT/surgery)
  • Unresectable stageIIIA/B: chemoXRT
  • Stage IV: chemotherapy
34
Q

NSCLC

A
  • 85% of all lung cancers
    • The most common signs and symptoms of lung cancer:
      • Cough
      • Chest pain
      • Shortness of breath
      • Hemoptysis
      • Wheezing
      • Dysphagia/Hoarseness
      • Recurring infections such as bronchitis and pneumonia
      • Weight loss and loss of appetite
      • Fatigue
    • Metastatic signs and symptoms:
    • Bone pain
    • Spinal cord impingement
    • Neurologic problems such as headache, weakness or numbness of limbs, dizziness, and seizures
35
Q

approaches of lung resection

A
  • Open thoracotomy: muscle splitting of muscle sparing thoracotomy, division of intercostal muscle and spreading of ribs
  • Minimally invasive thoracoscopy (small incision, no rib spreading, anatomic lung resection)
    • Video-assisted thoracoscopy (VATS)
    • Robot-assisted thoracoscopy
  • Surgeon dependent
36
Q

lung resection

A
  • VATS lung resection: minimally invasive
    • Small incisions, no rib spreading
    • Oncologically similar to open surgery
    • Less pain, reduced stress-response, reduced LOS, early return to work
  • Robotic lung resection: minimally invasive
    • Emerging technology with increasing numbers of adopters
    • Similar results as VATS lung resection
  • VATS as mentioned previously is a surgical approach
    • Also use VATS for other diseases and pathologies
    • Lung biopsies are fairly common, especially for interstitial lung disease, suspected TB
  • Open thoracotomy
  • In both approaches, ideally have one-lung ventilation by the anesthesiologist to deflate the operating side (usually using a double-lumen ET tube)
  • Lateral decubitus positioning helps by gravity perfusing the ventilating lung
37
Q

pleural effusion

A
  • Many reasons for effusion, but figuring out the etiology guides treatment
  • Typically recommend ultrasound-guided thoracentesis (most often by Interventional Radiology) with pleural fluid analysis if it’s the first time
    • If there’s enough fluid to tap
  • Different recommendations if it’s chronic, would explore surgery or permanent chest tubes in some cases
  • Exudative vs. transudative?
    • Another common cause mentioned earlier is post-CABG left pleural effusion
      • Would this be exudative or transudative??
38
Q

pneumothorax

A
  • Wide variety of presentations depending on etiology
  • Spontaneous ptx: usually asymptomatic until a bleb ruptures, then SOB, dyspnea like in our case
    • Tall, thin males
    • Secondary SP: variety of lung diseases
  • Iatrogenic or traumatic ptx: similar presentation, different history
  • Tension ptx: Hypotension, hypoxia, chest pain, dyspnea
  • Catamenial ptx: (rare) women 30-40yo, within 48h of menstruation, right-sided
    • Thought to be from endometriosis of the pleura
  • Always listen for breath sounds and compare sides, best way to tell (and then wait for your CXR)
  • Typically administer oxygen right away then assess depending on size, symptoms if chest tube is needed
  • If <15-20% can observe with repeat CXRs in ED
  • Surgery indicated if recurrent (2+), would need CT scan to look for blebs, resection
  • Usually VATS with bleb resection and pleurodesis
  • Pleurodesis is the process of creating an inflammatory reaction between the chest wall and lung pleura to make it “stick”
    • Mechanical or with talc
  • Ongoing care:
    • No flying until completely resolved
    • No smoking
39
Q

chest tubes

A
  • Chest tubes are very common, placed after almost all lung surgeries
  • CT service manages a lot of chest tubes in the hospital (even if placed by ED or IR)
  • The chest tube is ALWAYS connected to some sort of chamber, collection device, or more commonly, a Pleur-evac
  • Chest tubes are NEVER connected directly to wall suction (I’ve seen this too many times in my short career)
    • Never disconnect a chest tube from a device without clamping it first or having other guidance as you can cause a pneumothorax
  • To test for a bronchopleural fistula (more casually called an air-leak), have patient valsalva (cough) and watch water seal chamber for bubbles
  • Persistent air leaks aren’t uncommon after surgery (injury to lung)
  • If a chest tube is on suction, it is connected to a canister, on CONTINUOUS suction (not intermittent), usually -20cm H2O
  • “Water seal” means off suction because there is a column of water that “seals” the end of the chest tube system (don’t want air getting back in, it’s a closed system
  • Daily chest x-rays are standard with a chest tube in place
  • Heimlich Valve can be placed for discharge if CT can’t be removed (ongoing air-leak)
  • Many different kinds and sizes of chest tubes
  • Usually sutured in place
  • Always make sure drainage unit is below insertion site (gravity)
  • Check for kinks, properly secured to patient
  • To remove a chest tube, must cut suture holding it in place
  • U-stitch vs no U-stitch…the jury is out
  • Removing a chest tube
    • Once drainage is minimal (effusion usually <200cc/day)
    • Or once air leak resolves (and has been on water seal)
      • Controversial but some providers clamp chest tubes for 4 to 24 hours to prove there is no further air leak
    • Cut suture holding chest tube
    • Don’t cut the U-stitch if one is in place, since that is what you tie down after tube comes out
    • Have someone hold pressure while you quickly pull tube out
    • Then apply occlusive dressing (usually Xeroform) and gauze, leave in place 48-72 hours)
    • For larger bore surgical chest tubes, I usually give 2mg morphine IV prior to removal, but discuss with patient first
    • Ask them to hold breath while you swiftly remove

General Surgery 2 (8 decks)

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