W5: MC (part 2) Flashcards
What is open heart surgery?
How is the heart accessed?
Examples of open heart surgery?
How is the sternum closure done?
- Invasive procedure, used for complicated or severe heart presentations.
- Heart accessed via a median sternotomy
- CABG, valve replacement, repair of coronary vessels and congenital defects, removal of tumours and heart and lung transplants
- Closure of sternum- wires, sometimes plate, sometimes left open or unwired if complications expected and a return to theatre is expected
What is a heart-lung bypass?
Cardiopulmonary bypass (CPB) provides a ..... field for cardiac surgery. * During surgery, the heart is immobilized by ...... solution. * Bypass incorporates an ..... circuit to provide physiological support in which .... blood is drained to a reservoir, ..... and sent back to the body using a pump.
- Cardiopulmonary bypass (CPB) provides a bloodless field for cardiac surgery.
- During surgery, the heart is immobilized by cardioplegic solution.
- Bypass incorporates an extracorporeal circuit to provide physiological support in which venous blood is drained to a reservoir, oxygenated and sent back to the body using a pump.
Note:
Oxygen-poor blood is drained from the vena cava into a reservoir. It then passes through an oxygenator where it gets oxygenated. The oxygen-rich blood is then pumped back into the aorta to circulate through the body.
Possible complications from heart-lung bypass?
- MI
- CVA (cerebrovascular accident)
- Embolic episodes
- Arrhythmias
- Bleeding disorders due to thrombocytopenia and clotting abnormalities
- Electrolyte imbalances
- Reduced pulmonary gas exchange
- Red cell damage
- Inflammatory response
- Acute kidney injury
- Post-bypass syndrome (quite common!)
- 2-3 weeks later, ?auto immune type response, unwell, fever, lethargy
What is a coronary artery bypass graft?
- Open-heart surgery where a section of a peripheral blood vessel is grafted and relocated to the heart to bypass a blocked section of the coronary artery (stent not appropriate for them, multiple blockages & more complex)
Aim of a CABG?
Improve blood supply to the heart
Common grafts include?
Saphenous vein graft
Left internal mammary artery
Complications of a sternotomy
Complications of sternotomy
* Myocardial Injury
* Blood loss
* Atrial Fibrillation
* Pneumonia
* Memory/cognitive impairment
* Subxiphoid incisional hernias
* Brachial Plexus Injury
* Superficial Incisional Infection
* Sternal Instability/mediastinitis – 1-8% of patients worldwide
Common sternal precautions following open heart surgery?
- No lifting > 4kg
- No weighted activities at > 90 deg shoulder flexion/abduction
- No scapular retraction past neutral
- Avoid trunk flexion and rotation with supine ↔ sit
- No use of arms with sit to stand
- Only upper limb and thoracic AROM in pain free range (< shoulder height)
Issues with sternal precautions
- Variable across hospitals/surgeons
- Generally prescribed routinely with NO consistency (definition, duration & type)
- Precautions may be imposed from 4 weeks to 12 weeks postop
- Limited evidence base & not individualised for patients
- May be associated with long term functional impairments, musculoskeletal pain (shoulder and back) & post-sternotomy pain
- Using ultrasounds to scan for sternal stability –> studies have found there is more movement at the sternum in a cough/deep breath than arm movements (caused a shift in precautions away from using arms, etc
What is the new sternal saying being promoted?
Keep your move in the tube
When can’t you mobilise an open heart surgery patient?
Temporary pacing wires to get the heart back to its normal rhythm
How long is typical hospital stay post open heart surgery?
5 days
Mobility wise what is the goal day 1, 2 & 3-5?
Day 1: Transfer out of bed to bedside chair
Day 2: 100-160m 3-4x per day
Day 3-5: Ambulating 5-15 minutes in hall up to 2-3 x/day & Walk up/down 1 flight of stairs
ALL days includeL AROM, deep breathing, incentive spirometry, bicycle ergometer
What should patient education include following open heart surgery?
- Orient to ward
- Instruct on RPE scale for activity
- Answer questions
- Begin risk factor modification education
What is valvular surgery?
- Valves of the heart open and close to allow blood flow through the chambers of the heart.
- The opening and closing of the valves is specifically timed.
- Insufficiency of a valve (may not open or close fully) may reduce the blood flow into a chamber or cause blood flow to leak into another chamber when it shouldn’t.
Where is the tricuspid valve located and how many leaflets?
Located between the right atrium and the right ventricle (*3 leaflets)
Where is the bicuspid valve located and how many leaflets?
Located between the left atrium and the left ventricle (*2 leaflets)
Where is the aortic valve located?
Located between the left ventricle and the aorta.
Where is the pulmonary valve located?
Located between the right ventricle and the pulmonary artery.
Indications for valve surgery?
- Calcification and stiffening of aortic leaflets
- Destruction of leaflets by infection (e.g. rheumatic fever)
- Congenital malformations
- Endocarditis (inflammation of heart valves or inner layer)
Complications of open-heart surgery?
Peri-operative
* Bleeding/hypotension
* AMI
* Anesthesia issues
* Arrhythmia
* CVA
Post-operative
* Bleeding
* Hypotension/shock/LVF
* Atrial fibrillation/other arrhythmias
* Infection
* DVT
* Respiratory (hypoxia, collapse)
* Sternotomy related
* CVA
What is heart failure? What are the two types?
Refers to the decline in the hearts ability to pump as much blood as the body needs.
Two types: systolic failure & diastolic failure
What is systolic heart failure
The left ventricle loses its ability to contract normally. The heart can’t pump with enough force to push enough blood into circulation.
What is diastolic heart failure
The left ventricle loses its ability to relax normally (because the muscle has become stiff). The heart can’t properly fill with blood during the resting period between each beat.
Types of heart failure? 3
Right sided heart failure
Congestive heart failure
Pulmonary oedema
What is right-sided heart failure?
- Usually occurs as a result of left-sided failure, via pressure and volume overload. When the left ventricle fails, increased fluid pressure is transferred back through the lungs, ultimately damaging the heart’s right side.
- When the right side loses pumping power, blood backs up in the body’s veins.
What is pulmonary oedema (heart failure)?
- Collection of fluid in the lungs
- If left untreated can cause respiratory distress
*Commonly occurs due to congestive heart failure
What is congestive heart failure?
- As blood flow out of the heart slows, blood returning to the heart through the veins back up, causing congestion in the body’s tissues. Often swelling (edema) results in the lower legs
Signs and symptoms of chronic heart failure?
- Breathlessness/Shortness of breath worse on exertion
- Fatigue, lethargy, reduced exercise tolerance
- Cough & wheeze
- Orthopnea –> shortness of breath worse when lying flat
- Paroxysmal nocturnal dyspnoea –> sudden shortness of breath that wakes them up at night. Relieved with upright sitting.
- Fluid retention –> pulmonary & peripheral oedema
- Enlarged liver (hepatomegaly)
What is paroxysmal nocturnal dyspnea and how does it relate to chronic heart failure?
Lying at night the fluid settles in the lungs causing SOB. Settles when they sit up.
Why are cardiac failure patients often put on anti-diuretics?
Commonly put on anti-diuretics to manage fluid overload & the oedema.
Briefly describe the mechanisms of CHF?
Decreased Cardiac Output due to:
- Increased sympathetic NS
- Increased renin-angiotensin system
- Increased angiotensin hormone
Results in increased contractility, heart rate, vasoconstriction, circulating volume resulting in peripheral edema and pulmonary congestion
Physiotherapy for cardiac patients: oxygen movement and C02 movement impairment
- Due to anaesthetic from their surgery - the diaphragm is impaired
- Due to pain - not taking deep enough breaths to ventilate the whole lung
- Valve issues or heart failure (Reduced efficiency) to transport oxygen around the body
- Blockages - AMI not able to transport oxygen around the body
Physio: Education, breathing exercises and wound support
Physiotherapy for secretion clearance impairment
- Due to anaesthetic from surgery - not taking deep enough breaths
- Due to pain - reduced strength of cough and not taking deep breaths
Physio: Breathing/coughing exercises
Physiotherapy for mobility/deconditioning
- Potentially due to pain
- Due to bed rest
- Impacted due to sternal precautions
Physio: gait retraining, functional training & exercise
What is phase I of cardiac rehab?
- Phase I occurs in the hospital straight after surgery. Phase I care usually involves multiple sessions when on the ward, commencing the first day after surgery.
What is phase II of cardiac rehab?
- Phase II cardiac rehabilitation occurs in the outpatient setting after discharge from hospital following surgery and stenting. As well, people with coronary heart disease not requiring surgery are suitable for cardiac rehabilitation once cleared by a medical doctor. This phase usually runs once or twice a week for 6-8 weeks.
What is phase III of cardiac rehab?
- Phase III is a long-term maintenance program running in the community for people who have already completed the other phases.
When the right side loses pumping power, what happens?
When the right side loses pumping power, blood backs up in the body’s veins.
