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CI 1 > Week 11 - Cardiac Surgery > Flashcards

Week 11 - Cardiac Surgery Flashcards

1
Q

For cardiac surgery what is the incision and where

A

Sternotomy

Medial and directly cuts through the sternum

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2
Q

How do they enclose the incinsion

A

They use sternal wires

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3
Q

Can you remove sternal wires once healing is occuring

A

No, they stay there forever

These will be visible on Xrays. look like rings

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4
Q

Whate are chest drains for

A

Drain fluid out from the mediansternal area

Start with suction and then go off suction

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5
Q

When can chest drains be removed

A

When less than 100mls of fluid is remove in 24 hours. Clamp for a trial period

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6
Q

What is a atrium Dry suction chest Drainage

A

Incorporates Draining, water seal and suction to help remove the excess fluid in the chest

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7
Q

What should physios be aware of when a patient has a chest drain

A 
Avoid kinking and disconnecting the tube
be warey of taking off suction
Avoid positive airway pressure unlss indicated
Keep drains below level of inerstion
Have clams nearby in case of emergencies
Keep unit visible to prevent damaging
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8
Q

What is a CABG

A

Coronary artery bypass grafting

One of the most common operations in the western world

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9
Q

WHat is the mortality and morbidity post CABG

A

3% for both

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10
Q

PCI benefits over CABG

A

Less invasive
feed a deflated balloon up and artery and inflate it to allow blood flow and inplant stents or scaffolds to keep artery open

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11
Q

If PCI is great and less invase why do we still do CABG

A

CABG is the way to do it for multiple blockages. PCI is better suited for one or relatively small ones
This is still superior to PCI

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12
Q

how is blood still oxygenated and pumped around body while they are operating on the heart

A

Use a Heart lung machine

takes the blood, eliminates CO2, oxygenates it, controls temp and flow and pumps back into body.

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13
Q

List consequences of the heart lung machine

A

Non pulsatile perfusion - Abnormal ogran blood flow
Activation inflammatory cascades - exposure to foreign bodies
Blood component factors - Bleeding/ coagulopathy/ thromoctopenia

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14
Q

Why cannulation

A

Cave to cannulate the aorta and then cross clamp so you can harvest a LIMA graft

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15
Q

List the 2 common graft harvest sites

A
  1. Saphenous vein graft (SVG) - leg incision

2. Left internal mammory artery - close to phrenic nerve - may cause diaphragmatic paralysis

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16
Q

How long does a CABG take?

A

4-8 hours

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17
Q

What occurs on conclusion of surgery

A
  1. sternal closure
  2. multiple drain tubes are inserted
    Routine ventilation for 4-8 hours after
    Temporary pacing - they have been fiddling with heart so they put in a temporary pace maker into left ventricle
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18
Q

List some complications of CABG surgery

A 
PPC
Infection of wound and UTI
DVT
Haemorrhage
Renal failur
ventricular dysfunction
AMI
Abnormal BP
Cardiac arrythmias
cerebral complications
Musk prolems
19
Q

Name some RIsk factors for CABG operations

A 
Obesity
Diabetes
smoking
Pre exisiting lung issues
Osteoporosis
increased age
co morbities
20
Q

Why is LL atelectasis associated with this surgery

A

Due to close proximity of the heart to the lungs. even slight handling of the lungs will cause them to collapse

21
Q

Why can this surgery cause Pulmonary odeam

A

Agreesive fluid replacement

release of vasoactive substances and altered capillary permeability after bypass

22
Q

Why Pulmonary effusions

A

mainly on left side
due to Heart failure
Trauma or unknown origin

23
Q

List the effects on the pulmonary system post CABG

A
  1. Lower lobe Atelectasis
  2. pulmonary odema
  3. pulmonary effusions
  4. Pulmonary embolism
  5. Pneumothorax
24
Q

Physiotherapy post CABG?

A

DB and Mobilisation makes no difference to just mobilisation (Brasher et al 2003)

25
Q

What do you do if they can’t mobilise

A

Bubble PEP - Westerdahl et al 2005 showed this was helpful post cardiac surgery
Urell et al 2016, showed increase of DB and PEP post Cardiac surgery beneficial if in preventing PPC if unable to mobilise

26
Q

Lis some complications of chest surgery

A 
Brachial plexus injuries
Sternal instability
Drain site adhesions
SC and MS sublaxations
Rib # 
Phrenic nerve palsy
Scar thicking/ paraesthesia
Ant/ anterolate chest wall hyposensitivity
Deep chest wall pain
Left parasternal/ anterolat paraesthesia
27
Q

Reasons Musk complications for CABG

A

Sternal retractins
Dissection of the IMA
IJV cannulisation
Patient position

28
Q

DOn’t forget to get….. in pre op S/e

A

ANy Musk deformity or dysfunction
Type and date of procedure
reason for precdure
previous experience in post op phyiotherapy
risk factors for post op compications
usual sputum load/ clearnace
language and communcations barriers - need a translator?

29
Q

What evidene is there for pre op assessment

A

Snowden et al 2014 dhowed that pre op interventions decreased time to extubation and risk ration of developing PPC’s bt did not effect LOS

30
Q

What occurs day 0

A

Surgery
Extubation after 10 -1 2 hours
no physiotherapy

31
Q

what occurs at day 1 post op

A

Nurses SOOB
Physi chest RX if indicated
transfer from ICU to ward

32
Q

What occurs at day 1 afternoon

A

mobilise with physios
Further chest RX if needed
SOOB 1500-2000
remind of sternal precautions

33
Q

What occurs day 2 post op

A

Removal of pacing wires - nurse
Mobilise with physios - further this time
FUrther chest RX if indicated
Encourage SOOB all day, independent mobilisation if possile
introduce U/L thoracis ROM exercises

34
Q

Day 3-4

A

Increase independent mobilisation ( 200m several ties)

may not require chest physio

35
Q

Day 5

A

D/C
Stair check with physio - up and down 24 steps
Sternal check
Group education

36
Q

where does the sternum recieve it’s blood supply from

A

Brachnes of the Internal mammary artery/ internal thoracic artery
can result in lack of blood supply if these have ben the harvest arteries

37
Q

How long does sternum take to heal?

A

8-12 weeks

38
Q

What are symptoms of sternal instability

A

Clicking
instability of chest
pain and discomfort
at a certain stage you can put you finger in the groove

39
Q

List the sternal precautions

A

restrict range and or load to UL to minimise shearing or distraction forces on sternal edges
Use both arms
Use of no arms?

40
Q

What activities should be kept to a minimum

A

Pushing large objects
carrying weight > 5kgs
heavy manual tsks
swimming

41
Q

Sternal stability

A 
Palpate and ask to:
COugh
deep inspiration
fLateral flexion of trunk
Roation of trunk
Unilateral and bilateral flexion and abduction
42
Q

WHat do you observe about the sternal wound

A

Healing, temp colour, any discharge

Record position when standing

43
Q

List Grades of sternal motion

A 
0 = clinically stable - no detectable movement
1 = Minimally separated - slight increase in movement
2= Partially separated sternum - moderate increase in movement
3= complete separation of sternum (entire length) - marked increase in movement

CI 1 (8 decks)

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