Post-surgical intervention for cardiovascular and thoracic procedures

what is a posterolateral thoracotomy used for and what is damaged when doing it?

used for lung resection procedures

starts midway between T4 SP and scapula

curves around inferior angle of scapula to 5th and 6th Intercostal

lower trap, serratus anterior, and lat dorsi divided to avoid long thoracic nerve damage

what is a lateral thoracotomy used for and what can occur?

used for lung resection procedures

begins near the nipple line

extends towards the scapula

L.dorsi muscle is retracted

S.anterior and interocstals are incised

what is anterolateral thoracotomy used for and what is damaged?

used infrequently but can be used for cardiac procedures, pulmonary resections or esophagela procedures

4th and 5th intercostal, pec major is incised

fibers of serratus anterior are separated

breast tissue is reflected

what is a median sternotomy used for and how is the patient positioned?

patient supine

midline to suprasternal notch

extends to below the xiphoid

sternum divided along its midline

sternum closed with steel after procedure

what is a thoracoabdominal incision used for and where does it occur?

procedures on the diaphrgam, esophagus, biliary tract, liver, spleen, adrenal glands and kidney

8th/9th IC space at posterior axillary line to the mid-abdomen

transect lats, s.anterior, external obliques, rectus abdominis

what is the minimally invasisve appraoch that is used if possible?

video assisted thoracotomy

used for lung cancer, pleural problems

recovery is much quicker so becomign more widely used

what are some PT implications for surgical approaches?

shoulder pain is primary complaint from patients

chest tube placement can be irritating

prolonged positioning during surgery

long thoracic nerve damage

poor posture post-operatively can cause sub-acromial impingement

define: lobectomy

pneumonectomy

what is the most common reasons for both procedures?

lobectomy: removal of just one lobe

pneumonectomy: removal of an entire lung

lung cancer

what type of surgery is performed in patients with emphysema if bullae are greater than 1 cm? what is the main goal?

lung volume reduction surgery

incision is thoractomy or median sternotomy

improve expansion and recruitment of functional lung tissue

what are PT implications for thoracic procedures?

thoracic expansion

airway clearance

surgical approach

chest tubes

lung function

positioning

what will happen if you lie on the side the trachea is shifted to?

it will increase the shift and it shifts towards the side of the lobectomy/pneumonectomy

what are the 3 main revascularization procedures?

PTCA, stent implant, CABG

where is a cardiac cath entered and what can it measure?

entered into a artery or vein in the arm or leg

test can measure: blood pressure within the heart

how much oxygen is in the blood

information about the pumping ability of the heart muscle

evaluate congenital defects

what is an angiogram?

the catheter is used to inject dye into the arteries

pictures can be gained of the flow in the coronary arteries

what is the purpose of a PTCA?

a baloon tipped catheter is inserted via the femoral artery

balloon is then inflated, compressing the plaque and dilating the artery

what is a stent placement used for?

stents are often placed after the artery is widened

act as scaffold to stop the artery re-narrowing

looks like tiny coil of wire

typically coated with medication

what type of patients have PTCA, stents and cardiac caths?

heart attacks, congenital abnormality, blood coagulation pathology

what are some of the risks associted with these procedures?

bleeding, restenosis, blood clots, artery damage, arrhythmias, heart attack, ongoing disease

what are the PT implications of cardiac cath, angiogram, PTCA, and stent placement?

safety-know signs and symptoms

activity level: check activity orders before mobilizing patient

if radial artery used then you can mobilize more quickly

incorporate results of procedure into plan of care

what is the purpose of a CABG?

median sternotomy

performed for revascularization when greater than 3 vessels are invovled

vascular graphs come from saphenous and left internal thoracic a.

what are possible lines and tubes that someone who. hasa CABG could have?

endotracheal intubation

2 chest tubes

central venous line or arterial line

pulmonary a. cath

intravenous lines

what are PT implications of CABG?

pain

lines and tubes

sternal precautions

potential loss of joint motion

pulmonary complications

superficial incisional infection

blood loss

what are conservative sternal precautions?

no lifting, pulling, pushing greater than 10 lbs

no abd or flex greater than 90 when UE is weighted

shoulder AROM in pain free range

no scap retraction

avoid active trunk flexion

no UE use with sit to stand

no driving

no manual therapy

what area are the majority of heart valave replacements at? what are the 3 main types?

mitral or aortic

mechanical, tissue valve, and allografts or homografts

what are the PT implications for heart valve replacement?

very similar to post CABG if a sternal incision is used

advances in surgery have resulted in beign minimally invasive so PT implications are similar to post PTCA

what are the 3 different pacemakers and differences?

single chamber: one wire is placed in either the atrium or ventricle

dual-chamber: two wires, one paces the atrium, one paces the ventricle

rate responsive: sensors are present that automatically adjust HR based on someones physical activity

what are some items that do not affect a pacemaker?

CB radios, electric drills, electric blankets or shavers, ham radios, heating pads, metal detectors, microwave ovens

what are some things that do affect pacemakers?

power-generating equipment

welding equipment

certain pieces of equipment

some Tens/e-stim units

MRI

radiation equipment

diathermy

what are PT implications for a pacemaker?

restrict upper extermity AROM below shoulder height for 2 weeks

no lifting greater than 10 lbs for 2-3 weeks

most normal activies can be resumed at 6 weeks

swiming, golf, repeated overhead motion can be resumed at 3 months

no contact sports ever

important to know the type of pacemaker

what is an implantable cardioverter defibrillator?

implantable cardioverter defibrillator used to correct life-threatening arrhythmias

ventricular tachycardia

ventricular fibrillation

sudden cardiac death caused by arrhythmias

what are PT implications for ICD?

same as for pacemakers

always carry a card and dont go through airport metal detectors

what are the uses of intra-aortic balloon pump?

inflatation at beginning of diastole boosts intra-aortic pressure, restoring arterial pressure and improving perfusion

deflation during left ventricular systole decreases afterload and assists ventricle to eject a larger stroke volume

usually inserted in femoral artery sued for short term treatment of cardiogenic shock

what are the PT implications with intra-aortic balloon pump?

will be in ICU

Rn must be present if mobilizing

bedrest for 4-6 hours

perform brachial plexus screen

what is ECMO?

priamary indication for the use of ecmo is cardiac or respiratory failure

what is a ventricular assistive device?

a mechanical device that is used to take over the pumping function for one or both of the hearts failing ventricles

what is VAD used for?

bridge to recovery

bridge to translant

destination therapy

post-cardiotomy support

what can VAD’s be used to support?

right heart alone

both ventricles

more commonly the left ventricle

can be permananent or temporary

what do all VAD devices have?

pump, binder, system controller, batteries, power base and display module

what is a BiVAD used for?

to give the heart a rest often after a MI or cardiac surgery

is used when reversible heart failure is present

short term device

what are some major risk factors of VAD?

infection

bleeding

blood clots

right ventricular failure

what are PT implications for pre-VAD placement?

exercise prescription

bed mobility and transfers-independence with these activites is requried to be candidates

what are PT implications to post VAD placement?

equipment

contraindications to PT

precautions in this patient group

exercsise prescription

what are contraindications for PT post-VAD placement?

patient must have a new post-op PT order and be stable

refer to previous contraindications for exercise

during exercise-drop in pump flow since it may indicate pump failure

symptomatic: dyspnea, high RPE, dizziness, nausea, low O2 stats

how do you measure vital signs during exercsie on VAD patietns?

use RPE, symptoms and VAD flows, these patietns will not have a pulse

what are some genereral precatuions from Post-VAD placement?

components cannot get wet

no swimming, jumping or contact sports

individuals should not become pregnant

do not lie prone

don’t directly touch TV or computer screens

what are exercise prescription for VAD?

breathing techniques, warm-up/cool down

cardiorespiratory fitness

functional exercsie

edema management

body mechanics