Medical Interventions & PT Complications

Thoracic Cage Incisions: The median sternotomy is commonly used for what type of surgery?

cardiac surgery, including heart & heart-lung transplantation

Median sternotomy

Thoracic Cage Incisions Some mitral valve surgery is performed via a ________________ thoracotomy

Posterolateral

Posterolateral thoracotomy for mitral valve surgery

Thoracic Cage Incisions Lung surgeries are usually performed via the ___________ or ______________ thoracotomy incision

- Anterolateral

- Posterolateral

Anterolateral thoracotomy incision

Posterolateral thoracotomy incision for lung surgeries

Thoracic Cage Incisions Bilateral lung and live donor lobar transplantations typically use the _____________ incision

Clamshell

Clamshell incision thoracotomy

What is a thoracotomy?

An incision into the pleural space of the chest

What are the most common types of thoracotomies? (3)

- Posterolateral

- Anterolateral

- Lateral

Thoracotomies: Usually requires an ____________ for a couple of days to control for high pain after this procedure

epidural

Thoracotomies: Post-thoracotomy pain syndrome is a result of a ___________ emanating from the __________ nerves around the surgical approach

Neuralgia, intercostal

Thoracotomies: What is sometimes done in this procedure that is likely to irritate the intercostal nerves?

A rib can sometimes be removed during this approach

Thoracotomies: 5-20% of those who undergo a thoracotomy end up w/ ___________ __________ d/t the incision & surgical approach

chronic pain

Doing heart surgery through thoracotomy: This procedure would be for someone in....?

Cardiac arrest

Thoracotomy to access the heart/pericardium: What do you need to be sensitive of? (2)

- What has been cut through

- The pts pain level

Bronchoscopy: Can be done as an ____________ OR an ______________ tool

Intervention, assessment

What is a Bronchoscopy

Using a flexible or rigid fiberoptic endoscope, the larger airways down to the third or fourth divisions of the segmental bronchi can be visualized directly.

Bronchoscopy: If abnormality, what can be done?

- Bronchial brushing

- Bronchoalveolar lavage

- Transbronchial needle aspiration/ lung biopsy

Bronchoscopy Can be used as a therapeudic intervention removing retained _________ or aspirated _________ ____________

- Secretions

- Foreign bodies

Bronchoscopy: Can be used as as intervention to assist in difficult __________ & _________, & managing ___________ obstruction

- Intubation

- Hronchodilation

- Malignant

What is a lung lavage?

Bronchoscope is passed through the mouth or nose into the lungs & fluid is squirted into part of the lung & then collected for examination.

Lung Lavage: Also used to loosen and remove ___________

secretions

Lung Lavage: What is this the gold standard for?

Pulmonary alveolar proteinosis

Lung Lavage: This is the procedure where you ________ one lung and _________ the other to “clean” the lungs

Inflate, deflate

Pulmonary Resection: Whare are the Indications? (5)

- Bronchogenic carcinoma

- Bronchiectasis

- Fungal infections

- Tuberculosis

- Benign tumors

Pulmonary Resection: ________________ or _______________ thoracotomy incision

Anterolateral, posterolateral

Pulmonary Resection: Incision through the ____________ _____ corresponding to the lesion

Intercostal space

Pulmonary Resection: Division of the ___________ ___________ & _______________ muscles

Serratus anterior, intercostal

Pulmonary Resection: Sometimes they cut through what other muscles? (2)

Latissimus dorsi & rhomboid muscles

Pulmonary Resection: How are the surgical procedures named?

For the portion of the lung removed?

What type of Pulmonary Resection?: Removal of a small localized lesion

Wedge resection

3 multiple choice options

What type of Pulmonary Resection?: Excision of a bronchopulmonary segment

Segmentectomy

3 multiple choice options

What type of Pulmonary Resection?: Resection of an entire lung lobe

Lobectomy

3 multiple choice options

What type of Pulmonary Resection?: Removal of the middle lobe along with an upper or lower lobe

Bilobectomy

3 multiple choice options

What type of Pulmonary Resection?: Excision of a lobe & part of the main stem bronchus followed by anastomosis of the lower lobe(s) to the proximal bronchus

Bronchoplastic/sleeve resection

3 multiple choice options

What type of Pulmonary Resection?: Resection of an entire lung

Pneumonectomy

3 multiple choice options

Pulmonary Resection: How many chest tubes are required?

2

Pulmonary Resection: Where are the chest tubes placed w/ this procedure? (2)

- One at the apex of the lung aka pleural space

- One at the base or mediastinum

Pulmonary Resection: The chest tube at the apex aka pleural space is used to remove _________

Air

Pulmonary Resection The chest tube at the base/mediastinum is used to drain what? (2)

- Blood

- Serous fluid

Lung Volume Reduction Surgery is what type of procedure?

Palliative

Lung Volume Reduction Surgery: Resection of 20-35% of the lung tissue is most damaged by what?

Emphysema

Lung Volume Reduction Surgery: Done Via __________ or ________ ___________, although video-assisted thoracoscopy (VATs) in some centers

Thoracotomy, median sternotomy

Lung Volume Reduction Surgery: To improve the ___________ and recruitment of more functional lung tissue and to reduce _____________ volumes

Expansion, intrathoracic

Lung Volume Reduction Surgery: Restores shape of the ____________

Diaphragm

Lung Volume Reduction Surgery: For significant __________ & severe fixed _________ obstruction

Dyspnea, expiratory

Lung Volume Reduction Surgery: What must the FEV1 % be to be considered for this procedure?

Less than 40-45%

Lung Volume Reduction Surgery: Often done for obstructive or restrictive disease?

Obstructive

1 multiple choice option

Lung Transplant: What are the Indications? (7)

- End-stage COPD

- Interstitial pulmonary fibrosis

- Cystic fibrosis

- Primary pulmonary HTN

- Bronchiectasis

- Bronchiolitis obliterans

Lung Transplant: The patient cannot have any other serious comorbidities such as... (5)

- Morbid obesity

- Severe hypertension

- HF

- Cancer

- Cachexia

Lung Transplant: Usually less than _____ years of age, nonsmokers, ambulatory, & able to participate in ___________ ___________

65, pulmonary rehabilitation

Lung Transplant: Is typically done via a ___________ or ___________ incision

Thoracotomy, sternotomy

Lung Transplant:BLTx usually involve's what type of incision

Clamshell

Lung Transplant: What is always required w/ this procedure?

Immunosuppression

Myocardial Revascularization Procedures: To improve myocardial blood flow through stenotic __________ arteries

coronary

Myocardial Revascularization Procedures: What procedures does this include? (3)

- Catheter-based percutaneous techniques (such as PTCA)

- Coronary artery bypass grafting (CABG)

- Transmyocardial revascularization

Myocardial Revascularization Procedures: The word percutaneous means the procedure is performed through the ________, rather than through an open surgical procedure

skin

What is a Percutaneous Transluminal Coronary Angioplasty (PTCA)?

A balloon-tipped catheter is passed through the femoral artery → aorta → diseased coronary artery, using fluoroscopic guidance.

Percutaneous Transluminal Coronary Angioplasty (PTCA): A balloon-tipped catheter is passed through the __________ artery, up the _________, and then into a diseased coronary artery, using _____________ guidance

Femoral, aorta, fluoroscopic

Percutaneous Transluminal Coronary Angioplasty (PTCA): The balloon is positioned across a ___________ __________ & inflated

Stenotic lesion

Percutaneous Transluminal Coronary Angioplasty (PTCA): What is the goal of this procedure?

To ↑ the intraluminal diameter by fracturing the plaque & disrupting the vessel intima

Intracoronary Stent for PTCA: An intracoronary stent before inflation and in its expanded configuration, used to maintain the?

Patency of a vessel after PTCA

Intracoronary Stent for PTCA: ___________ occurs in 10-50% of patients undergoing PTCA, usually within the first _____ months; therefore, about 70-90% of PTCAs also involve placement of a ________

Restenosis, 6, stent

Intracoronary Stent for PTCA: T/F Plaque cannot build up around the stent

False

1 multiple choice option

Intracoronary Stent for PTCA: Return to activity in a ½ day, you need to monitor very carefully monitor very carefully because...?

Could clot or re-stenose

Intracoronary Stent for PTCA: When is discharge?

Usually the next day

Intracoronary Stent for PTCA: Stents can be put where?

In different organs

PTCA- Implications: What is the number one complication?

vasospasms (can cause angina)

PTCA- Implications: If you stop antiplatelet therapy what may happen?

Increased risk for a thrumbus

PTCA- Implications: Other risks? (5)

- MI

-Re-stenosis

- Damage to coronary vessel

- Thrombosis

PTCA: For pts treated within 60-180 min from the first medical contact, a nearly linear relationship btwn contact-to-balloon times & mortality was found in all four STEMI groups. Every 10-min treatment delay resulted in more pt deaths, b/c of this what is VERY important?

Early intervention

Coronary Artery Bypass Graft (CABG): also called what?

Aorto-coronary bypass (ACB) surgery,

Coronary Artery Bypass Graft (CABG): Uses autogenous ____________ vein or arterial grafts to bypass stenotic lesions of the coronary arteries

Saphenous

Coronary Artery Bypass Graft (CABG): Usually done through what artery?

The internal thoracic/mammary artery

Coronary Artery Bypass Graft (CABG): Do arteries or veins have longer longevity with this procedure?

Arteries

1 multiple choice option

Coronary Artery Bypass Graft (CABG): Performed via a?

Median sternotomy

Coronary Artery Bypass Graft (CABG) At closing, the ___________ is wired back together again

sternum

Coronary Artery Bypass Graft (CABG): After surgery how many chest tubes does the patient have in place?

2

Coronary Artery Bypass Graft (CABG): What are the chest tubes used for? (2)

- One to drain the mediastinum

- One intrapleural tube to reinflate the left lung, which was collapsed during surgery

Coronary Artery Bypass Graft (CABG): High ___________ demands are present post op

Oxygen

Coronary Artery Bypass Graft (CABG): Cooling of heart during CABG can affect ________ _______ and create arrhythmias (A FIB) after surgery

SA node

What are the Variations of a CABG? (4)

- Single, double, triple, quadruple

- On pump (ONCAB)

- Off pump (OPCAB)

- Minimally invasive (MIDCAB)

Variations of CABG: What does on pump mean?

On the cardiac bypass machine (machine that pulls blood out of body→ re-oxygenates it→ returns it to the body)

Variations of CABG: Which variation has higher risks such as CVA?

On pump (ONCAB)

2 multiple choice options

CABG: What should you check for post op?

EF

Complications of CABG? (7)

- A-fib

- CVA

- Pulmonary dysfunctions

- MSK & functional deficits

- Cognitive impairments

- Sternal instability and/or wound dehiscence

- Renal failure

After CABG A-fib usually occurs by day _____ & increased risk for _________

2, CVA

Minimally Invasive Direct Coronary Artery Bypass Surgery (MIDCAB): Is performed how?

Endoscopically & off-pump

Minimally Invasive Direct Coronary Artery Bypass Surgery (MIDCAB): How is it done?

Combination of small holes in the chest & a small incision made directly over the coronary artery to be bypassed

What are the Complications Associated with Cardiac Surgery via Median Sternotomy? (9)

- Myocardial injury

- Blood loss

- Atrial fibrillation

- Pneumonia

- Memory/cognitive impairment

- Subxiphoid incisional hernias

- Brachial plexus injury

- Superficial incisional infections

- Sternal instability/mediastinitis

What are the Primary RF's for Sternal Wound Complications? (3)

- Obesity/high body mass index

- Rethoracotomy

- Smoking

What is a Transmyocardial Revascularization?

Medical laser drills tiny channels into the myocardium, which improves blood flow by the physical contractility of the ventricles & triggers growth of new capillaries (angiogenesis)

Transmyocardial Revascularization: Transmyocardial laser revascularization ultimately stimulates the myocardium to form small ________ ___________, and this response appears to contribute to relief of ________ ___________ in 60% to 80% of patients within 6 months

Collateral vessels, chest pain

Transmyocardial Revascularization: During a typical procedure, approximately how many channels are made in each targeted region of the heart muscle?

10-50

Transmyocardial Revascularization: The channels in the heart muscle seal over almost immediately with little blood loss while the new channels allow....?

Fresh blood to perfuse the heart wall immediately

Surgical Treatment of Arrhythmias: What are the options? (4)

- Cardiac ablation

- Pacemaker insertion

- Automatic Implantable Cardioverter-Defibrillator (AICD)

- MAZE

Cardiac Ablation: Involves the use of ________ to destroy areas of ___________ that are related to the onset or maintenance of arrhythmias.

Energy, endocardium

Cardiac Ablation: Used for what heart rhythms.... (4)

- Supraventricular tachycardia

- Atrial flutter

- Atrial fibrillation

- Ventricular tachycardia