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Flashcards in Cardiac Surgery Deck (43):
1

What is the most common incision used for cardiac surgery?

Median sternotomy: Sternal saw cuts through sternum then a rib spreader is used, sternum closed with wires

2

What are chest drains used for post surgery?

To drain fluid and air from the mediastinum

3

When are chest drains removed?

Generally after 24 hours (better outcomes if removed in first 24 hours)

4

What can result if chest drains are left in for too long?

- Mechanical irritation of pericardium
- Infection
- Pain/discomfort
- Less able to mobilise due to pain - muscle wasting

5

What are the key safety points for handling chest drains?

- Take care when handling patient - keep tube visible
- Ensure unit is visible to avoid damage
- Avoid application of positive airway pressure unless indicated
- Check before disconnecting suction prior to intervention
- Maintain drain below level of the chest
- Ensure clamps are available for emergencies
- Monitor pain associated with drains

6

What are some of the common cardiac procedures?

- Coronary artery bypass graft (CAG, CABG)
- Valve repair/replacement (AVR, MVR)
- Repair of congenital defect
- Heart transplantation

7

What is an alternative to CABG surgery that is becoming more common?

Percutaneous coronary intervention (PCI)
- Patient is awake
- Wires inserted into arteries to clear blockages

8

How does surgical management compare to conservative in cardiac illnesses?

Surgical results generally better than conservative for some conditions

9

What are the functions of a heart-lung machine (cardiopulmonary bypass machine)?

- Receives blood
- Adds O2
- Eliminates CO2
- Controls body temperature
- Returns blood under pressure & flow

10

What are the consequences of a heart lung machine?

- Lungs aren't fully expanded (risk of PPCs)
- Non-pulsatile perfusion (abnormal organ blood flow)
- Activation of inflammatory cascades (hypotension)
- Blood component factors (bleeding, coagulopathy)

11

What is one of the risks of cannulation?

- Clamps arteries shut, causing a blood clot
- When released, can release the blood clot

12

What is the risk of a LIMA (left internal mammary artery) harvest?

- Proximity of phrenic nerve
- 2-10% diaphragmatic paralysis

13

What are the CABG graft sites?

- Aorta
- Right coronary artery
- Left anterior descending coronary artery
- Circumflex coronary artery
- Left main coronary artery

14

What are the two most common CABG graft harvest sites?

- Saphenous vein graft (SVG) - 25-50% functional 10 years post
- Left internal mammary artery (LIMA) - 90% functional 10 years post

15

What occurs at the conclusion of open heart surgery?

- Sternal closure
- Routine ventilation 4-8 hours
- Multiple drain tubes
- Temporary pacing wires

16

What are the possible complications of cardiac surgery?

- PPC
- Infections (wound, UTI)
- DVT
- Haemorrhage
- Renal failure
- Ventricular dysfunction
- AMI
- Cardiac tamponade
- Abnormal BP
- Cardiac arrhythmias
- Cerebral complications
- Musculoskeletal problems

17

What are the operative risk factors?

- Obesity
- Diabetes
- Smoking
- Pre-existing lung disease (restrictive/obstructive)
- Osteoporosis
- Increased age
- Co-morbidities (renal failure, malnourished, unwell)

18

How can cardiac surgery affect the pulmonary system?

Lower lobe atelectasis (mainly left, 30-88% patients)
- Compression of LLL
- Cold injury to phrenic nerve

Pulmonary oedema
- Agressive fluid replacement
- Consequences of heart lung machine

Pleural effusion (30%, mainly left side)
- Heart failure
- Trauma
- Unknown origin

Pulmonary embolism
Pneumothorax

19

What has physio management of cardiac surgery patients traditionally focused on?

Prevention of PPCs

20

What are the musculoskeletal complications of cardiac surgery?

- Brachial plexus injuries
- Sternal instability
- Drain site adhesions
- C/S & T/S dysfunction
- SC & MS subluxaion
- Rib fractures
- Phrenic nerve palsy
- Scar thickening
- Chest wall hypersensitivity
- Deep chest wall pain
- Paraesthesia

21

What are the possible reasons for MS complications?

- Sternal retraction
- Dissection of IMA
- IJV cannulisation
- Patient position
- Devascularisation of sternum

22

What are some of the questions that should be asked in the pre-op subjective Ax?

- Mobility/gait aids
- Home situation
- MS deformity/dysfunction
- Type/date of procedure
- Reason for procedure
- Previous experience of post op physio
- Risk factors for PPCs
- Usual sputum load
- Language/communication barriers

23

What does post-op respiratory care involve?

- Positioning (high sit is best)
- Mobilisation
- TE techniques
- FET/coughing with wound support
- PEP devices
- ACBT
- CPAP
- Humidification if indicated

24

What does post-op MS care involve?

- Reinforce sternal precautions
- Assessment, monitoring, management of sternum
- Thoracic/shoulder ROM

25

What generally happens day 0 post op?

- Extubated within 10-12 hours (breathing tube removed)
- No physio

26

What generally happens day 1 post op?

- SOOB
- Physio chest Rx if indicated
- Transfer to ward
- Mobilise with physios
- Remind patient of sternal precautions

27

What generally happens day 2 post op?

- Removal of pacing wires
- Mobilise
- Further chest Rx
- Encourage SOOB all day
- Independent mobilisation if possible
- Introduce UL/thoracic ROM exercises

28

What generally happens day 3-4 post op?

- Increase independent mobilisation
- May not require physio if managing chest & mobilisation

29

What generally happens day 5 post op (discharge)?

- Stair check with physio
- Sternal check
- Group education session (sternal precautions, exercise guidelines, ADLs, exercises)

30

How long does the sternum take to heal post sternotomy?

8-12 weeks

31

What are some of the symptoms of sternal instability?

- Clicking
- Instability of chest
- Pain & discomfort

32

What are the risk factors for sternal instability?

- Smoking
- Osteoporosis
- Female with large breasts
- Bilateral IMA harvesting
- PVD
- Prolonged mechanical ventilation
- Higher disability classification
- Obesity
- COPD
- Blood loss
- Resternotomy
- Diabetes

33

What occurs in sternal instability?

- Separation of sternum at midline
- Due to fracture/disruption of suture line
- Separation may be total or partial

34

What are the clinical features of early sternal instability?

- Broken/loose wires +/- infection
- Friction, pain, discomfort
- Excessive motion, clicking
- Wire/bone fracture, non-union, skin breakdown, infection

35

What are the clinical features of late sternal instability?

- Crepitus
- Clicking/clunking
- Pain/muscle guarding
- Disruption of ADL
- Increased morbidity/mortality
- Increased LOS

36

What is the rationale behind sternal precautions?

Restrict range/load applied to ULs to minimise shearing and/or distraction forces at sternal edges & facilitate bone healing

37

What activities should be kept to a minimum for 8-12 weeks?

- Activities above head
- Pushing large objects
- Carrying weights > 5kgs
- Heavy manual tasks
- Swimming

38

What additional sternal precautions are given to patients?

- Perform activities with 2 arms symmetrically
- Avoid heavy activities with one arm
- Ensure good posture
- Safe driving dependent on stable sternum & sound concentration levels

39

How is sternal instability diagnosed & measured?

- CT scan
- X ray
- Ultrasound (reliable & valid)
- Physical examination (subjective/objective)

40

What does sternal stability palpation involve?

Palpation of median sternal edge during:
- Deep inspiration
- Cough
- Unilateral/bilateral flexion & abduction of arms
- Lateral flexion of trunk
- Rotation of trunk

41

What is the standard for sternal stability testing?

- Record wound appearance
- Record patient position
- Record position of fingers
- Record degree of palpable separation
- Record extent of excessive motion
- Eliminate other sources of clicking
- Relate subjective & objective findings
- Assign grade that matches findings

42

What is the scale used for grading sternal instability?

0 = Clinically stable (no detectable movement)
1 = Minimal separation (slight increase)
2 = Partial separation (regional, moderate increase)
3 = Complete separation (entire length, marked increase)

43

What is the management for sternal dehiscence & instability?

- Exercise & activity modification guidelines
- Ortho stabilisation devices (brace)
- Surgery (parasternal weaving, pec muscle advancement)