What are the peri-operative (process or treatment, occurring or performed at around the time of an operation) physiotherapy aims?
■Prevent or minimise the adverse physiological changes associated with major surgical procedures
■Facilitate a return to optimal function
■Resumption of role within the community.
■Physiotherapy has played a significant role in minimizing the adverse effects of anaesthesia and the surgical process on the cardiorespiratory and neuromuscular systems for more than 50 years!!
What evidence proves that physio helps pre and post operative patients?
■The role of the physiotherapist has been investigated in clinical trials since 1947!
What is the role of physiotherapy in sugery?
■Advances in the surgical process
■Advances in pain management
■New forms of post-operative physiotherapy support
■Reduction in the incidence of clinically significant PPCs (Post-operative Pulmonary Complications)
Although there are advances in surgery now days, what are the complications that impact surgery manegement?
■Simultaneous increase in the age of patients undergoing surgery
■Increase in the prevalence of co-morbidities (simultaneous presence of two or more diseases or medical conditions in a patient) and long term conditions
■Impact of frailty and quality of life
■PPC incidence still remains high!
Some further considerations in surgery management are;
prehabilitation may decrease
focus of perioperative care
Give examples of what may cause these to happen.
■Prehabilitation may decrease
–PPCs, LOS (length of stay), functional recovery
What is prehabilitation?
A relatively ew concept in surgical care and refers to the strategies implemented prior to a planned intervention that aim to improve a patients capacity to withstand anticipated stressors, improve postoperative outcomes and reduce postoperative risk.
Think of the diagram, what are the four steps of prehabilitation?
The surgical process:
What are the types and duration of anaesthesia?
–(rapid 30 – 60mins); cream spray, gargle, gel - small area of the body eg tooth, mole
–Simple limb surgery or manipulation of closed fractures; large part of body like amr or leg.
–(Nerve blocks); injection of local anaesthetic into the main nerve supplying the area under operation.
■Spinal Anaesthesia *
- type of regional anaesthetic used to give total numbness, lasting about 3 hours, to the lower parts of the body, such as in the base of your spine
■Epidural Anaesthesia *
-type of regional anaesthetic usually used to numb the lower half of the body; for example, as pain relief during labour and childbirth
■General Anaesthesia *
- where you're totally unconscious and unaware of the procedure – often used for more serious operations
What are some considerations and complications of spinal anaesthetic?
■Less cardiorespiratory complications
■High risk patients & elderly patients but not always!
■Particular care of lower limbs needed
■Earlier post – operative mobilisation
–Check LL sensation & motor control has recovered
■Earlier discharge home
- Postural hypotension
- CSF leak (rare) 🡺 lie flat don’t mobilise
Explain (thinking of the labelled picture) how spinal and epidural anaesthesia is performed.
- During spinal anaesthesia a needle is inserted between the spinous processes of the lumbar vertebrae, passing through the ligamentum flavum, the epidural space and the dura arachnoid and into the subarachnoid space.
- Complete spinal block
- L3/L4 normally selected as in the adults the spinal cord has ended usually around L1, thus reducing the risk of spinal cord damage.
- Sensory motor and sympathetic blockade of the specific nerve roots as they pass from the cord through the intervertebral foramen.
- Generally used for operations below the level of the umbilicus and commonly in joint replacement surgery.
- Opioids: Morphine and fentanyl
Epidural anaesthesia/ Extradural block:
■Repeated injections or continuous infusion are made through a small catheter
■Opioids: Bupivicaine, fentanyl, morphine
■L2/3 –lower abdominal / perineal surgery
■T7- upper abdominal surgery
■T6/7- thoracic surgery
- A fine bore catheter is inserted into the thoracic or lumbar epidural space by an anaesthetist. The insertion site is sealed with an OpSite dressing and catheter is taped along its length up the patients back and over one shoulder.
- A pump is used to continuously infuse drugs via a bacterial filter.
- A band of anaesthesia will form depending on which nerve roots have been selected.
- Most common in the lumbar region.
- Epidural can also be administered using a patient controlled system PCEA
*Spinal and epidural anaesthesia. (A) Position of needle in subarachnoid space for spinal anaesthesia. (B) Position of needle in epidural space for epidural anaesthesia/analgesia.
What are the complications of spinal and epidural anaesthesia?
Spinal anaesthesia: Hypotension
Epidural: can lead to a complete spinal block (if catheter migrates into the subarachnoid space). Rarely, if migration of an epidural catheter into the subarachnoid space combined with substantial top up could lead to an accidental spinal anaesthesia which would cause extensive bradycardia, hypotension and respiratory distress necessitating CPR.
Both: Respiratory depression (slow and ineffective breathing) if opioids are being given via an epidural.
Often require HDU / ICU care
If you use epidural instead of or combined with general anaesthesia, what advantages does this have?
■Advantages (over, or combined with, general anaesthesia):
■reduced stress of surgery
■decreased effect on respiratory function - Epidural instead of a pca (patient-controlled analgesia - which has more morphine and higher effect of respiratory function)
■reduced incidence of postoperative deep vein thrombosis in major orthopaedic surgery
■relief of post-operative pain (continuous infusion techniques )
■increased cardiovascular stability in patients with ischaemic heart disease and good left ventricular function
What are some clear differences between a spinal and epidural anaesthesia?
*READ MAIN AND DENEHEY BOOK FOR MORE INFO ON DRUGS FOR ANALGESIA
What is general anaesthesia for? What are the advantages? What does it give to the patient (provide)? What are the stages it is delivered in?
most commonly used procedure for major sugery
- Advantages: Controlled, reversible, gross loss of awareness & response to stimulation
- Provides the patient with sleep, amnesia (loss of response to memory) & analgesia (loss of response to pain).
- Delivered in stages:
1.Pre-medication (optional-tho not really for major surgery)
2.Induction (going into general anaesthetic)
3.Maintenance (an anest test monerting blood pressure, o2, urine output, and heart rate levels - to check stability of patient and with all doctors working together)
4.Reversal (reverse the anaesthesia to wake patient)
What are the effects of pre-medication?
■Administration of drugs in period 1-2 hours before induction of anaesthesia
–Allay (help) anxiety & fear
–Enhance hypnotic effects of GA agents
–Reduce postop nausea and vomiting (antiemetic)
–Reduce volume & increase pH of gastric contents
–Attenuate (reduce effect of) vagal reflexes
–Attenuate sympathoadrenal reponses (so a good pre-med hopefully means less eventfull post-operative journey)
What is the induction - intravenous phase?
- Most common method
- is through a canular in back of hand
- avoids inhakation complications - like asperation
- rapid induction (for emergency surgery)
What is induction - through inhalation?
Using a mask
■For young children - then put in canular once asleep so less distressing
■Upper airway obstruction (epiglottis)
■Lower airway obstruction (foreign body)
■Bronchopleural fistula or empyema
■No accessible veins
What is maintenance anaesthesia used for and by what?
■Anaesthesia may be continued using inhalational agents, IV anaesthetic drugs or IV opioids
■May happen with tracheal intubation with/out muscle relaxants may be used. Particularly in abdominal surgery as can help pain control afterwards and make sure no movement for a better surgicle outcome.
What are the advantages and disadvantages of general anaesthesia?
■Reduces intraoperative patient awareness & recall
■Allows proper muscle relaxation for prolonged periods of time
■Facilitates complete control of the airway, breathing & circulation
■Can be used in cases of sensitivity to local anaesthetic agent
■Can be administered without moving the patient from the supine position
■Can be adapted easily to procedures of unpredictable duration or extent
■Can be administered rapidly & is reversible
■Requires increased complexity of care & associated costs
■Requires some degree of preoperative patient preparation
■Associated with changes in the cardiorespiratory system – especially lung volume
■Associated with complications such as nausea or vomiting, sore throat, headache, shivering, & delayed return to normal mental functioning
What are the risk factors of surgery?
■General Health Status - past medical history/previously undiagnosed medical problems/angina (severe pain in the chest, often also spreading to the shoulders, arms, and neck, owing to an inadequate blood supply to the heart), hypertension/dentures
■Duration & type of anaesthesia
What are some of the surgical terminology?
Questions to answer:
- Why are surgical incisions placed?
- The prefix of words can help to locate the surgery; what does enter, gaster and pneum stand for?
- What are some surgeries named after people? and think of what kind of prodecure it is
■Surgical incisions are placed to optimise the target organ
■Appreciation of the anatomy of the abdominal & thoracic organs
–Muscles & bony structures
■Prefix of words can help locate the surgery
–enter – small intestine
–gaster – stomach
–pneum – lung
■Surgery named after people
■Understanding ‘endings’ of words also helps to work out the type of surgery
Endings of words in surgical terminology descrive what they mean
More surgical terminolgy - beginnings of words
What are these Surgical Procedures used for?
Gastrectomy – removal of stomach – paramedian incision
Abdominal aortic aneurysm (AAA) repair is a procedure used to treat an aneurysm (abnormal enlargement) of the abdominal aorta – paramedian incision or horizontal transabdominal and lowermidline incision.
Hemicolectomy – removal of half of the large intestine (colon). Right hemicolectomy and left hemicolectomy refer to the resection of the ascending colon (right) and the descending colon (left). Longitudinal midline
Colecystectomy – removal of the gall bladder. Right subcostal incision.
Appediectomy – very common. surgical removal of the appendix.
Mastectomy – removal of breast.
Nephrectomy – removal of kidney.
Esophagectomy - Esophagectomy is a surgical procedure to remove some or all of the swallowing tube between your mouth and stomach (esophagus) and then reconstruct it using part of another organ, usually the stomach.
Try to remind urself of where each insicion is made for different surgeries and therefore where the pain might be and how big the surgery is.
- Lower midine insicion below the belly button - is quite small
- left paramedian insicion (which is a laparotomy) its from almost the xiphoid process down to the pubic symphysis, which is a big cut and can be very painful
- Looking at the lateral side, so a thoracotomy cutting between the ribs and then a thoracolaparotomy, which is where they do a thoracotomy and a long incision, likely to see this in an esophagectomy, which is a huge cut.
EFFECTS OF ANAESTHESIA AND SURGERY ON LUNG VOLUME:
What is FRC and also explain the functions of all other lung volumes. (second diagram of lung volumes on other card)
Functional residual capacity is the amount of air left in the lungs at the end of passive expiration (made up of your expiratory reserve and your reserve volume). It is a space in which gas exchange continues to occur throughout the respiratory cycle, which makes sense as blood is continuously passing through the lungs. If there were no FRC, we would be continuously reabsorbing carbon dioxide.
In surgery we are mainly interested in the function residual capacity (FRC). FRC is ur buffer. although we breath in and out, gaseous exchange at the internal and external level continously takes place so that the body can metabolise all the time - alot of this takes place in your FRC.
lung volumes second diagram
General anaesthetic (GA) & respiratory system. How does GA effect lung volumes (consider TV, FRC, closing capacity)
–30% @ 24hr
–Persist for 5-10 days post-op!!
■FRC nears closing volumes
■Closing capacity (The closing capacity is the volume in the lungs at which its smallest airways, the respiratory bronchioles, collapse. It is defined as the sum of the closing volume and the residual volume.)
The most profound effect on the lungs of a GA is the reduction in lung volumes, particularly functional residual capacity.
The timing of the greatest reduction in FRC, while varying between studies is generally on the 1st or 2nd post-operative day.