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Applied Clinical Veterinary Nursing > Thoracic Surgery > Flashcards

Thoracic Surgery Flashcards

(78 cards)

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1
Q

What are the typical clinical signs of thoracic conditions?

A

Tachypnoea
Orthopnoea/hyperpnoea/dyspnoea/abdominal breathing
Cough?
Pale MMs (cyanosis)
Exercise intolerance, collapse
Injuries? Systemic illness?

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2
Q

What initial management can be given to thoracic patients?

A

Oxygen therapy
Wound management - assess, flush, protect
Temperament - mild sedation?

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3
Q

What samples can we initially take from thoracic patients?

A

Bloods
Thoracocentesis for cytology and culture

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4
Q

How can we decide between using radiography and ultrasonography for thoracic patients?

A

Restraint for radiography can be life-threatening in dyspnoeic patients
Nurses can use TFAST scan for triaging

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5
Q

What are the surgical thoracic conditions?

A

Pneumothorax
Chest and lung trauma
Pulmonary blebs or bullae
Diaphragmatic rupture (abdominal approach!)
Pleural effusion
Pyothorax
Pericardial effusion
Pulmonary neoplasia

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6
Q

Describe an internal/closed pneumothorax.

A

More life-threatening!
Oesophagus/respiratory tract (trachea/small airways)

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7
Q

Describe an external/open pneumothorax.

A

Hole in the chest
Chest trauma e.g. dog attack
Iatrogenic e.g. post-lung lobectomy, diaphragmatic rupture, complications of thoracocentesis/thoracostomy

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8
Q

What are the clinical signs of pneumothorax?

A

Dyspnoea!
Lethargy
Cough
Exercise intolerance

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9
Q

How can we diagnose pneumothorax?

A

Unilateral/bilateral
Thoracocentesis

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10
Q

How can we treat pneumothorax?

A

Chest drain (may need bilateral drains if mediastinum intact)
Thoracotomy - massive air leak/ongoing and not sealing itself

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11
Q

How can patients get chest and lung trauma?

A

Accidents e.g. RTA/train, fall of cliff, impaling injury
Attack e.g. big dog, human, accidental vs deliberate

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12
Q

What are the clinical signs of chest and lung trauma?

A

Shock!
Dyspnoea
Soft tissue damage (extensive open wounds / progressive bruising/crushing wounds)
Ortho damage (rib fractures e.g. flail chest, other parts of skeleton)

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13
Q

What complications can we see with chest and lung trauma patients?

A

Infection/inflammation - depends on cause of trauma/degree of contamination
Healing - can be delayed/breakdown common depending on degree of tissue loss
Ongoing effusion/pneumothorax - depends on amount of trauma/tissue injury

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14
Q

What is the difference between pulmonary blebs and pulmonary bullae?

A

Blebs = on edges of lobes
Bullae = within lobes

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15
Q

What is the typical signalment for pulmonary blebs/bullae?

A

Large-breed, deep-chested dogs

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16
Q

What are the clinical signs of pulmonary blebs/bullae?

A

None if not ruptured!
Non-specific e.g. lethargy, anorexia, exercise intolerance
Respiratory - progressive e.g. sudden onset dyspnoea, tachypnoea/orthopnoea/coughing OR peracute e.g. spontaneous closed tension pneumothorax (if ruptured!)

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17
Q

How can we diagnose pulmonary blebs/bullae?

A

Radiography (diagnose pneumothorax but cannot localise affected lobes)
CT (assess which lobes affected, needed before surgery)

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17
Q

How can we surgically treat pulmonary blebs/bullae?

A

Thoracotomy and lung lobectomy (depending on how many lobes affected)

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18
Q

How can we conservatively manage pulmonary blebs/bullae?

A

Intermittent thoracocentesis / indwelling chest drain

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19
Q

How do patients get diaphragmatic rupture?

A

Blunt force trauma e.g. RTA, fall

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20
Q

What are the clinical signs of diaphragmatic rupture?

A

Can be peracute, acute or chronic
Can have no signs or just vague ill health
Dyspnoea, shock
Tachypnoea, orthopnoea

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21
Q

What affects severity of clinical signs of diaphragmatic rupture?

A

Herniation (what organs? How much torsion? Compressed thoracic contents?)
Size of tear

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22
Q

How can we initially stabilise diaphragmatic rupture patients?

A

Oxygen therapy
Analgesia
IVFT

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23
Q

How can we surgically treat a diaphragmatic rupture?

A

Explore chest and abdomen
Reposition abdo contents/remove if devitalised
Repair and debride as necessary
Chest drain due to iatrogenic pneumothorax

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24
What are the clinical signs of a pleural effusion?
Dyspnoea! Lethargy Cough Exercise intolerance
25
How can we diagnose a pleural effusion?
Unilateral / bilateral Imaging Thoracocentesis - SG, cytology, culture and sensitivity
26
Which conditions causing pleural effusion are medical?
CHF Pyothorax (cat)
27
Which conditions causing pleural effusion are surgical?
Pyothorax (dog) Diaphragmatic rupture
28
What is typical canine and feline aetiology of pyothorax?
Bacterial infection - E. coli in dogs / Pasteurella in cats Cats - idiopathic e.g. bites, extensions from pulmonary abscesses Dogs - FBs, oesophageal tears, pulmonary infections
29
What are the clinical signs of pyothorax?
Lethargy, inappetence, pyrexia Dyspnoea due to effusion
30
How can we diagnose pyothorax?
Imaging e.g. radiographs, ultrasound Cytology and culture of effusion
31
How can we conservatively manage pyothorax in cats?
Systemic antibiotics Chest drain +/- lavage
32
How can we surgically treat pyothorax?
Typically done early in dogs due to high % of FBs Sternotomy - explore, remove, debride, flush THEN post-op medical management
33
What are the typical aetiologies of pericardial effusion?
Idiopathic Neoplastic
34
What are the clinical signs of pericardial effusion?
Cardiac tamponade Depends on how quickly fluid forms - does pericardium have time to stretch?
35
How can we diagnose pericardial effusion?
Imaging e.g. radiography, echocardiography, advanced Cytology to rule in/out neoplasia
36
How can we treat pericardial effusion?
Repeated pericardiocentesis Surgery - pericardiectomy (does not prevent effusion forming! Prevents cardiac tamponade and converts into pleural effusion) Chest drain
37
What are the possible complications of pericardial effusion treatment?
Recurrence after draining/surgery Long-standing effusion causes adhesions
38
Describe which aetiologies of pulmonary neoplasia are most common.
Malignant more common than benign - benign is very rare! Secondary metastases far more common than primaries
39
What are the clinical signs of pulmonary neoplasia?
None! Non-specific e.g. non-productive cough, haemoptysis, dyspnoea, weight loss, exercise intolerance, anorexia Hypertrophic pulmonary osteopathy (paraneoplastic syndrome) - very painful!
40
How can we diagnose pulmonary neoplasia?
Biochem, haematology, urinalysis +/- cytology Imaging - inflated radiographs / advanced imaging
41
How can we treat pulmonary neoplasia?
Palliative Surgery - thoracoscopy / thoracotomy
42
What affects the prognosis of pulmonary neoplasia patients?
Presence of mets Histopathology Clean/dirty surgical margins
43
What considerations should we have for nursing thoracotomy patients?
Analgesia, hypothermia, IPPV once thorax open Monitoring - pain score, TPR Appropriate drug regime Surgical site/wound management Body bandages IVFT, urinary catheters, feeding tubes Chest drains
44
Define thoracocentesis.
Procedure involving the puncture of the pleural space for diagnostic and/or therapeutic purposes
45
What equipment do we need for thoracocentesis?
Oxygen Local anaesthetic Sterile prep + gloves/drape Needle / IV catheter / butterfly catheter +/- extension set Assistant 3-way tap 20ml syringe Kidney dish/jug
46
What samples can we collect from thoracocentesis?
EDTA, heparin, plain tubes - cytology, biochem, culture Smear for cytology Check specific gravity bed-side +/- Diffquik staining
47
Define chest drain.
A tube placed into the pleural space to allow ongoing, continuous or intermittent therapeutic drainage
48
What does the decision to place a chest drain usually depend on?
Underlying disease (if fluid/air continuing to be produced) Quantity of fluid/air being produced Patient temperament Treatment plan (if going to thoracotomy)
49
When is a chest drain usually placed?
Intermittent thoracocentesis not working - too much fluid/air being produced/fluid too thick/causing lung trauma Following thoracotomy - remove fluid/air introduced during surgery/produced due to underlying condition/due to complications of surgery Long-term pleural drainage e.g. pneumothorax due to underlying disease, pleural effusion Instillation of medication e.g. LAs, saline for lavage of pyothorax, antibiotics, chemotherapy
50
What are the types of chest drain?
Size - large bore / narrow bore Placement - trocar / Seldinger technique
51
What factors affect which chest drain is selected for placement?
Type e.g. trocar/narrow bore/PleuraPort Size (6Fr to 20Fr) Placement method e.g. open/closed chest Site (unilateral vs bilateral) Connectors Securing e.g. roman sandal sutures/anchor flanges with simple sutures Protecting e.g. body bandages, buster collars
52
Describe trocar-style chest drains.
Fenestrated with or without stylet Commonly placed under GA Subcut tunnel required as air leaks common Rigid so easy to place where wanted
53
What are the pros of trocar-style chest drains?
Lots of different sizes available Versatile, larger bore so less likely to block Robust/do not collapse Transparent so can monitor for clogs in tube
54
What are the cons of trocar-style chest drains?
Need GA to place Higher complication rate than narrow bore Need careful training to place Need good suture technique for anchoring Less comfy than narrow bore
55
Describe a narrow bore/Seldinger technique chest drain.
More expensive tube than trocar, but cheaper to place as no GA needed Less need for subcut tunnel as air leaks less likely Easy to place
56
What are the pros of narrow bore chest drains?
No GA Easy to place Easy to secure Versatile More comfy
57
What are the cons of narrow bore chest drains?
May not cope with pleural fluid / pyothorax Not as rigid so can be more difficult to place cranioventrally
58
When would we use a PleuraPort chest drain?
Palliative care where long-term drainage required
59
What equipment do we need to place a chest drain in a closed chest?
Sterile prep + gloves Anaesthetic e.g. GA/LA Assistant Chest drain pre-measured for length Scalpel and blade Basic instrument kit Fenestrated drape 3-way tap Syringes Extension set Kidney dish/jug Suture
60
Describe intermittent drainage of a chest drain.
Care of connectors particularly important! Typically every 4-8hrs and/or determined by resp rate/dyspnoea
61
Describe continuous drainage of a chest drain.
E.g. Heimlich valve/commercial drainage unit Used most often with large air-leak pneumothorax cases Care with suction level as can collapse tube/aspirate tissue
62
What analgesia can we consider for chest drains?
Local e.g. lidocaine / bupivacaine down the drain Opioids e.g. methadone/buprenorphine CRIs e.g. ketamine/lidocaine (no lido in cats) Paracetamol in dogs NSAIDs to go home
63
64
What issues with placement can we see with chest drains?
Unable to place Incorrect placement (went caudal, stuck in mediastinum) Use X-ray to check placement!
64
What can lead to chest drains failing to drain?
Accidental removal Tube disconnection/obstruction/kinking Patient interference!
65
What iatrogenic complications can we see with chest drains?
Haemorrhage/haemothorax Heart/lung damage Premature removal leading to recurrence Nerve damage Pneumothorax (check connectors/fenestrations) Pyothorax (aseptic technique) Seroma (self-resolving) Subcutaneous emphysema (around skin incision, self-resolving once tube removed)
66
List the four options for thoracic surgery.
Left lateral intercostal thoracotomy Right lateral intercostal thoracotomy Ventral sternal thoracotomy / sternotomy Thoracoscopy
67
Describe an intercostal thoracotomy.
Less painful than sternotomy Unilateral surgery - correct side to approach? Correct intercostal space?
68
Describe a sternotomy.
More painful Better for exploratory thoracotomy Better for bilateral conditions
69
Describe thoracoscopy.
Least painful Steep learning curve Specialised equipment Some limitations in which procedures appropriate
70
What groups of instruments do we need for thoracic surgery?
Long-handled basics e.g. tissue forceps/scissors/needleholders Retractors Tissue forceps Sternotomy instruments (to break bone)
71
What miscellaneous items might we need for thoracic surgery?
Lap swabs Wire/thick suture Suction Pre-selected chest drain and connectors Tourniquet Pledget sutures Vessel loops
72
What are the basic electrosurgery types?
Monopolar (need earthing pad to prevent patient burns) Bipolar
73
What is a pneumonectomy?
Removal of one half of the lungs! Cope surprisingly well - expands to fill the chest
74
Describe sutures vs staplers for lung lobectomy.
Sutures = slow, challenging, higher risk of leakage Staples = quick, lower risk of leakage, more expensive, steep learning curve
75
Describe leak testing.
Should always be done after a lung lobectomy! Fill chest with warm saline IPPV - check for air bubbles Suction fluid back out once happy no leaks
76

Applied Clinical Veterinary Nursing (40 decks)

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