Independent Learning PackageAcute2005

ABDOMINAL SURGERY Case 3 A 72 year old man is admitted to a general surgical ward for an Ivor Lewis Oesophagectomy PMHx : Dysphagia Difficulty swallowing Significant weight loss Ex-smoker, ceased 15 years ago, 20 pack year history CAL IHD OT : Ivor Lewis Oesophagectomy Post op orders : ICU Day 2 post op : RTW ICC swinging and draining Epidural insitu → good analgesia Wound ooze from abdominal incision ↓ UO C/O : Good analgesia - wound pain - nil at rest ↑ to 3/10 with deep inspiration and cough Nil nausea Dizziness 0 Numbness and weakness in lower limbs Nil sputum SOB on mild exertion O/E : Non distressed ↓ BS to the bases with fine end inspiratory crackles in bases Effective cough QUESTIONS 1. Outline the risk factors for this patient. 2. What incisions would you expect to see with this surgery? 3. Discuss the implications of these incisions. 4. Outline the patient’s post-operative presentation. 5. Review the precautions relating to ICC’s with UWSD. 6. Why is the N/G tube important in this case? 7. Interpret the assessment findings. 94 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

8. List the aims of Rx at this stage. 9. Discuss the techniques utilised to ↑ ventilation. ANSWERS 1. Risk factors: • Malnourished - ↑ susceptibility to infection • IHD • CAL • Ex-smoker 2. Incisions 2 incisions - a) upper midline - to mobilise the stomach b) thoracotomy - resection of the tumour and construction of the anastomosis ⇓ significant respiratory dysfunction post-operatively Some centres are utilising video assisted thoracotomies (VAT) when performing oesophagectomies. These patients experience less pain but still require an ICC post- operatively. A further change has been a limited number of patients undergoing this operation with VAT and laproscopic techniques for the gastric resection. 3. Implications of these incisions ¾ Significant respiratory compromise including diaphragmatic inhibition ¾ Need for ICC as the thoracic cavity has been entered ¾ 2 large incisions - can present greater difficulty in gaining effective pain control 4. Patient post-operative presentation : ¾ Position in high supported sitting ¾ O2 either via nasal prongs or mask ¾ 2 incisions - upper midline and thoracotomy / posterior VAT and upper abdominal ¾ ICC’s insitu ¾ N/G tube ¾ Jejunostomy tube for feeding ¾ Epidural or PCA for pain relief ¾ IV line for fluids and medications ¾ IDC ¾ TED stockings 95 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

5. Precautions for ICC’s Refer to Respiratory Condition - Case 3 - Chest Trauma 6. Importance of the N/G tube ♦ Placed below the level of the anastomosis and must be adequately secured so that it does not move upwards ♦ Allows drainage of gastric secretions 7. Interpretation of assessment findinngs: Fine end inspiratory crackles may represent 1. Atelectasis or 2. Fluid overload - which reflects his IHD and ability to cope with the fluids administered intra-operatively. Symptomatically this is revealed in his SOB on exertion. Numbness and weakness in the lower limbs reflects the distribution of the local anaesthetic of the epidural in the epidural space. In assessment objectively evaluate the distribution of numbness through sensation testing and evaluate muscle strength. 8. Aims of Rx: ♦ Optimise pain relief ♦ ↑ ventilation ♦ Prevent circulatory compromise ♦ ↑ mobilisation ( Effective cough therefore minimise potential for secretion retention) 9. ↑Ventilation ¾ Staged basal expansion with inspiratory holds depending on the patient’s SOB. He may only tolerate relaxed deep breathing until the frusemide is effective in increasing the clearance of fluid. ¾ Care with demand in the form of arm exercises in view of the SOB on mild exertion ¾ In view of the SOB, mobilisation may be more appropriate after the diuretic has been effective. 96 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ABDOMINAL SURGERY Case 4 A 63 year old woman is admitted to a general surgery ward for ? Liver resection / Biliary Reconstruction for metastatic Ca PMHx : Transverse Colectomy 6/95 for Ca Ex-smoker - ceased 6/95 with a 40 pack year history CAL IHD Hypertension OT : Hemihepatectomy via bilateral subcostal incisions with xiphisternal extension Post op orders : ICU Day 1 post op : RTW in pm C/O : Adequate analgesia via PCA (morphine) Nil nausea Dizziness when transferred from bed to chair in ICU Nil SOB Productive s/a yellow sputum O/E : Non distressed ↓ lateral costal expansion ( R ) > ( L ) ↓ BS ( R ) base, nil added sounds Effective productive cough Day 3 : Abdominal distension ++ ↑↑ Abdominal pain → 6/10 at rest BS absent Nausea CXR : ( R ) pleural effusion Bilateral basal collapse QUESTIONS 1. Outline the pre-operative risk factors for this patient. 2. Suggest a possible cause for the dizziness experienced Day 1. 3. Make a prioritised problem list. 4. Discuss your aims of treatment Day1. 5. What condition is becoming apparent Day 3? 97 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

6. Give a description of this condition. 7. Discuss the signs and symptoms of this condition that are evident. 8. Outline the medical management of this condition. 9. Describe the physiotherapy treatment of this presentation. ANSWERS 1. Pre-operative risk factors ƒ Lethargy → ↓ mobility ƒ Malignancy - ↑ risk of DVT ƒ CAL ƒ IHD ƒ HT ƒ Smoking history ƒ Extensive surgery - prolonged anaesthetic time 2. Dizziness Day 1 post-op Relates to the narcotic in the PCA 3. Prioritised problem list 1. Retained secretions 2. Hypoventilation 3. Delayed mobilisation - due to dizziness 4. Long anaesthetic time 5. Smoking history 6. CAL 7. IHD 8. HT 4. Aims of Rx - Day 1 ♦ Secretion mobilisation ♦ Secretion removal / assist expectoration ♦ ↑ Ventilation ♦ Mobilise in p.m. if dizziness has settled 5. On Day 3 the condition becoming apparent is : PARALYTIC ILEUS 6. Description : Cessation of movement of the gut / peristalsis not regained for a prolonged period 98 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

post-op. Maybe due to rough or excessive handling intraop or with peritonitis. 7. Signs and Symptoms of Paralytic Ileus : ™ No BS i.e. absent bowel sounds ™ Nauseated ™ Abdominal distention ™ Abdominal pain ↑ to 6 / 10 ™ Chest Xray - bibasal collapse and pleural effusion 8. Medical Management : • NBM with N/G tube • IV fluids • Parentral nutrition 9. Physiotherapy Rx : ¾ Abdominal distention ⇒ high sitting may not be comfortable and may prefer to stand for Rx. ¾ Encourage mobility as this ↓ the basal collapse and provides gravity to stimulate gut function. ¾ Some patients gain relief from massage to promote gut motility. Hepato-biliary surgery involves large incisions and long anaesthetic times. Some of the surgery can involve extensive reconstruction to re-establish biliary drainage. One of the extensive procedures is a WHIPPLES or PANCREATODUODENECTOMY to remove carcinoma from the head of the pancreas. These tumours are extremely difficult to diagnose early and therefore tend to present as a result of local or distant spread. Consequently the patients are often malnourished and very sick due to obstructive jaundice prior to surgery and therefore at a high risk of post-operative complications. 99 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ABDOMINAL SURGERY Case 5 A 45 year old female is admitted to the Urology Ward for OT as a Donor Nephrectomy Social History : Married with 3 teenage children - 13, 15 and 17 years of age 15 year old daughter has ESRF → for transplant PMHx : Nil significant PSHx : TAH and BSO 10 years ago No history of anaesthetic problems OT : ( R ) Donor Nephrectomy Post op orders : Strict hourly UO measures - notify if < 30 mls for more than 2 hours Routine post op observations NBM IV fluids Analgesia as charted Day 1 post op : UO 50 mls / hr Rate range 0 - 15 mls / hour Epidural insitu at 8 mls / hr C/O : Wound pain 3/10 at rest, ↑ to 6/10 with movement Nausea Nil SOB Nil sputum Nil calf pain O/E : Non distressed ↓ lateral costal expansion ( R ) > ( L ) ↓ BS ( R ) base nil added sounds Weak cough Calf check √√ Wound - nil ooze QUESTIONS 100 1. What does the abbreviation ESRF mean? 2. Describe the incision that would be involved? 3. Discuss the difference that this incision may make to handling of the patient. 4. Where would the incision be for the recipient of the kidney? 5. Why are the orders so specific regarding the UO? © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

6. From the subjective assessment what steps would you take? 7. Discuss the objective findings ANSWERS 1. ESRF - stands for end stage renal failure 2. Incision: Lateral loin + / - resection of the 12th rib 3. Difference to the handling due to the incision : ¾ Patient is not encouraged to use the back extensors as this would be painful. ¾ The patient is able to use his arms and abdominals to assist with bed mobility and transfers. ¾ To transfer out of bed the patient may be able to sit forward and swivel around to the side of the bed. 4. Incision for the recipient of the kidney ¾ Small lower abdominal incision as the kidney that is being replaced is not removed. The donor kidney is placed low in the pelvis and the ureter attached. ¾ With the low and smaller incision, the recipient has less pain than the donor. 5. The specific orders relating to UO (urine output) ¾ The donor is now reliant on the remaining kidney and the medical staff need to be sure it is coping with the load. 6. Steps following the subjective assessment : ¾ Need to review the patient’s pain relief if the objective findings support the patient’s perception. ¾ As experiencing nausea it is important to know the medication that the patient has utilised so that you can discuss the patient’s requirements with the nursing staff. 7. Objective findings : ♦ expansion and ↓ BS at the ( R ) base is consistent with the site of the incision. ♦ ↓ BS with no added sounds - ensure that the patient has been breathing deeply With the utilisation of a bolus of pain relief the effectiveness of the cough should be improved. 101 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ABDOMINAL SURGERY Case 6 A 59 year old female is admitted to a Gynaecological Ward for Wertheim’s Hysterectomy PMHx : Smoker 15 / day for 30 years NIDDM PE 3/95 following GA for laparotomy ⇒ warfarinised for 6/12 Pelvic mass ⇒ Ca PSHx : AAA Repair 6/94 Laparotomy for division of adhesions 3/95 OT : Wertheim’s Hysterectomy Post op orders : Routine post op observations Analgesia as charted S/C heparin TED Stockings SCD - for 48 hours Insulin sliding scale Day 1 post op : C/O : Adequate pain control Nausea Dizziness 0 Nil calf pain Nil SOB Moist cough with some difficulty expectorating O/E : Drowsy but rouseable Fair bibasal expansion BS - sl ↓ at the bases ( L ) = ( R ) Nil added sounds Moist weak cough For adjunct radiotherapy QUESTIONS 102 1. What is involved in a Wertheim’s Hysterectomy? 2. Discuss the differences between a Wertheim’s and TAH 3. What implications does this procedure have for physiotherapy? © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

4. What precautions have been taken to prevent complications? 5. Discuss the factors that may influence your management of this patient 6. Outline your prioritised problem list. 7. What are your aims of Rx for this patient? ANSWERS 1. Wertheim Hysterectomy : Involves TAH (Total Abdominal Hysterectomy), BSO (Bilateral Salpingo- oopherectomy – removal of ovaries and tubes) and removal of pelvic lymph nodes 2. Differences between Wertheim’s and TAH ♦ A Wertheim’s procedure is longer ♦ In view of the pelvic dissection there is an increased risk of complications. 3. Implications for Physiotherapy: • Removal of pelvic lymph nodes ⇒ allow time for re-establishment of drainage ⇓ Mobilisation delayed till late Day 2 ⇓ ↓ risk of Lower Limb lymphoedema • Pelvic dissection ⇒ ↑ risk of DVT - diligent with prophylaxis 4. Precautions to prevent the complication o f DVT : ♦ S/C Heparin - subcutaneous heparin ♦ TED Stockings ♦ Sequential Pressure Device for ~ 48 hrs ♦ Calf Check ♦ Active lower limb exercises 5. Factors influencing the physiotherapy management of this patient The patient’s previous surgery - AAA repair + Laparotomy for adhesions - as well as his previous radiotherapy. 103 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

\\6. Prioritised Problem List ¾ Drowsy ¾ Hypoventilation ¾ Potential for retained secretions ¾ Encourage bed mobility ¾ History of PE ¾ risk of DVT - ( smoking, malignancy, pelvic surgery and a long procedure) ¾ Smoking ¾ NIDDM 7. Aims of Rx ¾ Stimulate to keep patient awake ¾ Ventilation ¾ Assist secretion mobilisation and removal ¾ Mobilisation 104 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

VASCULAR SURGERY Revision of Lectures relating to Vascular Surgery and Amputee Management Patient 1 A 78 year old man who has a diagnosis of PVD What concomitant conditions may be evident in this patient’s history that predispose him to PVD? What signs and symptoms would you be looking for in view of the diagnosis of arterial vascular disease? What investigations may your patient have undergone to assess his PVD? Part of our treatment is to educate the patient regarding foot care precautions. Outline the advice you would give to your patient. The management for this patient would involve conservative treatment from the medical staff . Outline their advice / management to the patient. What are the implications of PVD for physiotherapy treatment in a hospitalised patient? Following investigations the management indicated is a sympathectomy. What is involved in this procedure? Why is it done? Outline some of the potential complications of this procedure Ensure you understand the procedures for the vascular reconstructive surgery outlined in the manual. A number of the procedures - femoral-popliteal, aorto-bifemoral, aorto-iliac bypasses and femoro-femoral crossover - all require modifications to their physiotherapy treatment. What are these modifications? 105 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

VASCULAR PROCEDURES : Revise before considering the following cases. 1.. Femoral-popliteal bypass involves a Dacron graft/saphenous vein from the femoral artery to the popliteal via a long incision or 3 small graft incisions on the medial aspect of the leg. 2. Aorto-bifemoral bypass involves a Y-shaped Dacron graft from the Aorta to two femoral arteries via an abdominal incision and two groin incisions. 3. Aorto-Iliac bypass involves a Y-shaped Dacron graft from aorta to iliac arteries via abdominal incision. 4. Femoro-femoral crossover involves Dacron graft from one femoral artery to the other via two groin incisions. 5. Axillo-femoral bypass involves a Dacron graft from the brachial artery to femoral artery with a femoro-femoral crossover. It is a subcutaneous graft involving an axillary incision, a number of small lateral abdominal incisions and two groin incisions. This procedure is often performed in patients with severe cardiac or respiratory disease who would not tolerate a lengthy general anaesthetic or patients who have extensive atherosclerotic disease of the aorta. 6. Abdominal Aortic Aneurysm Repair. An abdominal aortic aneurysm is an abnormal, weakened dilatation in the aorta which is usually located in the infra renal part of the aorta. It can be up to 10cm in size but will usually rupture when it gets to this size. The causes include - atherosclerosis - trauma - congenital weakness - post-op. complication A patient with an AAA may also present with CAD/MI, diabetes, COAD, HT, PVD, renal disease, liver disease and/or obesity. A patient with an AAA may present with a) an acute rupture, severe back and abdominal pain, shock, comatose, low BP. This is an emergency situation and carries greater risk for the patient. b) a slow leak or unruptured - slight back or abdominal pain, often found on routine examination of abdomen or lumbar x-ray. The elective repair procedure is to minimise the risk of rupturing. The operation involves the aorta being clamped above the aneurysm. The aneurysm is cut open and a graft sewn from one end of the aneurysm to the other. The aneurysm is then wrapped around it. If the aneurysm is suprarenal there is a high incidence of renal failure post-operatively due to occlusion of the renal arteries during the procedure. 106 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Patient 2 A 75 year old female who had a ( R ) femoral-popliteal bypass yesterday who proceeded to Recovery at 1500 hrs. It is now 1030 hrs the following day and you are to treat this patient. Would you consider mobilising this patient as part of your management? What are the signs of acute ischaemia which would indicate the limb is at risk? Outline your actions. In your notes the procedure for an axillo-femoral bypass graft is discussed. What precautions would be needed in the physiotherapy management of these patients? Patient 3 A 67 year old man with a history of HT, MI x 2 and a 43 pack year history of smoking, has been referred for physiotherapy prior to repair of his 5.5 cm infrarenal AAA. Outline your pre and post op management of this patient? Patient 4 A 74 year old female who is to undergo a Carotid Endarterectomy. She has been referred for a baseline neurological assessment. What is involved in a Carotid Endarterectomy procedure? Outline the risks specifically associated with this procedure. What signs and symptoms would you particularly want to report to the Medical Staff? 107 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ANSWERS Patient 1 PVD Patient ƒ Conditions predispose patient to PVD : * Diabetes * Atherosclerosis - familial * Abnormal fat and lipid metabolism * HT * Smoking * High cholesterol , high fat diet * Inc. age > 65 years * Previously greater proportion males c.f. females ƒ Signs and symptoms of Arterial Vascular Disease • Intermittent Claudication vs. Resting Pain - distance, eases with rest ischaemia in peripheral nerves -severe may require morphine • Paraesthesia - altered sensation • Trophic skin changes - dec. hair & nail growth - hairless, smooth shiny nail bed • Brown patches - melanosis • Absent or decreased peripheral pulses - DP PT • Slow or absent capillary return • Decreased temperature - Cool • Ulcers - poor wound healing • Cyanosis Ruborous cyanosis on foot becoming dependent • Wasting • Gangrenous Changes ƒ Investigations for PVD : • Angiogram / arteriogram • Segmental BP readings • Doppler flow probe readings - N/Staff in wards and Physios in Spinal Unit • Carotids - Duplex Scans - ultrasound Foot Care Precautions : • Podiatrist and well fitting shoes • No garters and no tight socks • Dry skin, particularly between toes • Seek medical advice early with cut/abrasions • PAC – regular checks and care with sensory loss 108 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ƒ Conservative treatment by Medical Staff: • Stop smoking • Weight loss • Peripheral vasodilators, or perhaps cholesterol lowering drugs • Walking programme • Ulcer healing – dressings ƒ Implications of PVD for physiotherapy treatment : • Care during treatment with regard to foot exercises, scraping of heel. • Correct footwear when walking. • Mobilise with reference to claudication distance. • Make sure a patient with PVD has sheepskin or bootees during their stay in hospital. • Electrotherapy precautions. • Infection control. ƒ Sympathectomy • Procedure Involves either open cutting or chemical destruction of lumbar sympathetic nerves often L2 and L3 as dilates the arterioles and increases blood flow. • Why Relieves rest pain mostly and effects smaller vessels • Complication Patient is often hypotensive on mobilising, with decreased sweating. They may get neuralgia. ƒ Modifications to physiotherapy treatment for Vascular Procedures : Vary with Suregon’s preference – check hospital protocol May include • Avoid hip F > 60o due to position of grafts for first 24 hours ⇓ log roll to auscultate posterior chest sitting no higher than 60o lower bedhead to do active hip flexion to 60o. • Care with handling of vascular leg. • Assisted leg exercises. Avoid tipping a patient with recently grafted aorta. 109 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Patient 2 ( R ) Femoral - Popliteal Bypass ƒ Mobilisation post-operatively The patient would not be mobilised at 1030 hrs as it is not 24 hrs post op. The patient would not mobilise before 1500hrs. Aiming for normal gait pattern + / - aid e.g. rollator / FSF ⇒ single stick ⇒ Aiming for unaided mobilisation at D/C with good gait pattern. ƒ Signs of Acute Ischaemia and action Signs of Acute Ischaemia - The “6” P’s ¾ Pallor ¾ Polar ¾ Pulseless ¾ Paralysis ¾ Paraesthesia ¾ Pain Action Nursing Staff and Medical Staff notified immediately as the ischaemia needs to br reversed to preserve the limb. Document findings in patient’s medical record ƒ Precautions in physiotherapy management of axillo-femoral bypass graft : AVOID - shoulder flexion >90o } ==> stretches - hip flexion > 60o } graft - sidelying • No pressure on graft from hands/ percussion/ positioning • Watch use of overhead ring • Advice re belts and bras not to constrict the flow in the graft • No constrictive clothing Patient 3 AAA Repair ƒ Pre-operative Management • Accurate chest assessment pre-operatively - may need active treatment in view of smoking history. • Whether or not you should cough the patient depends on whether there has been a leak or the size of the aneurysm < 6 cm - one cough / FET depends on chest condition and indication for coughing > 6 cm - risk of rupture therefore no cough preoperatively 110 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ƒ Post-operative Management • At a high risk due to severity of surgery and concomitant diseases. • Potential to develop respiratory failure and ... require intensive treatment for at least 5 days with appropriate techniques related to assessment. • Good pain relief is essential as is good wound support. • Do not tip. • Mobilise once cardiovascularly stable and dependent upon patient's condition. Emphasis on circulation exercises as surgery has been directly to arterial system. Patients who have had an emergency rupture will go to ICU and be ventilated - risk of ARDS, Renal Failure and MOSF, due to haemorrhage and PMH. Patients who had an elective repair may go to ICU for overnight monitoring or go to the ward. Patient 4 Carotid Endarterectomy ƒ Carotid Endarterectomy Procedure This is a clearing of the carotid arteries to remove atheroma and the tunica intima. Often performed after a patient has had a T.I.A. or is in the middle of an evolving CVA. Performed as either 1) Open: direct incision into artery or 2) Closed : small incision and use of Ring Stripper May or may not involve small patch graft to maintain lumen size by preventing constriction caused by suturing ƒ Risks associated with the procedure • Small emboli -> CVA • Cranial N. Damage esp. 10th 11th • Carotid Body Stimulation - hypertension / hypotension • Wound haematoma ƒ Signs and symptoms to report to Medical Staff • Deterioration in neurological status limb deficits tongue deviation speech disturbances - dyspnoea, stridor, hoarseness 111 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

CARDIAC SURGERY Revew lectures: Cardiac Disease I, II, III Cardiac Surgery Physiotherapy Management of Cardiac Surgery Ensure you have the necessary background understanding by answering the following questions : 1. List the risk factors that predispose an individual to coronary artery disease (CAD) ? 2. Outline the signs and symptoms of coronary artery and valvular disease? 3. List the common indications for cardiac surgery. 4. Discuss the most common aetiology for valvular disease? 5. What surgical options are there for valvular heart disease? 6. Consider the investigations commonly performed to assess CAD or valvular disease? 7. What are the surgical indications for coronary artery bypass graft (CABG) surgery? 8. Where is the homograft material harvested from the bypass conduit for the coronary arteries? 9. Consider the types of valve replacements available and the features of the different types. ANSWERS : 1. Risk factors for coronary artery disease (CAD) : Family History Hypertension Obesity ↑ cholesterol Smoking Age > 65 Sex ratio M>F Diabetes Sedentary lifestyle Stress The aim is to alter lifestyle factors. A long term exercise programme is necessary whether or not the patient progresses to surgery. 2. Signs and symptoms of cardiac disease : - Angina - exertional or at rest - exercise tolerance with lifestyle changes - ↑ SOB - chest tightness - PND - dizziness - sweaty - palpitations - syncope - drop attacks - sleeping upright - ↑ need for non routine medications 112 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

3. Common indications for Cardiac Surgery ♦ Acquired or Valvular or Ischaemic heart disease ♦ Congenital heart disease (Cardiothoracic Manual Sem. 2 ) ♦ Heart Failure ♦ Thoracic or Dissecting Aortic Aneurysm ♦ Pericardial effusion ♦ Trauma 4. Valvular disease May be congenital but most commonly caused by Rheumatic Fever The most commonly affected valves are the aortic and mitral The valve cusps become thickened by oedema and infiltration of capillaries. “Warty” vegetations form along the lines of closure ⇒ valve deformities. These deformities may take years to develop and are clinically evident as murmurs. Murmurs indicate regurgitation due to valvular incompetence or stenosis. AF may develop as a result of valvular disease with the risk of embolisation to the lung or brain. 5. Surgical options for valvular disease : ™ Valvotomy - reshaping of the patient’s own valve ™ Tissue valve replacement ™ Mechanical valve replacement Valve replacement or repair requires Cardiotomy or Aortotomy with excision of the valve or part thereof and the securing of the new valve by way of a cat’s cradle of stitches 6. Investigations : Most Common • ECG • Chest X Ray • Stress Test • Echocardiograph • Coronary Angiography Other investigations • ABG’s • Gated Heart Pool Scan 7. Surgical indications for Coronary Artery Bypass Surgery : • At least three vessels blocked • Blockage > 75% • LVEF > 50 113 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

8. Homograft material Harvested from the 1) Saphenous Vein - SVG 2) Internal Mammary Artery Graft - IMAG 3) Brachial Artery - BAG 4) Radial Artery Graft - RAG (Hand exs Day1 - wrist oedema) The IMAG is the conduit of choice particularly for lesions of the LAD as a pedicle graft can be utilised requiring only one anastomosis. IMAG have increased patency compared to SVG. A greater reduction in FVC and FEV1 is seen as the pleural cavity has been entered. Polytetrafluoroethylene and Gluteraldehyde grafts are available if homograft material is unsatisfactory. Reference : Jenkins, S.C, Soutar, S .A., Forsyth, A., Keates, J.R. and Moxham, J. 1989 “Lung function after coronary artery surgery using the internal mammary artery And the saphenous vein” Thorax, 44 pp. 209 – 211 9. Types of valve replacements : 1. Mechanical prosthesis - Edward Starr - these are durable and selected for use in younger patients. They are prone to thrombotic complications and lifelong anticoagulation is required. 2. Allografts - e.g. Porcine and Bovine 3. Homografts / Autografts - The advantage of all tissue grafts is their more normal function but may require replacement in 5 – 10 years. These grafts are immunologically treated prior to surgery therefore anti-rejection medication is not required. Open heart surgery is performed via a median sternotomy using a saw and protractors to hold the chest apart. The chest protractors rotate the first rib upwards and may exert tension on the brachial plexus. Cardiopulmonary Bypass (CPB) is instituted by cannulation of the SVC,IVC and Aorta. The lungs are deflated. Hypothermia is commenced with the use of CPB for myocardial and CNS protection. Cold cardioplegia solution placed in the pericardium stills the heart, further enhancing cardiac hypothermia and enabling easier access for the surgeon. This solution has been implicated as the cause of phrenic nerve injury due to ice injury. This has been suggested as one of the major causes of ( L ) Lower Lobe collapse seen post-operatively in 86 – 90 % of patients within the first 2 days post-op. CABG are then performed with either : ™ SVG - using an end to end anastomosis at the distal section of the occluded coronary artery and an end to side anastomosis to the aorta ⇒ bypasses occlusion or ™ IMAG - a pedicle graft using end to end anastomosis at the distal end of the occluded vessel only. 114 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Rewarming commences while the patient is on CPB, and they are gradually removed from bypass. During this process it is hoped the heart will re-establishes a rhythm but if none occurs, the heart is shocked and pacing wires are inserted. The lungs are reinflated and mechanical ventilation continues for the initial post-op ICU period. The sternum is held securely with wires that usually remain insitu. “Off Pump” patients - CPB is not used with the heart held still by suction clamp. These patients experience less atelectasis post-op. Alternative invasive but non-operative procedures for reducing obstruction in coronary vessels and valves respectively are : ♦ Percutaneous Transluminal Coronary Angioplasty - PTCA - used in proximal one or two vessel disease. The long term benefits have not been fully assessed. ♦ Balloon Valvotomy Valvular Surgery ↓ CPB time The procedure involves the valve only and no anastomoses and therefore the risk of complications is ↓ as this is proportional to the length of time on bypass. Heparin infusion : This is required as the valve used is a mechanical one and there is a higher risk of embolisation post-operatively. 115 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

CARDIAC SURGERY Case 1 - CABG A 68 year old male admitted to the Cardiac Surgery Ward for CABG tomorrow PMHx : HT - 30 years IHD - AMI 1990 with ongoing angina Ex-smoker ceased 2 years ago previously 20 per day for 35 years Investigations : Echo LVEF - 55% - 90% Angiography LAD - 70% - 75% RCA Circumflex OT Notes : Time in OR 1325 - 1550 hrs CABG x 3 vessels IMAG for LAD and OM1 SVG for RCA and Circumflex Temp 32 0 C CPB - 56 minutes Pacing wires inserted 3 drains on low suction Post op orders : Remain ventilated IV fluids as charted Omnopon / Morphine (IM) Dopamine infusion at 5 mcg /kg/min Tridil infusion 1.5mcg/kg/min Keflex 3 doses Hourly UO measures → notify if > 30 mls per hour Patient weaned and extubated at 0600hrs Registrar Review at 0800hrs 93% Patient drowsy but rousable FIO2 6 litres via mask SpO2 HR 70 b/min paced BP 160 / 75 Orders Leave paced Gradually wean tridil leave dopamine for present Remove one pericardial drain Continue IV fluids pain relief and medications as ordered 116 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Day 1 Post op C/O : Minimal pain 1/10 at rest and 4/10 with movement Pain in posterior mid thoracic spine O/E : Non distressed O2 2 litres via nasal prongs, SpO2 95% Obs. ↓ Bibasal expansion Palp. ↓ Lateral costal expansion ↓ (L) > (R) base Ausc. ↓ BS (L)LL anterior, lateral and posterior basal segments Treatment at 0830 hrs QUESTIONS : 1. Discuss your pre-operative management of a patient undergoing cardiac surgery. What information is it necessary to give? 2. Outline the pathophysiological effects of the surgery on the respiratory system. 3. What are the pulmonary complications that can occur after cardiac surgery? 4. Describe the patient’s presentation when you see him post extubation. 5. Discuss the medications that the patient is requiring post operatively. 6. Interpret the assessment findings. 7. Outline your Day 1 Rx. 8. What factors would you consider prior to mobilising this patient? 9. Discuss progression of this patient and the discharge advice that would be given 10. Outline a walking programme that would be suitable for your patient. 117 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ANSWERS : 1. Pre-operative Management : Check chart / patient history / investigations Assessment - chest - treatment should be instituted if indicated by findings - including exercise tolerance, circulation, home situation - ROM of neck and shoulder and thoracic mobility - observation of posture Discussion re post-op course i.e. ICU post op, overnight ventilation, extubation and the commencement of physiotherapy Explain mobility programme, management of musculoskeletal pain and progression of exercises as a home programme 2. Pathophysiological effects of bypass and Cardiac Surgery on the Respiratory System. Lecture on Cardiac Surgery and Physiotherapy Management of Cardiac Surgery Note particularly the CPB results in a systemic inflammatory reaction that manifests itself as capillary leak syndrome or “pump lung”, with fever, increased white cell count, coagulopathy and multiple organ impairment. The function of the other organs particularly the kidneys, liver and brain can be impaired. Some degree of reaction occurs in all patients but is usually self-limiting and does not present a major clinical problem. 3. Pulmonary Complications occur in 40-60 % of patients ¾ Atelectasis - particularly of the ( L ) Lower Lobe ¾ Lower respiratory infection ¾ Pulmonary oedema ¾ Ventilatory insufficiency 4. Post-op presentation Day 1 - post-extubation : Usually nursed in supine / ¼ turn from supine / high sitting ( usually not tolerate s/ly) Position for Rx usually high sitting Incisions - median sternotomy Uni / bilateral LL wounds with compression bandages (if SVutilised) Usually no TED stockings (depending on the Surgeon’s protocol) Equipment • Peripheral line + Arterial line, CVP line, ECG leads, O2mask or nasal prongs , pulse oximeter, IDC, temporary pacing wires • x3 wound drains - retrosternal (pleural), mediastinal and pericardial with UWSD + / - low pressure suction • Assistive devices such as an intra-aortic balloon pump (IABP) may be used to augment cardiac function in more unstable patients. • Bed rope to assist independent mobility 118 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

5. Post-op Medications: ¾ Tridil - GTN - Coronary Artery Vasodilators ¾ Dopamine - providing inotropic support. Other inotopes - digoxin, dobutamine, adrenaline. (Dopamine can be used for renal support in low doses) ¾ Keflex - prophylactic antibiotics ¾ Omnopon - for sedation and pain relief whilst ventilated ¾ Morphine for pain relief once extubated. (IM, NSAIDS are used also) Other medications that may be utilised include: ♦ Peripheral vasodilators e.g. hydralazine, ß blockers ♦ Diuretics - lasix ♦ Anti-arrhythmics ♦ Anti platelet aggregation - aspirin 6. Interpretation of assessment findings: • Pain control needs to be looked at closely as the report is 4/10 • Demonstrating the common ( L ) LL collapse post-op 7. Day 1 Treatment: At all times a problem solving approach based on assessment findings must be utilised. ™ Positioned in high supported sitting - patient able to position self independently using the bed rope as demonstrated pre-op. ™ Mobilise if cardiovascularly stable 5-10% of patients in studies developed chest infections. Clinically patients who develop respiratory complications post cardiac surgery need intensive respiratory management This may include • Sputum clearance techniques • Breathing exercises +/- BiPAP/ CPAP And must include • Mobilisation once the patient is haemodynamically stable. 8. Prior to mobilisation Day 1: ♦ Familiar with the particular surgeon’s protocol ♦ Check the cardiac rhythm to ensure stability before the stress of mobilisation ♦ Care disconnecting the suction from the drainage bottles ♦ Assess the need for O2 - generally utilised Day 1 119 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

9. Progress to discharge: Length of Stay 5 – 7 Day 2 - 2nd / 3rd drains removed Day 3 – 5 - Management of musculoskeletal pain and progression of walking programme NB. - Progressions will differ with individual patients depending on presentation and assessment findings DISCHARGE ADVICE: Home programme ƒ Thoracic mobility, neck and shoulder exercises ƒ Lifelong walking programme / aerobic training General Advice: - Ergonomics, posture and backcare - Modification of risk factors - cease smoking, regular aerobic exercise - If appropriate referral to Cardiac Rehab programme / exercise class - OT - Lifestyle modification and planning ADL - Dietitian - diet modification - Nursing Staff - wound care Estimated return to work 2-3 / 12, therefore the programme is graduated accordingly. 10. Walking Programme: Example only PR monitored throughout activity Week 1 – 2 - 10 mins x 2 / day ~ 400-800 m on the flat, rest if necessary Week 2 – 3 - 20 mins x 1 / day ~ 400-800 m on the flat continuously Week 3 – 4 - 20 – 30 mins x1 / day ~ 1 km on the flat continuously Week 4 – 8 - up to 5 – 6 km x3 / week including hills and inclines Although walking is the most suitable form of exercise swimming and cycling with the surgeon’s approval can be commenced 3-6 / 12 120 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

THORACIC SURGERY Review lectures: Thoracic Surgery Physiotherapy Management of Thoracic Surgery Ensure you have the necessary background understanding by answering the following questions : 1. What are the common indications for thoracic surgery? 2. What procedures are commonly used to diagnose or investigate thoracic conditions? 3. Name the most common thoracic surgical procedures. 4. Discuss the incisions used in thoracic surgery and the pain and disability associated with each. 5. Outline your pre-op assessment of a patient prior to thoracic surgery. ANSWERS : 1. Common indications for thoracic surgery : • Lung neoplasm - resectable primary disease, mediastinal tumours, solitary pulmonary metastases where the primary is controlled • Encapsulated cysts • Pleural defects • Pneumothorax unresponsive to conservative treatment • Oesophageal, tracheal and thoracic aortic repairs • Trauma • Thymectomy - for cancer or the treatment of Myasthenia Gravis • Cosmetic repairs of the chest - e.g. pectus excavatum or carinatum (Marfan’s Syndrome) • Infective lesions - e.g. TB, bronchiectasis (confined to 1 or 2 lobes only), lung abcess which is unruptured 2. Procedures used to investigate thoracic surgery : ♦ Chest X Ray - CXR ♦ CT Scan of the chest ♦ Bronchoscopy - flexible scope initially, rigid used if needed ♦ Cervical mediastinoscopy / Anterior mediastinoscopy ♦ Chest tube drainage ♦ Open lung biopsy ♦ Video assisted thoroscopy - VAT ♦ Pleural biopsy ♦ Fine needle aspiration biopsy - FNAB ♦ Sputum cytology Ensure that you have an understanding of the nature of these procedures. 121 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

3. Common thoracic surgical procedures : ™ Resection for lung neoplasm ™ Pneumonectomy ™ Pleurodesis ™ Pleurectomy ™ Decortication If you are unsure of these procedures review a surgical text 4. Incisions : ƒ Posterolateral Thoracotomy - divides rhomboids , lower trapezius, lat dorsi, serratus anterior and intercostals. As a result chest wall and lung expansion are limited post-op. Additionally rib retraction causes strain on the costochondral, costovertebral and costosternal joints. ƒ Anterolateral Thoracotomy - intercostals and the serratus anterior are the only muscles divided ƒ Transaxillary Thoracotomy - TAT - passes under the axilla between the border of the pectoralis major and lat dorsi ƒ Median Sternotomy - the sternum is split longitudinally and the ribs divided on either side of the sternum. This incision is utilised for cardiac surgery, thymectomy and repair of chest deformities. Pain is much greater in the thoracotomy patient, particularly a posterolateral thoracotomy. This is due to the intercostal incision and stretching of the incision with movement. For thoracotomy patients the pleural pain is greater as the pleura is cut and pleural drains are used post-operatively. The drains cause discomfort where they pass through the chest wall. 5. Pre-operative Assessment and Explanation to the Patient - Note that thoracotomy patients may be more debilitated due to their disease pre-operatively and thus more of a surgical risk. 122 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

THORACIC SURGERY Case Study A 66 year old male admitted for resection of an adenocarcinoma of the apical segment of the RUL Investigations CXR - opacity in the RUL apical segment Bronchoscopy - tumour unable to be visualised FNAB - presence of adenocarcinoma Sputum cytology - confirmed the presence of malignant cells CT Scan - no evidence of spread OT Notes : OR time 0930 - 1110 hrs Anterolateral thoracotomy Epidural - T6 - T7 interspace Fentanyl and Bupivicaine R U Lobectomy ICC’s x2 Post op Orders IV fluids as charted Pain relief as ordered NBM for 4 hours then diet as tolerated Day 1 Post op C/O : Itchy and nauseated Pain 2 / 10 at rest to 5 / 10 with movement or cough O/E : Obs : Looks in pain FIO2 2 litres via nasal prongs Sp2 94% Basal - S a B × D a ICC Apical - S a B a D × Wound nil ooze Calf Check soft non tender Palp : ↓ Lateral Costal Expansion ↓ ( R ) > ( L ) base Ausc : ↓ BS (R) upper zone,(L) LL ant and lat basal segments > (R) LL Fine late inspiratory crackles (L) LL ant and lat segments Spontaneous cough with movement weak pain inhibited QUESTIONS : Review the investigations undertaken pre-op and be sure you understand the information they provide. 1. Revise the structures involved in an anterolateral thoracotomy. 2. Describe the patient’s post-operative presentation Day 1 123 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

3. Outline a prioritised problem list. 4. Discuss your aims of treatment. 5. Discuss the pain relief received by this patient and the alternatives. 6. Outline your Day 1 Rx of this patient. 7. Discuss progression of management and the discharge advice you would provide. ANSWERS : 1. Post-op Day 1 presentation : • Positioned in high sitting • Breathing spontaneously with supplemental O2 via nasal prongs (or mask) • ICC’s x2 - apical for air and basal for fluid with UWSD - under water seal drainage. • IV access + / - IVAC • Epidural connected to infusion pump • Bed rope to assist patients to move in bed. Patients should be encouraged to take the weight through the unaffected arm and legs. • + / - IDC May be nursed initially with the operated side up to allow maximum V / Q matching in the dependent (good) lung 2. Prioritised problem list : ♦ ↓ pain control ♦ Itchy and nauseated ♦ Hypoventilation ♦ Potential for secretion retention ♦ Potential for circulatory complications ♦ Potential for ↓ shoulder girdle mobility ♦ Potential for postural abnormalities 3. Aims of Rx : ♦ Optimise pain relief through discussions with the Nursing Staff ♦ Ensure anti-emetics have been maximised ♦ ↑ ventilation ♦ Mobilise any retained secretions ♦ Assist with secretion removal ♦ Prevent circulatory compromise ♦ Commence upper limb and shoulder girdle ROM exercises ♦ Postural correction 124 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

4. Pain relief : Ensure adequate pain relief prior to treatment This patient is receiving an epidural with a combination of fentanyl (narcotic) and bupivicaine (local anaesthetic). Alternatives - PCA - e.g. morphine or pethidine - IM narcotics - NSAIDS - may be given PR - per rectum - TENS - Simple oral analgesics - panadol or panadeine 5. Day 1 Rx : Frequency of Rx is dependent upon patient presentation and the extent of any collapse that may be evident. • Position in high supported sitting • Breathing exercises - Staged basal expansion with inspiratory holds • Incentive spirometry • Assisted ( R ) Upper limb ROM - for demand ventilation as well as for UL and shoulder girdle mobility • Active ( L ) UL ROM • Mobilise usually with one (1) assist and posture correction + / - trolley for ICC’s • Supported cough with towel binder 6. Progress to discharge : ™ Frequency of Rx - ↓ determined by condition ⇒ CXR adequate re-expansion ™ ICC’s removed - apical when lung re-expanded - basal when minimal fluid draining ⇓ Aim for full ROM of ( R ) UL & Commence trunk movements - especially lateral flexion and rotation Stair climbing or bicycling to increase exercise tolerance Discharge Advice - 1 to 2 weeks post-op Continue ™ Walking programme ™ Arm and trunk exercises - continue for 1 / 12 or until no scar restrictions ™ Breathing exercises Consider the modifications you would need to make to your management with each of the different thoracic surgical procedures. There are significant safety implications ensure you have a thorough understanding of their impact. 125 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

HEAD AND NECK SURGERY Review lecture: Head and Neck Surgery The major risk factors in the development of cancers of the head and neck are substantial alcohol intake and / or cigarette smoking. Other factors such as heredity, environmental, occupational and hygiene are of lesser significance. Surgical procedures used for these patients are usually very extensive, may be disfiguring and often involve grafting of other tissues to repair the defect left by the resection of the tumour. Some of the more common procedures used are : Laryngectomy : involves the removal of the larynx and is performed via a collar or U- shaped incision over the anterior neck. A permanent tracheostomy is created with a tracheostomy tube in place in the initial post-op period, but this will be subsequently removed and the stoma will remain open. This procedure may be partial or total. The site of the cancer may be supraglottic, glottic (involving the vocal cords), or infraglottic / subglottic. Lymph nodes are more commonly involved with glottic cancers, and these are more aggressive cancers. The major cause of laryngeal cancer is cigarette smoking. Pharynolaryngectomy : is a more extensive procedure and may be performed for a larger or more extensive tumour. The procedure involves the removal of the larynx, orolarynx and the creation of a tracheostomy. A piece of jejunum is usually used to reconstruct the pharynx. Thus the patient has an abdominal incision as well as the neck incision. Survival rate at 5 years ranges from 20 - 90%, depending upon the cancer type and site. Commando Procedure : involves dissection and removal of the floor of mouth, hemi / total glossectomy, half the mandible and lymph glands. A myocutaneous flap is used to reconstruct the floor of the mouth - usually deltopectoral, lat dorsi or radial forearm flap is used. Radical Neck Dissection : involves wide dissection of - lymph glands; - salivary glands ;- sternocleidomastoid; - internal jugular vein (IJV); - fascia - accessory nerve. The removal of the IJV can lead to an increased intracranial pressure due to decreased venous return. Trapezius dysfunction will result if the accessory nerve has been sacrificed. A modified, less extensive version of this procedure is the Functional Neck Dissection. Common complications of these procedures include : - speech impediment or loss, / altered communication - swallowing difficulties which can lead to aspiration pneumonia - shoulder droop, arm weakness, pain and paraesthesia - cosmetic deformity / change in self image. -permanent alteration of respiratory function. 126 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

A 50 year old lady is to undergo a glossectomy, laryngectomy, radical neck dissection, radical forearm flap and tracheostomy. She has a history of heavy cigarette and alcohol intake and has a chronic productive cough. She has been admitted one week pre- operatively for an intensive work-up QUESTIONS : 1. Why would she be admitted so early pre-operatively? 2. What are the major respiratory problems for patients undergoing this type of surgery? 3. Describe your pre-operative management. 4. Describe the patients post-operative presentation. 5. Why is it important to remain in high sitting? 6. Why are the drains important? 7. Why should humidification be on continuously? 8. Describe your Day 1 treatment of this lady. 9. When would you mobilise the patient provided there were no complications? 10. How would you progress the patient towards self-care of the stoma? 11. When would you begin arm, neck and jaw movements? 12. What would you consider to be some of the long-term issues for this patient? 13. What discharge advice would you give the patient? 14. What other specific rehabilitation might the patient need? ANSWERS : 1. The patient is admitted early for • Investigations : CT Scan Panendoscopy - requires a light GA • Pre-op work up : Chest physiotherapy Exercise / walking programme Stop smoking Counselling Speech pathology review 127 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

2. Major respiratory problems include : • Loss of upper respiratory tract (URT) ⇒ loss of humidification and filtering role • Loss of ability to cough post-operatively • Often a history of heavy cigarette smoking ⇒ ↓ cilia action and thick secretions • Often a PMHx of respiratory disease • Very long procedure - can be > 6 – 10 hours ⇒ increased risk of chest and circulatory complications • Generally debilitated / malnourished ⇒ more susceptible to infection 3. Pre-operative management includes : • Assessment i) Subjective Assessment - questioning to establish the current situation regarding SOB, cough, sputum production, smoking history, exercise tolerance and social and home situations ii) Objective Assessment - a) chest - in view of the patient’s chronic productive cough pre-op treatment may be needed b) range of movement of neck and shoulder • Teaching i) Immediate post-op exercise - appropriate deep breathing exercises and circulation exercises ii) Clearance of post-op secretions - huffing the most effective technique iii) Neck and shoulder range of movement exercises - as appropriate • Explanation of i) Post-operative presentation, incisions, attached equipment and positioning in at least 300 head up ii) Tracheostomy and the need for suctioning, huffing and humidification iii) Role of physiotherapy for chest, circulation, mobilisation and neck and shoulder movements iv) Communication method to be used post-op until a more permanent mode is suitable v) Importance of commencing a walking programme to increase general fitness pre-operatively vi) The need to cease smoking 128 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

4. Post-operative presentation Often go to ICU immediately post-op for overnight observation and return to the ward Day 1 Presentation • High sitting • Multiple drains - Redivac or Yeates depending on Surgeon’s preference • Tracheostomy tube - attached to tape on the patient’s shoulder, not tied around the neck so there is no additional pressure on the suture line • Humidified oxygen • IV line • NG tube 5. Importance of high sitting • To ↓ possible oedema • To aid drainage • Often the IJV is removed and high sitting assists maintenance of ICP NB - Caution is needed with i) techniques such as suctioning which can cause the ICP to rise or ii) neck positions that occlude jugular drainage 6. Drains are important for : Drainage of i) Haemoserous fluid from the operation site to prevent haematoma ii) Lymphatic fluid as lymph nodes are often removed to prevent seroma 7. Humidification should be on continuously as : ¾ Bypassing the warming and filtering performed by the Upper Respiratory Tract ¾ Secretions become thicker ¾ Without it airways become blocked by dried, encrusted secretions ¾ Enhances cilia action 8. Day 1 Treatment : ¾ Carefully read op notes ⇒ thorough understanding of implications of procedure to the immediate post-op course ¾ Position in high sitting ¾ Appropriate breathing exercises + vibration if necessary ¾ Arm exercises on the non-graft side ¾ Calf check prior to circulation exercises ¾ Huff or suction + / - normal saline to clear the secretions 129 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

9. Mobilisation if no complications Usually late Day 1 or Day 2 10. Progression towards self-care of the stoma ♦ Independent huff ♦ Patient takes responsibility for wiping secretions - may need a mirror to assist initially ♦ Once the tracheostomy tube is removed, a small soft tube called a BIVONA is placed insitu to ensure there is not too much shrinkage of the stoma ♦ Eventually the bivona is only worn at night ♦ When the bivona is not insitu the stoma should always be covered Nursing Staff will teach the patient to ƒ Clean the stoma with gaze or a handkerchief ƒ Insert and clean the bivona ƒ Prevent dry encrusted secretions or a hacking cough by using home humidification 11. Arm, neck and jaw movements commence • Usually on Day 7 - MUST check with the Surgical team prior to movement to ensure the graft is stable. The extent of lymph node excision and the length of time the drains are insitu can influence when movement is begun 12. Long term issues for these patients include : ♦ Care of the respiratory system - ensure adequate humidification and effective hufff or clearance of secretions ♦ Risk of aspiration in the shower ♦ Risk of burn if inhale too close to the steam inhalation ♦ Radiation therapy (adjunct treatment of the cancer) may cause inflammation and irritation which may ⇒ airway oedema and secretions ♦ Tendency for neck and shoulder problems from loss of muscle power from resection 130 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

13. Advise for discharge : ™ Inhale in the shower to prevent secretions from becoming encrusted ™ Wear shower shield in the shower or when hair is cut to prevent aspiration ™ Wear cover (preferably moistened) over the stoma at all times ™ Wear bivona at night Continue ™ neck and shoulder exercises as home exercise programme ™ walking programme to improve general fitness ™ to cease smoking Referral to ™ Support groups in the metropolitan area i.e. “Lost Cord Club” 14. Other specific rehabilitation includes : Musculoskeletal If the accessory nerve is cut trapezius function will have to be re-taught Speech Pathology • Swallow re-training • Re-training of lip movements • Voice re-training via : i) Electrolarynx - artificial device held under the hroat and provides an artificial voice from the patient’s efforts moving air in the throat ii) Oesophageal Speech - involves “gulping” air into throat and then controlling its release as the patient speaks and iii) Tracheoesophageal prosthesis (Blom Singer) which involves the creation of a fistula between the trachea and the oesophagus with the insertion of a prosthesis to create voice 131 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

MASTECTOMY Review the lecture: Breast Surgery and Physiotherapy Management Answer the following questions before undertaking the case What are some risk factors that have been linked with Breast Cancer? From your lecture notes revise the descriptions for the following procedures 1. Lumpectomy / wide local excision 2. Simple Mastectomy 3. Modified Radical Mastectomy + / - Axillary Clearance Discuss the differences in the Day 1 physiotherapy treatment for the above procedures Patient 1 A 57 year old lady who is to have a Modified Radical Mastectomy tomorrow Discuss what you would include in your preoperative preparation of this lady. What is the function of the drains used post operatively What are some operative complications that need to be considered? Explain how you would progress the exercises for this patient What incidents intra or post operatively may impact on the patient’s movement? Discuss the impact of these on an exercise programme Outline the information to be discussed with this patient prior to discharge Outline the possible causes of arm oedema if it appears : 1. Immediately post op 2. Following radiotherapy 3. Years after the mastectomy How can arm oedema be treated? 132 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

MASTECTOMY Answers • Risk factors linked with Breast Cancer • Gender - predominantly female • Age > 50 years ? oestrogen link • Family History 1 in 4 • Past History of Breast Cancer • Procedures Lumpectomy / Wide Local Excision - Lump and surrounding breast tissue and a few nodes for biopsy Day 1 - Full arm movements within the limits of pain Simple Mastectomy - Breast tissue and a few nodes for biopsy (1 drain only) Day 1 - STAGE 1 Exercises commenced - Elbow, wrist and hand movts - STAGE 2 commenced when the drainage is less than 100 mls over a 24 hour period. The drains are usually removed when less than 25 mls drained . Modified Radical Mastectomy - R /O breast tissue, axillary lymph nodes + / - pectoralis major + / or minor Day 1 - Elbow, wrist and hand movements - STAGE 1 Exercises STAGE 2 Exercises are commenced once the combined drainage from drains A (axilla) and B (breast) is less than 100 mls over a 24 hour period. Stage 1 & 2 exercises are those outlined in the Queensland Cancer Fund guide to Breast Surgery which is given to all breast surgery patients. In view of early discharge planning or ongoing drainage some patients may be discharged with drains insitu. These patients will be advised regarding Stage 2 exs which will commence on the Surgeon’s or physiotherapist’s advice (according to protocol) FULL SHOULDER ROM would be expected 3/12 postoperatively. 133 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• Pre-operative preparation for a Modified Radical Mastectomy • Respiratory assessment and treat as appropriate • Pre operative measurement of shoulder range of movement • Baseline circumferential measurements 10 cm apart up the arm • Functional level • Assess posture • Assess any sensory loss pre op • Support as patient may be anxious re extent of surgery • Pre op advice - avoid mentioning the actual wound or teaching arm exercises as unsure as to the extent of the surgery. Wound support taught post op The extent of surgery is not known until during the operation a frozen section is taken - a positive result may require proceeding to a full mastectomy. The reasons for the course of action will be explained to the patient by the Medical Staff. • Function of the drains • Initially prevent haematoma by draining blood then • indicates when lymphatic drainage re-established by draining serous fluid by about Day 3 • Prevents pockets of serous fluid accumulating ==> seroma • Drains are usually removed when drainage is less than 25 mls. • Operative Complications • Pneumothorax - with more radical procedures • Haematoma - if infective - evidence of cellulitis • Nerve damage - intra operatively • Vascular Injuries • Contraction of Incision • Stiff Shoulder • Lymphoedema - 1 in 3 • Brachial Plexus damage • Graft Failure ==> operation • Psychological problems - importance of follow up and support groups • Exercise Progression ¾ Stage 2 exercises are continued post discharge - 10 repetitions x 4 times per day ¾ Patients must be advised not to exercise into pain ¾ Resisted exercises are not commenced until the patient has full ROM of the shoulder ~ 2-3 months post op. Follow up physiotherapy post discharge. Patients should be reviewed at 5 days and then 1, 2, 3, 6, 12, 18 months and at 2 years post op at which time their ROM and circumferences are measured 134 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• Incidents intra-or post operatively ⇒ impact on movements Palsy post op or nerve sacrificed intra operatively (seen in OT notes) Long Thoracic Nerve to Serratus Anterior ⇒ Scapular winging Day 1 observe with shoulder flexion to 900 If no intervention ⇒ Glenohumeral deviation and shoulder pain If transient palsy - recovers slowly over 3 - 4 months ⇒ follow up to progress exercises Thoracodorsal Nerve to Latissimus Dorsi Possibly several months to be evident - time for atrophy and weakness to become apparent Patient may have shoulder pain from muscle imbalance May ⇒ hypertrophy of teres major and scapular abductors Post D/C strengthening - Rhomboids, mid and lower trapezius - to help stabilise the scapula medially • Information discussed prior to Discharge • Progression of arm exercises - needs a home programme • Discuss the risk of lymphoedema related to the surgery + / - follow up radiotherapy Precautions for affected arm to prevent lymphoedema ¾ No BP taken on the effected arm } Not compromise ¾ No injections or blood tests in effected arm } the circulation ¾ Avoid carrying heavy objects on the effected side - including handbags - Static hold ¾ Avoid static hanging during activities e.g. housework ¾ Avoid trauma to the limb ⇒ seek help if it occurs ¾ Gloves to be used for gardening ¾ Consider the time the limb is dependent vs resting in elevation PRECAUTIONS APPLY FOR LIFE APPLIES TO GROIN OR PELVIC LYMPH NODE REMOVAL ALSO 135 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• Possible causes of arm oedema Immediately post op Following radiotherapy Years post Mastectomy Drains blocked Destruction of lymph nodes Late onset lymphoedema Infection by radiotherapy Recurrence of cancer Seroma Inflammatory response post radiation Haematoma (along the suture line) Lymphatic obstruction • Treatment of arm oedema • Positioning with pillows • Pressure garments • Pressure bandaging • Exercise • AME pump • Lymphopress • Massage • Complex Physical Therapy combination of 1. Massage 2. Bandaging 3. Graded exercise programme 136 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ICU If you feel you know this area well, you might prefer to attempt to answer the following questions before undertaking any revision. Alternatively, complete the revision then answer the questions. The answers to these questions are at the end of this section. Procedures to be reviewed : ♦ Insertion of guedels and nasopharyngeal airways - including indications for airways, risks and contraindication ♦ Suctioning a) ETT or tacheostomy b) Non-ventilated - guedel or nasopharyngeal ♦ Manual hyperinflation ♦ Intensive Care Management - including equipment, their purpose and implications for physiotherapy treatment Before considering some specific scenarios, consider the variety of patients that may be admitted to an ICU. PATIENT 1 A 54 year old female presents with a severe community aquired pneumonia (CAP), predominently involving her L LL. Her ventilator settings and monitoring are as follows: SIMV 10 x 600 PEEP 5cm H2O PS 10 FiO2 0.55 CVP 12 SpO2 91% ABP 100/60 Temp 38.9 She is sedated with Morphine and Midazolam What is the purpose of the equipment you expect to see attached to this patient? Outline any precautions that should be taken with each piece of equipment. Before treating a ventilated patient, what parameters do you need to consider? What would your aims of treatment be for this patient? How might you achieve these aims? Would you tip this patient? Why is manual hyperinflation (MHI) a technique to be considered for ventilated patients? Outline the list of contraindications and precautions associated with MHI. What are the precautions and side effects associated with suctioning? 137 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

When you have completed the manual hyperinflation, you reattach the patient to the ventilator and observe to ensure the breaths are being delivered. The ventilator is not functioning so outline what your actions will be? This patient progresses steadily though still has poor gas exchange when extubated on Day 4. She is now on BiPAP - IPAP 10 EPAP 5 FiO2 0.5. How might your treatment change at this time? Would you be able to mobilize this patient? What difficulties might be experienced when mobilizing patients in ICU? PATIENT 2 A 69 year old male Day 1 post repair of a ruptured sigmoid diverticulum, complicated by peritonitis. His abdomen is markedly distended and his ventilation settings are as follows: SIMV 10 x 1000mls PEEP 5 cm H2O PS 10 FiO2 0.4 SpO2 93% PIP 22 CXR - bibasal collapse, L pleural effusion On Day 4 his respiratory function deteriorates and his ventilatory parameters are changed: SIMV 12 x 700 PEEP 10 cmH2O PS 12 FiO2 0.55 SpO2 91% PIP 35 His CXR at this time shows bilateral pulmonary infiltrates. He is cool peripherally and his ABP is 90/60, supported by NorAdrenaline of 8. What would your treatment consist of Day 1? What might have caused the deterioration in respiratory function on Day 4? What indicates this to you? How would you explain his other symptoms Day 4? How would your treatment change Day 4? How would you progress your treatment as he improves? If respiratory function continued to decline, what mode of ventilation might be used? 138 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

PATIENT 3 A 23 year old male presents following a high speed MVA. He has sustained a CHI, (closed head injury) requiring evacuation of a haematoma, a base of skull # , # ( R ) ribs 5, 6, 7 with an associated pneumothorax and a # ( R )midshaft femur which has been ORIFed. What major effect might physiotherapy have on the acute HI patient? What additional equipment might be attached to this patient? Outline any precautions necessary with this equipment. What is CPP and how is it calculated? CPP should usually be maintained above what level? Discuss methods of preventing an increase in ICP during your Physiotherapy treatment. Your patient's CPP begins to drop whilst manually hyperinflating, from 75 ->71 mmHg. What would you do? If this patient is given paralysing agents as part of the management of his ICP, what effect might this have on his respiratory function? After 5 days, this patient is extubated. He remains drowsy, poorly co-operative, and his cough is ineffective. His CXR demonstrates collapse/ consolidation of his R LL. What techniques would be contraindicated with this fellow? How would you now treat this gentleman? How would you mobilize this patient? ANSWERS • Variety of patients in ICU - Lecture notes Common Conditions in ICU Physiotherapy Management in ICU 139 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• Equipment severe CAP ETT – Endotracheal tube is an airway, oral or nasal - usually cuffed in a ventilated patient Precaution don’t dislodge, kink or push against the tube when suctioning and care when positioning the patient Equipment attached and the purpose and precautions can be reviewed from PHTY 3250 / 7825 notes.: • ECG monitor • Arterial line • CVP line • Rectal Thermometer • IDC Pulse Oximetry - measures the arterial oxygen saturation of peripheral blood and provides an indication of the adequacy of tissue oxygenation Accuracy effected by • poor peripheral perfusion • heavy skin pigmentation (e.g. nicotine stains or jaundiced) / nail polish • arrhythmia • low saturation levels • additional light • movement • Ventilator parameters / settings a) Type of Ventilator b) Mode of Selection - revise definitions c) Settings • TV - Male 800 -1 000 mls Female 700 - 800 mls • Rate - 10 - 12 breaths / minute • Minute Volume - MV = TV x Rate • I:E Ratio - Normal 1:2 Obstruction 1:3 Pulm oedema 2 :1 • Airway Pressure - Mean - average pressure generated in lungs - Peak - PIP = Mean airway pressure + PEEP • PEEP • Pressure support • Fraction Inspired Oxygen • Patient’s spontaneous TV and Rate • Flow Rate • Aims of Treatment : ¾ Improve ventilation ¾ Mobilize and remove retained secretions ¾ Improve gas exchange ¾ Prevent circulatory compromize ¾ Maintain muscle strength and joint ROM 140 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

¾ Minimize functional deterioration Percussion and vibes • Treatment: Suction via ETT ¾ Position right side lying ¾ Manual Hyperinflation ¾ ¾ Active/ passive limb movements ¾ • Would you tip? There is no contraindication to tipping this patient as it will assist secretion drainage and her blood pressure will tolerate it. If the patient is on continuous nasogastric feeds, it would be worthwhile to ask nursing staff to cease these feeds 1/2 hr before tipping to minimize risk of aspiration. • Manual Hyperinflation Why the technique is used? Revise Lecture notes on Airway Management, Tutorial and Prac notes on equipment Precautions • Bronchospasm • Bullae / COAD • HT • HR decreases with the technique ==> back on the ventilator • Beta Blockers Contraindications • Unstable BP / Poor cardiac status • Undrained pneumothorax • Clamped ICC • Gross pulmonary oedema • Early ARDS • Massive haemoptysis • Hypovolaemia Do you clearly understand why these are contraindications • Suction - Indications, Precautions and Side-Effects Indications • Artificial airway ==> no cough • Lack of co-operation or decreased conscious level • Weakness • Excess secretions Precautions • Acute HI - Raised ICP Suction Continued 141 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Side Effects • Hypoxaemia • Haemodynamic alterations • Arrhythmia • Trauma • Atelectasis • Distress • Increased ICP - particularly the Acute HI NB - With nasal or oral suctioning there is the potential for laryngospasm, vomiting or gagging as well as trauma • Ventilator Malfunction Reattach the patient to the bagging circuit and deliver breaths of TV not the volumes for hyperinflation given during physiotherapy treatment If the electricity fails similar action is necessary • Treatment once extubated: This patient still has marginal gas exchange, so it is important at this stage to optimize respiratory function with Physiotherapy treatment, to minimize the need for reintubation. Reintubation carries risks of: ¾ vocal cord damage ⇒ avoided if possible ¾ infection ¾ trauma ¾ potential for aspiration Treatment at this time might include: ¾ Positioning ( eg high sitting or other dependent upon objective findings). ¾ Breathing exercises (type will be dependent upon objective findings) ¾ +/- secretion removing techniques ¾ Cough - remove BiPAP mask to cough 142 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• Mobilization commenced: ¾ As soon as the patient is haemodynamically stable. When attempts are made to wean the patient from ventilatory support, it is important not to hinder this by fatiguing them and thus prolonging the duration of weaning. As such, mobilization should be tailored to suit both the medical plan as well as the patient's physical ability. In patient 1: ¾ Mobilization should commence whilst the patient is still intubated. ¾ Initially SOOB in a Halstead chair (or similar) if available, or being hoisted into an arm chair. ¾ Mobility should then be progressed from standing/ walking on the spot with assistance to walking (+/- rollator) as able. Assistance would be required during this time to bag the patient once disconnected from the ventilator. • Difficulties with mobilizing ICU patients ¾ Multiple attachments ¾ Instability of patients ¾ Lack of co-operation ¾ Other injuries ¾ Multiple assistants required - can be time consuming and resource dependent PATIENT 2. - Post operative repair ruptured sigmoid diverticulum • Treatment Day 1 - Ensure adequate pain relief - Position high supported sitting - Manual hyperinflation, DBEs as able on the bag - UL and LL active exercises - Suction - SOOB if haemodynamically stable • Cause of deterioration in respiratory function day 4 It is possible that this gentleman has developed ARDS. ¾ Increased PEEP requirements ¾ Smaller tidal volumes delivered to minimize barotrauma ¾ Increased FiO2 requirements ¾ Higher PIPs ¾ Bilateral pulmonary infiltrates on CXR 143 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003