Surgery ILP

Question 1

Pre-op medications implications for physio

Answer 1

• patient may be drowsy, impaired coordination, impaired memory
• may affect pre-op assessment
• pts should be assessed/treated prior to medication

Question 2

General Anaesthesia adverse effects

Answer 2

Impaired ventilation 
- respiratory inhibition
- reduced FRC
- atelectasis 
- V/Q mismatch - hypoxaemia 
Impaired airway clearance 
- loss of cough 
- drying of cilia - impaired mucociliary clearance
- secretion retention

Question 3

GA physiotherapy implications

Answer 3

GA has greater respiratory effects

• > 20 minutes - greater chance of hypoxaemia
• > 30 minutes - greater chance of DVT

Question 4

Epidural anaesthesia

Answer 4

• catheter in epidural space
• blocks pain below level, muscle power should stay intact, respiratory system intact
• can also be pt controlled (PCEA)

Question 5

Epidural anaesthesia physio implications

Answer 5

• catheter may remain in-situ for post-op pain management
• pt - controlled bolus should be used 20 minutes prior to physio treatment
• observe epidural site for signs of redness, leaking, swelling, haematoma, muscle strength in LL
• report any new muscle loss to medical team
• check BP for hypotension prior to mobilising

Question 6

Spinal anaesthesia

Answer 6

Catheter in subarachnoid space, blocks sensory, motor and pain inputs of that level, respiratory system intact

Question 7

Spinal anaesthesia physio implications

Answer 7

As dura is punctured pt may report a headache, caused by CSF leakage, pt remain in supine until symptoms resolve

Question 8

Nerve block

Answer 8

Injections of local anaesthesia close to the nerve, motor and sensory block

Question 9

Nerve block physio implications

Answer 9

Patients may have residual analgesia and loss of sensation and motor function in innervated area

Question 10

Patient Controlled Analgesia (PCA)

Answer 10

background infusion rate + pt controlled bolus with lockout period 
usually narcotics (morphine, fentanyl combined with ketamine and clonidine)

Question 11

Narcotics adverse effects

Answer 11

Respiratory depression (RR<8bpm)
Postural hypotension, syncope
Drowsiness
Nausea, vomiting
Paralytic Ileus
pruritis/itchiness
urinary retention

Question 12

PCA - implications for physio

Answer 12

• encourage pt to deliver pain relief at beginning of assessment and throughout management
• Monitor pts respiratory rate and SpO2 to ensure breathing is not becoming depressed
• carry vomit bag when mobilising
• If drowsy and unable to mobilise notify medical staff for review of medication

Question 13

Epidural side effects

Answer 13

Hypotension (SBP <90mmHg)
Sedation
Respiratory depression (<8bpm)
Motor and sensory loss of upper and lower limbs
Urinary retention
Infection, haemmorhage, inflammation, displacement of catheter
Epidural haematoma

Question 14

Oesophagectomy

Answer 14

Oesophageal carcinoma or perforation
Removal of all or part of oesophagus
Ivor Lewis - upper abdominal incision, R) posterolateral thoracotomy
Thorascopic-assisted - abdominal incision and 4-5 port incisions posteriorly

Question 15

Oesophagectomy physio implications

Answer 15

• avoid HDT for gastric reflux
• care with nasopharyngeal suction as anastomosis may be damaged
• neck motion may be limited to prevent stress on anastomosis
• present post-op with ICC

Question 16

Pyloroplasty

Answer 16

pyloric muscle is divided and defect is sutured transversely, leaving larger gastric outlet

Question 17

Nissen Fundoplication

Answer 17

anti-reflux surgery, gastric fundus mobilised and wrapped around lower oesophagus, eliminates reflux and heals oesophagitis
procedure is often laparoscopic
post-op protocol may dictate that no nausea or vomiting is allowed

Question 18

Gastrectomy

Answer 18

• removal of all or part of the stomach, closure of duodenum and anastomosis of oesophagus to jejunum

Question 19

Cholycystectomy

Answer 19

Removal of gall bladder from liver bed
Open - performed via Kocher’s incision or R) paramedian incision - cystic duct is catheterised with a T tube - may be left in for 10 days to prevent stenosis of bile duct
Laparoscopic cholycystectomy now common

Question 20

Whipple’s Procedure

Answer 20

usually for cancer of the head of pancreas
involves a large incision, removal of pancreas, common bile duct, part of stomach and duodenum with re-anastomosis of remaining portions

Question 21

Whipple’s - implications for physio

Answer 21

Pt may be malnourished as a result of cancer spread

often have obstructive jaundice prior to surgery - high risk of post-op complications

Question 22

Hemicolectomy

Answer 22

resection of segment of colon with end to end anastomosis - no stoma formed

Question 23

Hemicolectomy - anterior resection

Answer 23

resection of rectal malignancy via a low midline incision - sigmoid colon and upper rectum with end to end anastomosis

Question 24

Hemicolectomy - high anterior resection

Answer 24

sigmoid colon and upper rectum

Question 25

Hemicolectomy - low anterior resection and ultra low anterior resection

Answer 25

lower rectum - anal sphincters are preserved Use jejunum to form J pouch - instead of rectum Temporary loop ileostomy often formed to enable healing of anastomosis

Question 26

Abdominoperineal resection (APR)

Answer 26

removal of rectum and anus - low midline and perineal incisions usually have stoma and permanent colostomy

Question 27

Abdominoperineal resection - implications for physiotherapy

Answer 27

pt in supine, sidelying or high sidelying avoid sitting in bed, over edge of bed to avoid pressure on perineal wound site encourage to mobilise Day 1 allowed to sit out of bed only with customised sitting pillow

Question 28

Hartman's Procedure

Answer 28

for diverticular disease proximal colon is externalised through the formation of a colostomy distal end of rectum is oversewn to form a rectal stump rectum and colon may be rejoined and colostomy reversed at a later date

Question 29

Total Colectomy + proctocolectomy

Answer 29

excision of the whole colon (total colectomy) + rectum (proctocolectomy) pt may have permanent ileostomy

Question 30

Stoma

Answer 30

``` artificial opening between colon or ileum and the skin of the abdominal wall Types: terminal colostomy side colostomy loop colostomy defunctioning colostomy ileostomy ```

Question 31

Colostomy and Ileostomy - implications for physio

Answer 31

Check level of fluid/gas before mobilising If full, notify nursing staff to empty When teaching pt supported cough, ensure not directly over stoma/bag

Question 32

Vascular Surgery - general implications

Answer 32

- assess circulation and pulses - avoid scraping feet during exercises - adhere to ROM limitations - use correct footwear when walking - mobilise with reference to post-op claudication distance atient with PVD has sheepskin or bootees during their stay in hospital - complications include: post-op infection, aneurysm, thrombotic occlusion

Question 33

Fem-pop bypass

Answer 33

- graft from femoral artery to popliteal via long incision or 3 small graft incisions - medial aspect of leg - Day 1 - chest care, mobilised Day 1 or Day 2 - Ensure no hip flexion >60 degrees with knee straight - care of incision when handling limb - inform pt of blood rush when sitting up - normal - when mobilising encourage normal gait

Question 34

Aorto-bifemoral bypass

Answer 34

graft from lower aorta to femoral arteries via midline abdominal incision and uni/bilateral groin incisions

Question 35

Aorto-iliac bypass

Answer 35

aorta to iliac arteries via abdominal incision

Question 36

Femoro-femoral crossover

Answer 36

one femoral artery to another via C-shaped graft, two small vertical groin incisions, unilateral iliac artery occlusion

Question 37

Axillo femoral bypass

Answer 37

axillary artery to ipsilateral femoral artery with additonal side limb to common femoral artery on contralateral side via unilateral subclavicular incision dividing pec major and minor, and two vertical groin incisions

Question 38

Axillo-femoral bypass - implications for physiotherapy

Answer 38

avoid - shoulder flexion >90, hip flexion >60, sidelying avoid pressure on graft from hand placement eg. percs and vibes avoid use of overhead ring when mobilising advice re bras, belts and tight clothing not to constrict graft avoid using axillary crutches

Question 39

Abdominal Aortic Aneurysm - implications

Answer 39

Pre-op - <6cm - limit cough/FET - >6cm - no cough Post-op - potential to develop respiratory failure - effective pain relief and wound support essential - No HDT - Mobilise once CV stable

Question 40

NGT

Answer 40

used for drainage or feeding - used pre-op in pts with GIT obstruction to prevent aspiration or regurgitation - either on free drainage, regular aspiration or low pressure suction

Question 41

NGT - implications

Answer 41

- often pinned to pillow - ensure NGT not pulled out - ensure tube is well secured with tape - not pulled out when mobilising - switch off NG feeds when suctioning or when in HDT - NG feeds can be disconnected when mobilising

Question 42

Nasal Prongs

Answer 42

delivery of supplemental oxygen pts on narcotic infusion will receive supplemental O2 to help overcome effects of respiratory depression can be used to improve PaO2

Question 43

O2 devices - implications

Answer 43

check device is worn correctly and correct concentration is being delivered monitor SpO2 with pulse oximeter mobilise pts with portable O2

Question 44

In-dwelling catheter (IDC) + implications

Answer 44

used when pts cannot mobilise to toilet - ensure bag is not too full prior to mobilising - keep bag below level of catheter - do not pull out catheter when mobilising

Question 45

IV line + implications

Answer 45

peripheral venous line - maintenance of fluids/medication - care with arm exercises - do not dislodge IV - care with bed mobility - limit movement of joints close to insertion of IV - if pt C/O pain at drip site report to medical team as thrombophlebitis may occur

Question 46

ICC + implications

Answer 46

removes fluid or air from pleural space, re-establishes normal negative pressure in pleural space, promotes re-expansion of lungs - do not pull out - check whether fluid is swinging, draining or bubbling - keep bottle system below level of insertion - if bottle breaks: previously no bubbling - double clamp and replace, previously bubbling - no clamp and replace - if chest tube disconnects, reconnect and assess system

Question 47

Wound drain

Answer 47

provides channel of exit from wound to prevent accumulation of fluid Open drain Closed drain Closed suction drain

Question 48

Wound drain - implications

Answer 48

do not pull out infection can be a problem can mobilise with drain - keep below level of wound

Question 49

Vacuum assisted closure (VAC)

Answer 49

negative pressure delivered uniformly to wound, wound is sealed over by a plastic film - prevents entry of bacteria, vacuum removes secretions and reduces infection

Question 50

VAC - implications

Answer 50

- do not pull out - check if suction can be removed prior to mobilisation - ensure VAC unit is below level of wound - hissing noise = leaking dressing

Question 51

Thromboembolic deterrent (TED) stockings

Answer 51

- remove to expose legs for DVT check - do not leave rolled around ankle - can ambulate in TEDs as long as shoes are also worn