Post Operative Cardiothoracic Surgery Complications PDF

Post operative cardiothoracic surgery complications DR ALYAA ABULLAH ZAID  A)Chronic post sternotomy pain  What is The sternum is known as the breastbone. This connects to the ribs with the cage. It has a flat the shape. The sternum is part of the rib ca...

Post operative cardiothoracic surgery complications DR ALYAA ABULLAH ZAID  A)Chronic post sternotomy pain  What is The sternum is known as the breastbone. This connects to the ribs with the cage. It has a flat the shape. The sternum is part of the rib cage, a series sternum? of bones that protect the heart and lungs from injuries and accidents. Patient ((Of course, I knew that my sternum had been wired together but with every breath or movement I could feel those two sternal halves rubbing, yes grinding against each other. This was not only quite painful but very anxiety-producing, creating fears that the wires may not hold if I move too suddenly, or forcefully and god forbid that I ever had a coughing spasm or worse yet, have to sneeze! In fact, I had been pre-warned by a former patient who said his first sneeze was the scariest and most painful moment he experienced. Thus, I completely stifled sneezing for a full three weeks! When I finally did sneeze it was still very frightening and painful. Unfortunately, I had heard accounts of patients actually coughing and/or sneezing right through their sternotomy wires so naturally anxiety was high)  Median sternotomy.  Median sternotomy. The patient is positioned supine with one or both arms abduced and placed on an arm holder or placed at the patient’s side. The skin incision is median, from the sternal notch to the xiphoid process. The pectoral fascia and sternal periosteum are incised with diathermy. The interclavicular ligament on the superior margin of the manubrium is divided, and a finger is inserted to develop a substernal space. The xiphoid process is mobilized or removed to facilitate a substernal plane caudally. The sternum is divided in the midline from the top down or from the bottom up with a right blade or rotating disk saw. While splitting the sternum, the anesthesiologist interrupts ventilation to minimize the risk of lung injury. Once the sternum is divided and the two edges are retracted, periosteal bleeding may be controlled with electrocautery. In patients with significant bleeding from the bone marrow, bone wax may be supportive in control of the bleeding. A sternal spreader is placed and gently opened. The anonymous vein should be mobilized and pericardial adhesions and ligaments should be dissected to prevent unintentional tearing of the anonymous vein or opening of the pericardial or pleural space. Before closure, a 24 or 26 F mediastinal chest tube should be placed through a stab incision; if the pleural space has been opened, a 26 F chest tube should be inserted in the pleural cavity for drainage through a separate stab incision. To close the sternotomy, six to eight transsternal or parasternal sutures of stainless steel wire are placed. Two to three uppermost wires are placed through the manubrium to facilitate the strength of the osteosynthesis and to avoid damage to the subclavian joint. The ends of the wires are twisted and secured into the sternal tissue. The pectoral fascia and linea alba are closed with absorbable sutures in a running fashion. A subcutaneous drain may be inserted and the subcutaneous tissue adapted. The skin should be closed with care, preferably with intracutaneous running sutures  chronic pain post-surgery Generally, chronic pain post-surgery is the pain that occurs either continuously or intermittently in the location of surgery, lasts beyond the normal rehabilitation period of a tissue for about three months after surgery and different from that suffered pre- operatively  chronic pain  However, some authors identify 12 months as the minimum duration of pain to be considered chronic. Some authors define chronic pain with no fixed duration but any pain that extends beyond the expected period of healing TO DEFINE CHRONIC POST STERNOTOMY PAIN, THE PAIN MUST DEVELOP POST-OPERATIVELY AT THE MEDIAN STERNOTOMY LOCATION; IT MUST BE OF AT LEAST 2 MONTHS AFTER SURGERY AND OTHER CAUSES OF PAIN (INCLUDING THE POSSIBILITY THAT THE PAIN IS FROM A PRE- EXISTING CONDITION) ARE EXCLUDED.  Importance and incidence of chronic post sternotomy pain A SIGNIFICANT NUMBER OF PATIENTS WHO UNDERGO MEDIAN STERNOTOMY FOR HEART SURGERY (ESTIMATED TO BE OVER 2 MILLION ANNUALLY); SUFFER FROM PERSISTENT PAIN DEFINED AS CHRONIC POST-STERNOTOMY PAIN. IN THE IMMEDIATE PERIOD AFTER SURGERY; SEVERE UNCONTROLLED PAIN NEGATIVELY AFFECTS PATIENT RECOVERY AFTER CARDIAC SURGERY. Importance and incidence of chronic post sternotomy pain  Chronic pain following median sternotomy  Chronic pain following median sternotomy is common after cardiac surgery. If left untreated, chronic sternal pain can reduce quality of life, affecting sleep, mood, activity level, and overall satisfaction. This has a significant societal effect given the large number of cardiac surgeries annually.  Untreated pain may lead to: adverse hemodynamic consequences such as tachycardia, arrhythmias and hypertension; can lead to pulmonary complications such as atelectasis, pneumonia and coagulation disorders such as hypercoagulability and platelet activation it also can lead to sleep, mode and behavioral changes  Importance and incidence of chronic post sternotomy pain ❖ All of these consequences of pain can result in: ❖ increased intensive care unit or hospital length of stay ,hospital readmission, prolonged recovery and negatively affect quality of life on those affected ❖ Chronic pain after coronary artery bypass surgery, was estimated to occur in 25–50% of patients and the incidence of severe pain is 5–10% of them ❖ All of these consequences of pain can result in: ❖ increased intensive care unit or hospital length of stay ,hospital readmission, prolonged recovery and negatively affect quality of life on those affected ❖ Chronic pain after coronary artery bypass surgery, was estimated to occur in 25–50% of patients and the incidence of severe pain is 5–10% of them  Causes and mechanisms of chronic post sternotomy pain After ruling out myocardial ischemia or sternal wound infection as possible causes for chest pain; the etiology of post-sternotomy pain can be theoretically attributed to two main causes, first nerve injury and second musculoskeletal factors  Nerve injury factors  Defalque and Bromley attributed chronic post sternotomy pain to the development of scar-entrapped neuromas at the sternotomy site caused by sternal wires.  andintercostal neuralgia, due to damage of the intercostals nerves during internal mammary artery (IMA) harvesting.  Nerve injury factors Brachial plexus injury from over retraction of sternal plates, the later could also cause upper extremity pain, chest pain in dermatome T1, and painful sternum Nerve injury originates mostly direct from surgical injury of the peripheral nerves, or as a consequence of active inflammation resulting in neuropathic pain which is characterized by loss of sensation, hypersensitivity of the affected body area with allodynia and spontaneous, sometimes paroxysmal pain.  Musculoskeletal factors  Musculoskeletal factors that might be the cause of chronic post-sternotomy pain include:  sternal fracture, incomplete healing of the sternum and sternal instability, sternocostal chondritis, rib or costal fracture, broken and or migration of the steel sternal wire towards the skin, and sternal pseudoarthrosis  Risk factors of chronic post sternotomy pain  severe pain on the third postoperative day, and female gender are independent predictors for the development of chronic thoracic pain.  Allergy to the wire used for sternum closure, younger age, and the use of the IMA can be also considered risk factors  It has been suggested that the severity of acute postoperative pain and greater need for analgesics during the first few days after surgery may predict future chronic pain.  Risk factors of chronic post sternotomy pain  That reflects the importance of management of the acute postoperative pain for the purpose of disrupting the possible peripheral and central neural processes responsible for the transition to a chronic pain  Risk factors of chronic post sternotomy pain Excessive sternal retraction can result in a trauma to muscles, bones, tendons and ligaments beside its effects on the brachial plexus. A local inflammatory component will usually follow the surgery, in addition to a general inflammatory response due to cardiopulmonary bypass.  Risk factors of chronic post sternotomy pain Preoperative anxiety, depression and catastrophizing (tendency to exaggerate the threat value of pain and to feel helpless in the context of pain), are associated with higher rates of chronic post sternotomy pain  Management of chronic post sternotomy pain  Itis essential to rule out important causes of chronic anterior wall pain such as myocardial ischemia, and mediastinitis in every cardiac surgery patient presenting with chest pain.  The management of chronic post sternotomy pain  The management of chronic post sternotomy pain requires a multidisciplinary approach that starts first with preventive measures that involves intensive perioperative psychological, medical, physical therapy, and second utilizing pharmacological and non-pharmacological measures aimed at preventing and treating the factors that increase the risk of chronic post stereotomy pain and associated negative consequences.  The surgical therapy includes sternal wire removal; which may be an effective treatment for pain in a subgroup of patients. If the pain persists after wire removal, referral to a chronic pain management specialist is recommended. ❖ Pharmacological treatment  ❖ Non- pharmacological approach for managing this pain Technical measures Psychological intervention Sternal wires removal  Osteopathic manipulative treatment  Osteopathic manipulative treatment is another form of therapy that can be tried to reduce chronic pain after sternotomy, Osteopathic manipulative treatment is defined as: “The therapeutic application of manually guided forces by osteopathic physician, to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction”  It was successful in alleviating post sternotomy pain without clear mechanisms  Osteopathic manipulative treatment may improve mechanical stress in the mediastinum and reduce the nociceptive afferent signals that develop following a surgical intervention, or could reduce the production of inflammatory cytokines PART 2  PART 2 SternalPrecautions and Sternal Instability Management  Sternal Precautions and Sternal Instability Management  Sternal instability, infection, and wound dehiscence are the primary complications of median sternotomy.  While the incidence of complications is involved, the rates of subsequent morbidity and mortality are high.  The proper healing of the sternum is a priority for ensuring good patient outcomes  Sternal Precautions and Sternal Instability Management  Traditional Sternal Precautions  There is no universal definition of sternal precautions. As a result, the type and duration of activity restrictions vary widely across facilities. Common precautions include:  No lifting more than 5-10 pound (lbs.).  No reaching behind the back.  No pushing or pulling through the arms.  Additional instructions may prohibit reaching overhead with one or both arms, or driving. Recommended adherence can last anywhere between 4 to 12 weeks.  Recommendations after sternotomy  Bilateral movements of the arms in the horizontal level, backwards or over the shoulder level, should only be performed within pain-free limits during the initial 10 days following sternotomy or until the wound is healed.  Loaded movements of the arms should only be done at a pain-free level.  In general, patients should keep the upper arms close to the body for 6-8 weeks.  Patients with BMI≥35 should wear a supportive vest to protect the sternum for 6-8 weeks.  Recommendations after sternotomy Patients should be taught to hug a pillow over the surgical incision when coughing and sneezing for 6–8 weeks.  Patients whocough frequently should wear a sternal vest supporting the entire circumference of the thorax.  Management of Sternal Instability  Sternal instability can be described acutely as sternal dehiscence/disruption or chronically (>6 months postoperatively) as sternal nonunion.  Sternal separation can occur along the entire sternum or a limited portion sternal infection, (usually the caudal end) and is closely interlinked with which can result in sternal clicking, excessive sternal movement, pain, and difficulty performing functional tasks  Management of Sternal Instability  Overheadlifting, pushing, pulling, and lifting objects that weigh more than 5-10 pound (lbs.) and activities which place large amounts of stress through the sternum, particularly lying face down and applying direct pressure or impact to the chest, should be avoided until the instability has healed. Thoracic support  Thoracic support during coughing, applying counter pressure to the median sternotomy incision (i.e., “splinted coughing”), is thought to prevent dehiscence, reduce pain, and facilitate cough effectiveness.  Once serious conditions have been ruled out and the sternal instability has been confirmed as minor and non-displaced, treatment of instability can be started.  Management of Sternal Instability  Local application of heat or cold may provide temporary relief of discomfort, in conjunction with pain relieving medication.  The therapist will instruct patients in deep-breathing exercises to promote full lung expansion, relieve muscle spasm, and mobilize lung secretions.  when the condition is stable, shoulder and trunk stretching exercises may be used, to relieve discomfort, promote chest expansion & functional shoulder mobility, and improve posture.  Management of Sternal Instability  Once the instability has healed, there can be a gradual return to normal activities, provided there is no increase in pain and other symptoms.  This should take place over a period of weeks to months.  When returning to contact sports or ball sports, the use of protective padding or chest guards may be required to prevent further injury.  When returning to contact sports or ball sports, the use of protective padding or chest guards may be required to prevent further injury.  Patientswith more severe sternal instability, particularly those which require surgical correction, or when other structures have been involved, will usually require a prolonged period of management over many months before recovery can take place. INTRODUCING KEEP YOUR MOVE IN THE TUBE: Keep Your Move in the Tube https://youtu.be/e4Oz6RGfMNI?si=S4PpwKzgbsEFv2Ep INTRODUCI NG KEEP YOUR MOVE IN THE TUBE:  Keep Your Move in the Tube  We moved away from load and time restrictions and instead used standard kinesiological principles to develop this new approach. Because Keep Your Move in the Tube is based on the ergonomics that shorten the length of the outstretched arm (lever arm reduction), it enables patients to perform previously contraindicated movements. The first step in applying this approach is to explain to patients in layman’s terms what happened to their sternum during surgery, using an illustration of the attachments of the pectoralis major on the sternum, the humerus, and the clavicle.  Keep Your Move in the Tube  By keeping their upper arms close to their body, as if they were inside an imaginary truncal tube, patients can modify load-bearing movements and thus avoid excessive stress to the sternum. More specifically, limiting the movement of the humerus minimizes the lateral pull on the sternum and decreases the leverage of the hand and forearm during load bearing actions such as rolling a wheelchair, opening a heavy door, or lifting a toolbox. Th e graphic’s simple drawings show movements that are “in the tube” (green) versus “out of the tube” (red). Th ese color-coded diff erences are easy to comprehend, and the overall format overcomes barriers related to language preference and reading ability. INTRODUCING KEEP YOUR MOVE IN THE TUBE: INTRODUCING KEEP INTRODUCING KEEP YOUR MOVE IN THE TUBE: YOU MOVE IN THE TUBE:  https://www.bing.com/videos/riverview/relatedvideo?q=INTRODUCING+K EEP+YOUR+MOVE+IN+THE+TUBE%3a&&view=riverview&mmscn=mtsc&mid= 36ECE856BA7D0842F59936ECE856BA7D0842F599&&aps=10&FORM=VMSOV R  What to expect from physiotherapy immediately after a cardiac operation  Evidence-Based Perspective on Movement and Activity Following Median Sternotomy | Physical Therapy | Oxford Academic DR ALYAA ZAID