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Procedures

Procedures. Intermediate Format: Pericardiectomy/Pericardial Window. Objectives. Assess the related terminology and pathophysiology of the heart. Analyze the diagnostic interventions for a patient undergoing a pericardiectomy.

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Procedures

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  1. Procedures Intermediate Format: Pericardiectomy/Pericardial Window

  2. Objectives • Assess the related terminology and pathophysiology of the heart. • Analyze the diagnostic interventions for a patient undergoing a pericardiectomy. • Plan the intraoperative course for a patient undergoing_____________. • Assemble supplies, equipment, and instrumentation needed for the procedure.

  3. Objectives • Choose the appropriate patient position • Identify the incision used for the procedure • Analyze the procedural steps for pericardiectomy. • Describe the care of the specimen

  4. Terms and Definitions • Pericardium • Decortication • Pericardial effusion • Cardiac tamponade

  5. Definition/Purpose of Procedure • Partial excision of adhered, thickened fibrotic pericardium to relieve constriction of compressed heart and large blood vessels • Removal of a segment of pericardium, permitting pericardial fluid to drain into the pleural space for treatment of cardiac tamponade • Surgical stripping of the pericardium

  6. Pathophysiology • Chronic pericarditis • Tubular • Rheumatic • Viral • Neoplastic • Constrictive

  7. Pathophysiology • Signs & Symptoms • Chest pain • Fever • Cough • Dyspnea • Palpitations • Friction Rub

  8. Surgical Intervention:Special Considerations • Patient Factors • anxiety • Room Set-up • For heart surgery • Possibly cardiac bypass on standby

  9. Surgical Intervention: Positioning • Position during procedure • Supine, arms on armboards at 90 degrees • Supplies and equipment • Special considerations: high risk areas

  10. Surgical Intervention: Special Considerations/Incision • Special considerations • State/Describe incision • Median sternotomy • # 10, # 15 blades

  11. Surgical Intervention: Supplies • General: Cardiac pack • Specific • Suture • 4-0 & 5-0 Prolene, wire for sternum • Pledgets • Medications on field (name & purpose) • Heparinized saline solution and other meds as indicated on preference card (may have protamine on standby) • Catheters & Drains: Chest Tubes

  12. Surgical Intervention: Instruments • General: Chest and Heart sets • Specific • Have all cardiac bypass instrumentation available if needed

  13. Surgical Intervention: Equipment • General • Specific • Cardiac defibrillator on standby with internal and external paddles • Cardiac bypass on standby

  14. Surgical Intervention: Procedure Steps • The lungs are displaced laterally, and the right and left phrenic nerves are identified and protected • The pericardium is incised • Decortication begins with the left ventricle • To prevent development of pulmonary edema and Rt Side Heart Failure, which could happen if one starts w/right ventricle • A plane is developed between parietal & visceral pericardium • Caution must be taken to prevent calcified portions of the parietal pericardium from penetrating the heart’s chambers, esp the atria. • The outer, thickened pericardium is removed as indicated • Have cartilage scissors ready

  15. Surgical Intervention: Procedure Steps • Fibrous portions adhering to the atria and ventricles are carefully dissected w/dry dissectors and scissors • Extreme caution used to prevent perforation of atria and right ventricle—small areas of adherent pericardium may be retained • STSR is prepared with loaded 4-0 or 5-0 pledgeted Prolene sutures. • Dissection is continued; large blood vessels are exposed and freed as needed; the Atria, Ventricles, and both Cavae are freed • Drainage catheters are placed near the heart or through the pleural spaces • STSR has chest tubes ready with closed drainage system • Sternum is closed w/ stainless steel wire, and remainder of wound closed “usual manner”

  16. Counts • Initial: Sponges, Sharps, instruments • First closing • Final closing • Sponges • Sharps • Instruments

  17. Specimen & Care • Identified as pericardium • Handled: routine

  18. Resources • STST Ch 22 pp. 918, 919 • Taber’s Cyclopedic Medical Dictionary • Alexanders Ch 27, p. 1143, 1156-1157 • Lemone and Burke pp. 895-897

  19. The surgical incision most likely for open heart surgery is: • Anterolateral thoracotomy • Posterolateral thoracotomy • Median sternotomy • supraclavicular

  20. Which medication is commonly given IV about 3-5 min prior to cross-clamping the artery during Arteriotomy? • Epinephrine • Protamine sulfate • Papavarine • Heparin

  21. All of the following are sutures used in CV surgery to suture vessels or vascular grafts except: • Polytetrafluoroethylene (PTFE or Gore-Tex) • Polyporpylene (Prolene) • Polyester (Dacron) • Surgical gut (chromic)

  22. Which of the following procedures would commonly require the use of extracorporeal circulation (heart-lung bypass)? • Abdominal Aortic Aneurysmectomy with Graft • Pneumonectomy • Coronary Artery Bypass Graft • Vena Cava Umbrella insertion

  23. The vessel used to increase the overall blood supply to the heart following CABG is the : • Saphenous artery • Brachial artery • Carotid artery • Internal mammary artery

  24. The creation of a commuication between an artery and a vein for hemodialysis access is called a(n) • Bypass Graft • Aneurysmectomy • Vena Cava Umbrella Filter Placement • Arteriovenous Fistula Formation

  25. Which of the following bypass grafts would require preclotting? • Knitted polyester (Dacron) • Saphenous vein • Human umbilical cord graft • Polytetrafluoroethylene (PTFE)

  26. The procedure in which a Fogerty Catheter is used to remove blockage of a vessel is referred to as: • Arteriovenous shunt • Endarterectomy • Embolectomy • Ligation and stripping

  27. The autogenous graft which is left in place after destruction of the internal valves and then sutured into the arterial system is: • In-situ saphenous vein graft • Human umbilical cord graft • PTFE graft • ligation and stripping of the saphenous vein

  28. The artery that carries deoxygenated blood in the adult is the: • Aorta • Carotid artery • Pulmonary artery • Coronary artery

  29. Common artery bypass procedures include all of the following except: • axillo-popliteal • Femoro-femorol • Axillo-femoral • Femoro-popliteal

  30. Specific equipment used during surgery on a pt with a pacemaker in place should include: • A magnet • Mono-polar ESU with its patient return electrode applied to the patient • Mono-polar ESU without its patient return electrode applied to the patient • Bi-polar ESU with its patient return electrode applied to the patient

  31. Suture material used to place vascular grafts would include: • PDS • Vicryl/Dexon • Prolene • Stainless steel

  32. A Femoro-popliteal Bypass is scheduled. Which self-retaining retractor would be used to facilitate exploration of the femoral artery? • Harken • Debakey • Weitlaner • Gelpi

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