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Key Questions - Cardiothoracics

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Liz Allibone, PGCTLCP, BSc, RGN, is nurse teacher, nursing development, Royal Brompton and Harefield NHS Trust.

Is surgery for primary lung cancer curative?

Yes – surgery is currently the only treatment that can claim to cure patients of lung cancer. However, this only applies to lung cancer diagnosed as non-small cell lung cancer (NSCLC) at a surgically resectable TNM stage (TNM – primary tumour (T), regional lymph nodes (N), distant metastasis (M)). Approximately 20-30% of such patients may be suitable for radical surgery. The term ‘five-year survival rate’ - rather than the word ‘cure’ - is preferred because the patient may have undetected microscopic cancerous cells that may result in the cancer returning within five years. The five-year survival in the UK post radical surgery for TNM stage I NSCLC is currently estimated at 60-80% but this rate reduces as the staging suggests more advanced cancer.

What are the signs and symptoms of acute cardiac tamponade?

Cardiac tamponade may occur when blood or fluid collects in the pericardial space and compresses the heart. It is important for nurses to recognise the warning signs as early as possible because, if untreated, cardiac tamponade may lead to severe haemodynamic compromise and cardiac arrest.

In the initial post-operative period the signs and symptoms of cardiac tamponade might include dysrhythmias, decreased voltage on the ECG, hypotension, low cardiac output, raised central venous pressure, restlessness, sudden cessation of mediastinal chest drainage and low urine output. The patient may also feel cool to touch. The central venous pressure (also known as right atrial pressure) is increased owing to the heart being restricted – this distinguishes tamponade from hypovolaemic shock.

What are the complications of cardiopulmonary bypass (CPB)?

As with any major surgery there is a risk of death, shock, haemorrhage, wound infection and breakdown, and gastrointestinal disturbances.

For patients who undergo cardiac surgery via CPB (when the heart is cooled down, paralysed and unable to beat and a machine controls the circulation instead) there are a number of system-related complications. Cardiovascular complications include cardiac ischaemia, arrhythmias, coagulopathy (owing to heparinisation during the surgery), haemodilution and hypothermia (which can lead to labile blood pressure). Respiratory distress syndrome or atelectasis are also complications because CPB reduces surfactant production and may initiate an inflammatory response that increases capillary permeability. Neurological events such as a cerebrovascular accident, cognitive dysfunction or post-pump psychosis may occur as a result of an air embolism, disruption of a calcified plaque or a systemic response to CPB. Acute renal failure may also develop owing to decreased renal blood flow during surgery. The blood glucose may be elevated due to an inflammatory response because the blood has been in contact with a foreign surface.

Why do patients become oedematous after cardiac surgery?

The inflammatory response, temperature changes peri- and postoperatively and the haemodilution that occurs as a result of CPB cause the patient to be in a catabolic and hypermetabolic state that may increase capillary permeability. This may lead to a redistribution of fluid and electrolytes from the intravascular space to the interstitial compartment (also called the ‘third space’).

What are the complications of a thoracotomy wound?

The main complication of a thoracotomy wound is a ‘frozen shoulder’ and chronic pain for many years after the operation (often called post-thoracotomy pain syndrome), if it is not managed effectively in the early postoperative period. Patients may report aching, burning or numbness that then leads to ‘pins and needles’ for months to years after surgery. Infection and wound breakdown are also complications but are rare.

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