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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

Intermediate Format:

Pericardiectomy/Pericardial Window


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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.


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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


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Terms and Definitions

  • Pericardium

  • Decortication

  • Pericardial effusion

  • Cardiac tamponade


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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


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Pathophysiology

  • Chronic pericarditis

    • Tubular

    • Rheumatic

    • Viral

    • Neoplastic

    • Constrictive


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Pathophysiology

  • Signs & Symptoms

    • Chest pain

    • Fever

    • Cough

    • Dyspnea

    • Palpitations

    • Friction Rub


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Surgical Intervention:Special Considerations

  • Patient Factors

    • anxiety

  • Room Set-up

    • For heart surgery

  • Possibly cardiac bypass on standby


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Surgical Intervention: Positioning

  • Position during procedure

    • Supine, arms on armboards at 90 degrees

  • Supplies and equipment

  • Special considerations: high risk areas


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Surgical Intervention: Special Considerations/Incision

  • Special considerations

  • State/Describe incision

    • Median sternotomy

    • # 10, # 15 blades


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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


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Surgical Intervention: Instruments

  • General: Chest and Heart sets

  • Specific

    • Have all cardiac bypass instrumentation available if needed


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Surgical Intervention: Equipment

  • General

  • Specific

    • Cardiac defibrillator on standby with internal and external paddles

    • Cardiac bypass on standby


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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


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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”


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Counts

  • Initial: Sponges, Sharps, instruments

  • First closing

  • Final closing

    • Sponges

    • Sharps

    • Instruments


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Specimen & Care

  • Identified as pericardium

  • Handled: routine


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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


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  • 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


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