Treatment of a Cardiac Patient in the Acute Care Setting BY: KATIE - PowerPoint PPT Presentation

Treatment of a Cardiac Patient in the Acute Care Setting BY: KATIE OWENS/LEWIS

Patient Information o 84 y/o male o PMHx: o Coronary Artery Disease (CAD) o Hypertension (HTN) o Hyperlipidemia (HLD) o S/p Coronary Artery Bypass Graft (CABG) o thoracic arch aneurysm o thoracoabdominal aneurysm o Admitted due to severe chest pain o Pt. was diagnosed with a Type B Intramural Hematoma

What is a Type B Intramural Hematoma? o We know for sure: o Identified by the occurrence of bleeding into the intimal wall 1 o Cause of the bleeding is up for debate: o Vasa vasorum bleeding into the aortic media 2 o Presence of an intimal defect (might be considered a subset of aortic dissection in this case) 2

Medical Management of Intramural Hematoma Possible Treatments: o TEVAR 2 o Open surgical repair 2 o Anti-impulse therapy 2 o No difference in outcome when comparing surgical treatment and medical treatment of 62 patients with a Type B Intramural Hematoma 3

PT was ordered o PT ordered to address R LE weakness… PMHx: R hip disarticulation per patient was completed approximately 10 years ago

Evaluation Family/Home Accommodations: Subjective: o Family: o Functional level prior to Lives with daughter o hospitalization: Daughter works full time o o Bed mobility: Mod I Home Accommodations: o o Transfer to/from w/c: Mod I Ramp to enter home o ADLs: Minimal Assistance o 1 st floor bedroom and bathroom o o Pain Trapeze above bed o o 3/10 pain at rest W/c accessible house o

Evaluation continued… o Vital Signs: Objective: o Resting heart rate 58-60 BPM o AROM: o Respiration rate 18 breaths per minute o WFL for all extremities o Blood pressure 110/70 o Strength: o SpO2 96% o Approximately 3+/5 in L LE o Lines & Leads o Approximately 4/5 in bilateral UEs o PIV o Bed Mobility (Supine to/from Sit): o Arterial line (at the radial artery) o Sensation o Moderate Assistance o Intact bilateral UEs and LEs

Evaluation Continued Home Exercise Program o 2 sets of 10 supine straight leg raises o 2 sets of 10 supine hip abduction o 3 sets of 10 supine ankle pumps o 3 sets of 10 seated knee extension o 3 sets of 10 supine glute squeezes

Outcome Measure Utilized AM-PAC Score on Evaluation Raw score=7 o 84.99% impaired based on the 5 Item o conversion table Recommended cutoff scores to determine o discharge recommendation: 42.9 4 Post-acute care vs home o FIM is an additional outcome measure that o could have been used but it is very time consuming, and likely not practical for the acute care setting. 5

Goals and Recommendations Goals Recommendations o Discharge to a skilled nursing facility based on o Mobilize supine to/from sit: Mod I this patient’s AM-PAC score and lack of 24/7 care o Transfer sit to/form stand: Mod I at home o Perform a low pivot transfer to/from bed to w/c: Mod I

Treatment Vital Signs Mobility AMPAC o Raw score: 11 o Heart rate 64 beats per o Supine to/from sit: Minimal minute Assistance o Percent impaired: 60.88% impaired o Respiratory rate 18 breaths o Sit to/from stand: Moderate per minute Assistance o Completed 3 sit to/from stands o Blood pressure 108/68 o Low pivot transfer from bed to chair: Moderate Assistance

Updated Goals and Recommendations Goals Recommendations o Mobilize supine to/from sit: Mod I o Discharge to a skilled nursing facility despite improvements in this patient’s o Transfer sit to/form stand: Mod I AM-PAC score due to lack of 24/7 care and inability to perform transfers with o Perform a low pivot transfer to/from modified independence. bed to w/c: Mod I

Is Exercise Safe for Patients with Abdominal Aneurysms? 6 o This study explores the safety of exercise for patients with abdominal aortic aneurysms by monitoring aortic aneurysm enlargement in the presence and absence of 1 year of specified exercise. o 57 patients with abdominal aortic aneurysms between the size of 3.0cm-5.0cm were recruited for this study and the resultant patient population was made up of predominantly white, males who had hypertension . o Symptom limited exercise with a target Borg perceived exertion score of 12-14 on a treadmill, stair climbing, cycling, rowing , and elliptical training 3x/week for 45 min/session + 10 min of resistance exercises o Results of this study suggests that exercise has no effect on the diameter of pre-existing abdominal aneurysms and patients were able to lower their submaximal heart rate significantly o ”Exercise-based rehabilitation result in improved risk factor profiles, higher exercise capacity, and reduced morbidity and mortality.”

Is Exercise Safe for Patients with Acute Aortic Dissections? 7 o Comparison between early rehabilitation and traditional treatment of Type B Aortic Dissections o Traditional treatment - 7 days of bedrest and antihypertensive o Rehabilitation treatment - Anti-hypertensives day 1 and began walking short distances day 3 post- onset o Resulted in statistically significant decreases in: o Delirium o Respiratory complications o No difference between aortic diameter enlargement and mortality rates

Prognosis for Individuals with a Type B IMH 8 o 45 patients with a Type B Intramural Hematoma were studied for a time period of 2.7-9.9 years following initial diagnosis: o 40% received no additional treatment during this time period o 47% had to undergo TEVAR o 24% experienced progression to a Type B Aortic dissection o 24% experienced dilatation of the Aorta o IMH related mortality rates: o 30 days-1.6% o 6 months-6.3% o 1 years-6.3% o Greater than 1 year-47.6%

Questions?

Bibliography 1. Li L, Jiao Y, Zou J, Zhang X, Yang H, Ma H. Thoracic Endovascular Aortic Repair versus Best Medical Treatment for High-Risk Type B Intramural Hematoma: A Systematic Review of Clinical Studies. Ann Vasc Surg 2018;52:273-279. doi:10.1016/j.avsg.2018.03.010. 2. Tanaka A, Leake S, Estrera AL. Management strategies in acute type B aortic intramural hematoma. Curr Opin Cardiol 2017;32(6):687-691. doi:10.1097/HCO.0000000000000453. 3. Maraj R, Rerkpattanapipat P, Jacobs LE, Makornwattana P, Kotler MN. Meta-analysis of 143 reported cases of aortic intramural hematoma. Am J Cardiol 2000;86(6):664-668. 4. Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS, Jette AM. AM-PAC “6-Clicks” functional assessment scores predict acute care hospital discharge destination. Phys Ther 2014;94(9):1252-1261. doi:10.2522/ptj.20130359. 5. Functional Independence Measure | Shirley Ryan AbilityLab - Formerly RIC. Available at: https://www.sralab.org/rehabilitation-measures/fimr- instrument-fim-fimr-trademark-uniform-data-system-fro-medical. Accessed November 16, 2018. 6. Myers JN, White JJ, Narasimhan B, Dalman RL. Effects of exercise training in patients with abdominal aortic aneurysm: preliminary results from a randomized trial. J Cardiopulm Rehabil Prev 2010;30(6):374-383. doi:10.1097/HCR.0b013e3181ebf2db. 7. Niino T, Hata M, Sezai A, et al. Optimal clinical pathway for the patient with type B acute aortic dissection. Circ J 2009;73(2):264-268. 8. Schoenhoff FS, Zanchin C, Czerny M, et al. Aorta Related and All-cause Mortality in Patients with Aortic Intramural Haematoma. Eur J Vasc Endovasc Surg 2017;54(4):447-453. doi:10.1016/j.ejvs.2017.07.001.