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Cardiothoracic Princ. III > 1: Lightning Bolts & Bullseyes #1 > Flashcards

1: Lightning Bolts & Bullseyes #1 Flashcards

all of the starred/highlighted content for exam 1

1
Q

considerations for squamous cell caricinoma

A

central lesions (predominantly)
often with endobronchial tumor
mass effects: obstruction, cavitation

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2
Q

considerations for adenocarcinoma

A

peripheral lesions
extrapulmonary invasion common
most pancoast tumors
growth hormone, corticotropin
hypertrophic osteoarthropathy

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3
Q

considerations for large cell carcinoma

A

large, cavitating peripheral tumors
similar to adenocarcinoma

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4
Q

considerations for small cell carcinoma

A

central lesions (predominantly)
surgery usually not indicated
paraneoplastic syndromes
Lambert-Eaton syndrome*
fast growth rate
early metastases

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5
Q

Lambert-Eaton syndrome

A
  • impaired release of acetylcholine from the terminals; lower limb weakness
  • sensitive to non-depolarizers and respond poorly to anticholinesterase reversal agents
  • may improve after surgery
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6
Q

considerations for carcinoid tumors

A

proximal, endobronchial
bronchial obstruction with distal pneumonia
highly vascular
benign (predominantly)
no association with smoking
5 year survival > 90%
carcinoid syndrome (rarely)

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7
Q

carcinoid*

A

severe hypotension may need to use specific antagonists: octreotide or somatostatin

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8
Q

care of the patient on Bleomycin

A

low FiO2 d/t pulmonary toxicity (avoid hyperoxia)

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9
Q

care of the patient on Cisplatin

A

NSAIDs contraindicated d/t increased creatinine

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10
Q

4 M’s of Anesthetic considerations in lung cancer patients

A
  1. Mass effects
  2. Metabolic effects
  3. Metastases
  4. Medications
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11
Q

mass effects of lung cancer

A

obstructive pneumonia, LUNG ABSCESS, SVC syndrome, tracheobronchial distortion, pancoast syndrome, recurrent laryngeal nerve or phrenic nerve paresis, chest wall or mediastinal excision

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12
Q

metabolic effects of lung cancer

A

Lambert-Eaton syndrome, HYPERCALCEMIA, HYPONATREMIA, cushing’s

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13
Q

metastases effects of lung cancer

A

particularly to bone, brain, liver, and adrenal

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14
Q

medication considerations for lung cancer patients

A

Bleomycin, mitomycin: pulmonary toxicity
Doxorubicin: cardiac toxicity
Cisplatin: renal toxicity

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15
Q

of the lung cancer considerations, which are the most detrimental?

A

mass effects

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16
Q

Preop Lung Function: what is the 80-40-15 rule?

A

FEV1 > 80% (no testing needed)
PPO FEV1 DLCO < 40% (increased risk, exercise test)
VO2 Max < 15 mL/kg/min (increased risk)

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17
Q

most valid test for respiratory mechanical function

A

FEV1

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18
Q

most valid test for lung parenchymal function

A

DLCO

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19
Q

most valid test for caridopulmonary interaction

A

maximal oxygen consumption (VO2)

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20
Q

ABG CO2 > 45 mm Hg

A

indicator of poor ventilatory function

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21
Q

SaO2 < 90%

A

preop hypoxemia

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22
Q

albumin < 3.6 and BUN > 22

A

important predictor of pulmonary complications

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23
Q

renal function and nephrotoxic drugs

A

methotrexate & cisplatin

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24
Q

what is a more reliable indicator of poor outcomes with thoracic surgery?

A

desaturation with exercise

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25
Q

findings consistent with pulmonary disease (echo)

A

RIGHT ATRIAL CHAMBER ENLARGEMENT i.e. disease, pulmonary hypertension

26
Q

arterial line in the . . . (mediastinoscopy) ox

A

Aline = RIGHT to detect compression of innominate artery
BP cuff = left
Pulse ox = right to detect compression of innominate artery

27
Q

aline position for thoracotomy

A

in DEPENDENT arm to monitor possible AXILLA artery compression

28
Q

pros/advantages of DLT

A

EASY TO PLACE
repositioning rarely needed
bronchoscopy to isolated lung
suction to isolated lung
CPAP EASILY ADDED
can alternate OLV to either lung easily
placement possible without bronchoscopy
best device for absolute lung isolation

29
Q

pros/advantages of bronchial blockers

A

size selection rarely an issue
easily added to regular ETT
allows ventilation during placement
easier placement in 1) difficult airways and 2) children
postop two-lung ventilation by withdrawing blocker
selective lobar lung isolation possible
CPAP to isolated lung possible

30
Q

Cons/disadvantages of DLTs

A

size selection more difficult
difficult for difficult airways/abnormal tracheas
not optimal for postop ventilation
potential laryngeal trauma
potential bronchial trauma

31
Q

cons/disadvantages of BBs

A

more time needed for positioning
repositioning more often
bronchoscope essential for positioning
limited right lung isolation d/t RUL anatomy
bronchoscopy to isolated lung impossible
minimal suction to isolated lung
difficult to alternate OLV to either lung

32
Q

DLT FM < 160 cm

A

35

33
Q

DLT FM > 160 cm

A

37

34
Q

DLT M > 170 cm

A

41

35
Q

DLT M < 170 cm

A

39

36
Q

FM < 152 cm

A

examine bronchial diameter on CT scan
consider 32-Fr DLT

shorter patients (<155 cm) height is not a good predictor

37
Q

M < 160 cm

A

consider 37 Fr DLT

38
Q

DLT insertion: resistance?

A

There should be NO resistance with placement but slight resistance when you reach the bifurcation.

39
Q

indications for DLT

A

descending thoracic aortic aneurysm

left lung transplant
left-sided tracheobronchial disruption
left-sided pneumonectomy

40
Q

what can cause malposition of the DLT?

A

overinflation
surgical manipulation
head extension

41
Q

how to diagnose malposition?

A

fiberoptic

42
Q

s/s of malposition?

A

hypoxemia

43
Q

DLT in optimal position but lung deflation is not achieved

A

suction cath to lung collapse

(make sure to remove)

44
Q

other problems with DLT

A

airway trauma
DLT too big
rupture of bronchus or aneurysm
unexpected air leak
subQ emphysema
airway bleed
protrusion of cuff into filed
tension PTX in dependent lung during OLV

45
Q

benefits of bronchial blockers (again)

A

challenging airway
previous oral or neck surgery
pediatrics

46
Q

complications of BBs

A

lack of seal within bronchus
distal wire stapled into the lobectomy

47
Q

when is a patient considered high risk

A

advanced age
poor general health status
COPD
BMI > 30 kg/m2
low FEV1
low predicted postop FEV1

48
Q

interpleural space

A

potential space between the parietal pleura of the internal chest wall and the visceral pleura covering the lung

49
Q

intrapleural pressure

A

NEGATIVE/SUBATMOSPHERIC
lungs recoil inward and the chest wall recoils outward

50
Q

inward and outward forces are equal at ?

A

FUNCTIONAL RESIDUAL CAPACITY

51
Q

intrapleural during tidal breathing

A

always negative

52
Q

intrapleural pressure becomes negative during ____ and positive during _____

A

inspiration; expiration

53
Q

vasalva maneuver

A

intrapleural pressure becomes positive during a forced expiration or during expiratory effort against a closed glottis

54
Q

zone 1 (west)

A

dead space

region is ventilated but not perfused

55
Q

zone 2 (west)

A

waterfall

arterial pressure exceeds alveolar
flow is solely dependent on arterial flow

56
Q

zone 3 (west)

A

swan ganz

pulm arterial and venous pressures exceed alveolar pressure; dependent portion of the lung

57
Q

zone 4 (west)

A

pulmonary edema (pahological)

interstitial fluid compresses the vessels and occlude their flow

58
Q

zone 3 is …

A

dependent
better ventilation
better perfusion

lower V/Q ratio
less negative intrapleural pressure

59
Q

west zones describe ______ in the lungs

A

PERFUSION

60
Q

which portions of the lung receive greater amount of blood flow?

A

dependent

due to gravity, vessel recruitment, and distensibility

results in optimal gas exchange

61
Q

R–>L shunt

A

Blood pumped by the Rt heart passes to the Lt heart without being oxygenated

Reasons: anatomic defect, blood passing through the lungs does not come in contact with O2 in the alveoli-intrapulmonary ie ARDS

62
Q

L –> R shunt

A

Blood is pumped from the Lt heart back to the right usually in neonate

Ductus arteriosus or foramen ovale

Cardiothoracic Princ. III (8 decks)

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