53. Thoracic surgery Flashcards
Eaton lambert syndrome and cancer
Associated with small cell carcinoma
Cancer not related to smoking and characteristics
Carcinoid. Survival 90% (5Y)
No responsive to usual vasopressors. Tx Octreotide
Increase risk of desaturation in chest surgery if
Poor PaO2 during 2LV
Right thoracotomy
Normal spirometry o RLD
Supine
V/Q high
Adjustments in OLV
TV 5 - 6 mk/kg (IBW)
Peak p < 35, plateau > 25
PEEP 5 - 10 mmHg
RR 12 rpm
Best test for pulmonary mechanics
Predicated post op FEV1
Segments in lungs
Right. 6 - 4 - 12
Left 10 -10
Pre anesthesia in thoracic surgery
If METs > 2 spirometry (ppo FEV1, DLCO)
If METs < 2 Consultation + optimization
Post op predicted FEV1
> 60 ok
30 - 60 simple exercise test
< 30 cardiopulmonary testing
< 20 unacceptable
Arrhythmias after thoracic surgery (lung resection)
60 - 70 % afib
incidence 30 - 50%
Innominate artery characteristics
Brachiocephalic artery
Blood supply to the right arm. Pressure can cause desaturation and flat wave if pulsometer is in the right
Cardiac herniation carac.
50% death
Rupture of pericardium
< 24 h
Bronchopleural fistula carac.
Sudden onset of dyspnea
Subcutaneous emphysema
Contralateral deviation of trachea
Decrease fluid levels
Increase risk for thoracic surgery if
FEV1 (ppo) < 40. high < 30
DLCO < 40
O2 consumption < 15 ml/kg/min. < 10 very high
Double lung tube sizes
female < 160 35
>160 37
Male < 170 39
> 170 41
Absolute C.I lung transplant
Malignancy < 2y
Chronic d. HB…
Spinal chest deformity
Non adherence
Substance addiction
Psychotic disorder
Toxicity of chemo
Cisplatin Renal
Bleomycin Lung
Doxorubicin Cardiac
Massive hemoptysis if blood loss
> 200 ml
Complication in thoracic surgery
15 - 20% resp
10 - 15 cardiac
4 death
Pulmonary Hypertension carac
Avoid hypotensive drugs
Ketamine ok (doesn’t exacerbate)
Ephedrine, Vaso, phenilep, OK
Use inhaled vasodilators
Thoracic epidural with caution
DLCO FEV1 and chemo
Chemo affects DLCO, no FEV1
Lower limit in FEV1 or DLCO for surgery
Patient with < 20 not candidate
HyperK and HyperNa, cancer
Squamous CC
Perioperative risk in thoracic surgery by test
< 15 l/kg/min high risk , 10 very high
6MWT 450 = 15
Shuttle WT 250 = 10
Increase risk if SPO2 in exercise spirometry increase more than 4%
Extubation criteria after thoracic surgery
FEV1 > 40%
FEV1 > 30% and exercise tolerance good (6MWT > 450m)
FEV1 > 20 in VATS and good tolerance
Incidence of heart ischemia after thoracic surgery and when
5%
POD 2-3
Treatment to prevent Afib
Diltiazem
Patient with pulmonary hypertension. What drugs to avoid
Dobutamine and milrinone, decrease SVR and increase HR
Age, preoperative assesment and thoracic surgery
If more than 70 Echo
If normal surgery (and no DM, CHF o IHD)
If no normal Dobutamine stress echo. If no normal also angiography
COPD staging
1 >50% FEV1
2. 35-50
3. <35%
Lung cancers
Most common complications during thoracic surgery
- Hypoxemia
- Sudden severe hypoT
- Changes in ventilation
- Arrithmias
Single and DL tubes relationship
7.0 - 28
8.0 - 35
9.0 - 37
10 - 41
Position of DL tube
Heightx10 +12
Indication for Right DL tube
Airway bronchoscope view
Left. LLL + LUL (2 branches after)
Right. RUL 3 branches + RML + RLL
Minimal length of exchange cathether
83 cm
French for exchange cathether
35-37 11
39-41 14
Maximum depth exchange catheter
24 cm
Segments in the lungs
RUL 3
RML 2
RLL 5
LUL 4
LLL 4
Dependent vs non dependent lung
Dependent ventilated. Down
Most common injury in legs in side surgery
Dependent peroneal nerve
Non dependent (up) sciatic nerve
