7 - Green

Question 1

How do you prevent peri-operative atelectasis & pneumonia

Answer 1

PFTs pre-op on anyone with significant lung disease
Optimize pre-op meds and puffers
Quit smoking
Aggressive post-op pulmonary toilet - incentive spirometer and chest physio

Question 2

How do you treat peri-operative atelectasis & pneumonia

Answer 2

Incentive spirometry
Chest physio
O2
Culture-guided abx
PPV pen (biPAP/intubation)

Question 3

What are the risk factors for peri-op aspiration?

Answer 3

Induction of anesthesia/intubation
Post-op sedation
NGT
Altered swallowing mechanics

Question 4

What is the treatment for peri-operative aspiration?

Answer 4

Aggressive initial suction (+/- bronchoscopy) immediately post-aspiration
Supportive care
Abx only required if positive culture

Question 5

How do you prevent peri-operative aspiration

Answer 5

Proper intubation technique with cricoid pressure
NPO pre-op
Pre-op maxeran and ranitidine
Early removal of NGT
Avoid over-sedation
Ad-lib swallowing assessment before restarting PO intake

Question 6

What is an acute lung injury

Answer 6

PaO2/FiO2 <300
Normal manifestations of immune response to a wide variety of disease states
Found in most patients under surgical stress

Question 7

What is the definition of ARDS

Answer 7

Acute change in lung function
Bilateral infiltrates on CXR
PCWP <20 mmHg + no evidence of CHF
PaO2/FiO2 <200

Question 8

What are ventilator strategies in ALI/ARDS

Answer 8

Tidal volume 6-8ml/kg
Peak plateau pressure <35 cm water
Allow permissive hypercapnia
Adjust level of PEEP to inflection point

Question 9

What are the indications for intubation

Answer 9

Clinical :
Shortened speech 
Use of accessory muscles 
Subjective air hunger 
Change in mental status 

Lab:
PaO2/FiO2 <250 
PaCO2 >50
PH <7.25
RR >35 
Ve >12 L/min
Vc <15 ml/kg
NIF <25 cm H20
AaDo2 >35

Question 10

What are big risks for post-op ventilation

Answer 10

FEV1 <1 L

Vc <35%

Question 11

What parameters are predictive of a successful extubation

Answer 11

Negative inspired pressure >25 cm H20
Tidal volume >5-7 ml/kg
RR <20
RR/tidal volume <100 (so called rapid shallow index)
Vital capacity >10 -15 mL/kg
Ve 6-8 L/min
PEEP 5cm H20 or less
PSV 5-8 cm H20 or less
GCS 14 or less
Hemodynamically stable + breathing comfortably
Absence of excessive secretions requiring suction more often than q4h

Question 12

What is the management of chylothorax

Answer 12

TPN or medium chain TGs
Drainage of pleural space by thoracentesis or chest tube
If persists 3-4 days -> talk pleurodesis may be tried
If medical management fails after 2-4 weeks -> legate duct at injury site

Question 13

What are complications of a chylothorax

Answer 13

Nutritional
Hypovolemia
Hyponatremia
Decreased immune status