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Advanced Clinical Nursing Theory > Anaesthesia for Thoracic Surgery > Flashcards

Anaesthesia for Thoracic Surgery Flashcards

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1
Q

what is the main anaesthetic consideration when opening the thorax?

A

ventilation

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2
Q

why is ventilation a concern when opening the thorax?

A

opening the thorax removes negative pressure in the pleural space

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3
Q

what is the impact of the removal of negative pressure through opening the thorax?

A

when the chest wall expands on inhalation there is little or no air entry into the lungs as the pressure in the lungs is the same as atmospheric pressure
ventilation is inadequate and gas exchange impaired

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4
Q

what is needed during thoracic surgery to ensure adequate ventilation?

A

manual or automatic IPPV throughout surgery

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5
Q

what is caused by opening the thoracic cavity?

A

atelectasis

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6
Q

what is decreased by atelectasis?

A

total lung capacity
vital capacity
functional residual capacity

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7
Q

what is commonly seen during thoracic surgery even with IPPV?

A

atelectasis

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8
Q

what can worsen atelectasis during thoracic surgery?

A

packing off lung lobes
manipulation of blood vessels altering supply
leak testing
pathology patient was admitted with

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9
Q

what is functional residual lung capacity?

A

gas left in the lungs after expiration

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10
Q

what is the role of functional residual capacity?

A

reserve gas exchange occurs between breaths

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11
Q

which surgical approach to the thorax is more painful?

A

sternotomy - more retraction required and more muscle damage than thoracotomy

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12
Q

what thoracic surgical approach is least painful?

A

thoracoscopy

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13
Q

what must be considered when patients are undergoing thoracoscopy?

A

large volume of CO2 insufflation
lungs can become compressed

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14
Q

when may ventilation be required from the start of abdominal surgery?

A

diaphragmatic hernia repair

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15
Q

why is thoracotomy so painful?

A

skin incision
nerve damage
retraction of ribs to allow access leading to muscle damage
inflammation at surgical site

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16
Q

what can be caused by poor analgesia during thoracic surgery?

A

hyperalgesia

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17
Q

what is the impact on patient ventilation following thoracic surgery?

A

ventilation less effective as lung inflation is compromised due to pain making patient unwilling to move their chest

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18
Q

what are the main reasons for thoracic surgery?

A

respiratory system
cardiovascular
oesophageal FB
thoracic duct ligation

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19
Q

what are the main respiratory system reasons for opening the thorax?

A

lung lobe torsion
bulla
neoplasia
abscess

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20
Q

what are the main considerations for thoracic surgery involving the respiratory system?

A

pre existing pneumothorax
hypoventilation
hypoxaemia
pre-disposed to decompensation
pathology already compromising respiration

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21
Q

what are the main cardiovascular system reasons for opening the thorax?

A

patent ductus arteriosus
persistent right aortic arch
pericardectomy
heart surgery

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22
Q

what are the main considerations for thoracic surgery involving the cardiovascular system?

A

CVS changes due to primary lesion or surgical manipulation
bleeding
hypotension
risk of arrhythmias

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23
Q

what are the main considerations for persistent right aortic arch?

A

paediatric
present with regurgitation
risk of aspiration
may be malnourished

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24
Q

what should you be aware of during PDA closure?

A

may be significant changes
bradycardia and hypertension

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25
Q

what are the main considerations for opening the thorax for non-respiratory/CVS reasons?

A

contamination risk
infection
pain
risk of aspiration
risk of regurgitation
sepsis

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26
Q

what is vital for thoracic surgery?

A

preparation

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27
Q

what is involved in preparation for thoracic surgery?

A

blood type
check blood availability
hypotension treatment plan (drugs/fluids)
pre oxygenation
check ventilator or IPPV facilities
ensure monitoring equipment ready
analgesia plan

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28
Q

what must happen before thoracic surgery?

A

patient is as stable as possible

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29
Q

how may patients be stabilised for thoracic surgery?

A

chest drainage
pre-oxygenation
fluids

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30
Q

what must be considered about pre-oxygenation?

A

must not cause further stress as may worsen respiratory function
method should be best available for patient

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31
Q

what is the aim with all anaesthetic drugs for thoracic surgery?

A

minimal CVS depression
analgesia

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32
Q

what drug type might be avoided in thoracic surgery patients?

A

alpha-2 agonists
ACP

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33
Q

what drugs may likely be needed during thoracic surgery?

A

inotropes (e.g. noradrenaline)
additional analgesia infusions (e.g. fentanyl)

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34
Q

what is etomidate used for?

A

induction
CRI

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35
Q

is etomidate licensed for animals in the UK?

A

no

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36
Q

what type of drug is etomidate?

A

IV
ultra short acting
nonbarbituate

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37
Q

what are the advantages of etomidate?

A

minimal CVS depression

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38
Q

what are the disadvantages of etomidate?

A

poor quality of induction unless premed is very good or the animal is very sick

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39
Q

what is the main benefit of fentanyl during anaesthesia?

A

MAC sparing

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40
Q

what is the benefit of giving MAC sparing drugs such as fentanyl during anaesthesia?

A

reduce CVS/respiratory system depression seen with volatile anaesthetic agents as the level can be reduced

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41
Q

what is the speed of onset of action of fentanyl?

A

within 5 minutes

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42
Q

what is the duration of analgesic effect of fentanyl?

A

20 minutes (lowest dose) to 40 minutes (highest dose)

43
Q

what is the benefit of one lung ventilation?

A

isolation of one lung for ventilation if pathology only affects one
increases surgical exposure

44
Q

what are the options available for one lung ventilation?

A

single lumen ET tube advanced into one bronchus
double lumen tube
endobronchial blocker

45
Q

what is the main disadvantage of one lung ventilation?

A

placement difficult
must be very careful moving patients with endobronchial or double lumen tubes placed as trauma is possible

46
Q

what is the benefit of a single lumen ET tube advanced into one bronchus for one lung ventilation?

A

easy (er)

47
Q

what is the disadvantage of a single lumen ET tube advanced into one bronchus for one lung ventilation?

A

may not achieve effective one lung ventilation
risk of contamination between lungs
difficult in large dogs (>20kg) due to tube length

48
Q

what is the benefit of endobronchial blockers for one lung ventilation?

A

effective

49
Q

what is the disadvantage of endobronchial blockers for one lung ventilation?

A

bronchoscope required to place
needs skill and training to place
expensive

50
Q

what is the benefit of double lumen tubes for one lung ventilation?

A

can be done blind

51
Q

what is the benefit of double lumen tubes for one lung ventilation?

A

can be placed blind

52
Q

what is the disadvantage of double lumen tubes for one lung ventilation?

A

bulky and difficult to place
not achievable in dogs >20-25kg due to tube length

53
Q

how is an endobronchial blocker placed?

A

advanced through single lumen ET tube

54
Q

what must be followed when using endobronchial blockers?

A

stated inflation volumes for the cuff to prevent bronchial wall damage

55
Q

when should an endobronchial cuff be inflated?

A

only when one lung ventilation is needed

56
Q

what should be avoided once an endobronchial blocker is placed?

A

movement of patient as this can cause the blocker to dislodge

57
Q

what must be avoided once an endobronchial blocker is placed and the cuff inflated?

A

movement of the patient due to the risk of bronchial wall damage

58
Q

why is the size of the patient for double lumen tubes limited?

A

size of human tubes

59
Q

what is the best ventilation option for thoracic anaesthesia?

A

mechanical
make do with manual if necessary

60
Q

what is the ventilator setting range for tidal volume?

A

10-15ml/kg
(maybe 8-10ml/kg for cats)

61
Q

what is the ventilator setting range for tidal volume during thoracic surgery to aid visualisation?

A

6ml/kg

62
Q

how can you judge tidal volume settings are correct?

A

observe thorax
adapt to monitoring

63
Q

what is the ventilator setting range for Peak inspiratory pressure?

A

8-12 cm H2O

64
Q

when may PIP settings be altered?

A

if open or closed thorax
increase if recruitment

65
Q

what is the ventilator setting range for respiratory rate?

A

10-30 bpm

66
Q

when may respiratory rate settings be altered during ventilation?

A

adapt to animal
increase if tidal volume reduced

67
Q

what is the ventilator setting range for I:E ratio?

A

1:2 max

68
Q

what should I:E ratio be adapted to?

A

RR

69
Q

does IPPV require NMBA?

A

not necessary in most cases

70
Q

what are the main issues associated with ventilation?

A

CVS depression
trauma
re-expansion pulmonary oedema

71
Q

why can ventilation lead to CVS depression?

A

decreased venous return

72
Q

how can the CVS depressive effects of ventilation be reduced?

A

limit I:E ratio to at least 1:2

73
Q

how can the risk of trauma during ventilation be reduced?

A

limit pressure/volume applied to the chest

74
Q

how can re-expansion pulmonary of ventilation be reduced?

A

be careful not to over expan lungs at the end of surgery - allow them to reopen over time

75
Q

what monitoring techniques will be used for anaesthesia for thoracic surgery?

A

blood gas
capnography
oxygen monitoring
as well as standard

76
Q

what must you be aware of when using capnography with an open thorax?

A

EtCO2 unlikely to reflect PaCO2

77
Q

why are there differences between EtCO2 and PaCO2 in animals with an open thorax?

A

altered ventilation and perfusion relationships in different areas of the lungs

78
Q

how can PaCO2 be used to inform EtCO2 in patients with an open thorax?

A

PaCO2 reading obtained from art line
calculate difference between PaCO2 and EtCO2
use this to inform required EtCO2 level to keep PaCO2 between 35-45mmHg

79
Q

how should oxygen levels be monitored during thoracic surgery?

A

SpO2 as a minimum
PaO2 if possible

80
Q

how is hypoxaemia detected during surgery?

A

PaO2 via art line

81
Q

how can hypoxaemia be managed?

A

check patient on 100% FiO2
check ET tube patency
ensure CVS function optimised

82
Q

how can you alter ventilation to manage hypoxaemia?

A

switch to manual IPPV and give larger breaths
alveolar recruitment manoeuvre
introduce PEEP
reduce Fi inhaled agent
re-expand collapsed lung - communicate with surgeon

83
Q

what may affect ET tube patency during thoracic surgery?

A

endobronchial blocker may have become dislodged and blocked the ET tube lumen
secretions may block tube lumen

84
Q

how can you ensure CVS function is optimised during thoracic surgery?

A

ensure anaesthetic depth is appropriate
ensure circulating blood volume is adequate (IVFT?)
confirm surgeon isn’t decreasing venous return

85
Q

what is the alveolar recruitment manoeuvre?

A

temporary airway pressure is increased during mechanical ventilation so as to open up the collapsed alveoli

86
Q

what pressure is needed for a alveolar recruitment manoeuvre?

A

30 cmH2O airway pressure for a breath

87
Q

what are the main supportive therapies used for thoracic surgery patients?

A

IVFT
hypothermia management

88
Q

what analgesia is needed for a thoracic surgery patient?

A

combination of local and systemic techniques

89
Q

what drug types may be used for analgesia following thoracic surgery?

A

full mu agonists
LA
NSAIDs

90
Q

what full mu agonists may be used for thoracic surgery?

A

methadone
fentanyl
morphine epidural

91
Q

what local anaesthetic techniques may be used for thoracic surgery?

A

intercostal nerve block (lateral thoracotomy)
LA down chest drain at end of surgery
LA infiltration around sternotomy site

92
Q

why must NSAIDs be used with caution post-op?

A

if patient has had unstable BP throughout NSAIDs should not be given due to prostaglandin effects

93
Q

when should the end of IPPV be timed with during thoracic surgery?

A

chest closure and drainage as won’t be able to breathe spontaneously before this

94
Q

describe the process of weaning from the ventilator

A

turn off ventilator
support respiration with IPPV
gradually decrease IPPV to allow PaCO2 to rise
decrease anaesthetic and analgesic drugs
reverse NMBA, if used, before stopping IPPV completely
continue until breathing spontaneously

95
Q

what techniques can be used to aid pulmonary re-expansion?

A

alveolar recruitment manoeuvre

96
Q

when is an alveolar recruitment manoeuvre useful?

A

following lavage atelactasis

97
Q

when is the risk of re-expansion pulmonary oedema higher?

A

if lungs collapsed for more than 12 hours

98
Q

what is a vital part of the recovery process from thoracic surgery?

A

weaning patient on to room air
oxygen supplementation if needed
IVFT

99
Q

what monitoring is needed for patients in recovery from thoracic surgery?

A

pulse ox
assess chest drain for air, blood or fluid

100
Q

what should be done if the patient isn’t saturating adequately in recovery?

A

assess chest drain for air, blood or fluid
supplement O2

101
Q

when can oxygen toxicity occur?

A

> 6 hours on high FiO2

102
Q

when may a blood transfusion be necessary?

A

if >20% blood loss - check PCV

103
Q

how can you check if a patient is actively bleeding from a chest drain?

A

PCV of fluid from chest drain

104
Q

what are the key factors involved in anaesthesia for thoracic surgery?

A

IPPV**
pain management
basic support (temp, fluids)
good anaesthesia protocol: MAC sparing and good analgesia

Advanced Clinical Nursing Theory (36 decks)

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