Anesth. for Thoracic Surgery Flashcards
Wiggly-arm's powerpoint on thoracic surgery. Pretty much all the crap on the slides.
6 disease states that would require thoracic surgery?
- lung tumors
- esophageal disease
- mediastinal tumors
- infection
- bronchiectasis
- thoracic aneurysms
Name 2 endoscopy procedures and 2 mediastinal procedures.
Endoscopy:
- bronchoscopy
- esophagoscopy
Mediastinal:
- mediastinoscopy
- thymectomy
Should you put in an A-line for all major thoracic surgeries?
yes, yes you should.
What type of anesthesia can be done for a bronchoscopy with a flexible scope? How about with a rigid scope?
MAC or GETA for flexible scope
GETA for a rigid scope
What are some complications that can occur from endoscopic procedures? (4, or so)
- facial, dental, laryngeal injury
- airway rupture, pneumothorax
- hemorrhage
- airway obstruction – blood, FB, edema
What are some things to consider when doing an endoscopic procedure? (7)
- Small ETT vs. Double-lumen tube
- Laser tube and laser precautions
- Short-acting hypnotic agent
- Inhaled agents vs TIVA
- Short-acting narcotics
- Short-acting muscle relaxant
- Local anesthesia – post-op
What are the two types of approaches for a mediastinoscopy?
cervical
anterior (Chamberlain procedure)
What are complications associated with mediastinoscopy procedures? (7)
- # 1 Rupture/laceration to major vessels
- # 2 Pneumo (Hemo)-thorax
- Intermittent occlusion of R innominate artery
- Tracheal collapse
- Tension pneumomediastinum
- Mediastinitis
- Chylothorax
Surgeries that require a median sternotomy? (3)
- Thymectomy
- Mediastinal masses
- Sternotomy for Bilateral Pulmonary Resection
Thymectomy is the treatment of choice for what?
myasthenia gravis
autoimmune disease that causes a decrease in the number of post-junctional ACh receptors
Should a myasthenia gravis patient hold their anticholinesterase medications on the day of surgery?
yes
What is different about the Eaton-Lambert Syndrome from traditional myasthenia gravis?
Easton-Lambert Syndrome is an autoimmune disorder that causes a pre-junctional decrease in ACH release. It does not affect the receptors.
In these patients, the symptoms will improve with exertion.
Things to consider prior to anesthesia for mediastinal masses. (5)
- Degree of functional impairment
- Orthopnea
- Supine & upright PFT’s
- Specific CT report/examination
- Close communication with surgeon
Things to consider for a dynamic airway obstruction. (3)
- Position/muscle tension dependent
- Fine with upright/spont vent, dead with supine & relaxed
- What if you can’t ventilate even with properly placed ETT? –> Rigid bronch emergently, position change, spont vent
Name a few open thorax procedures. (8 referenced in his slides)
- Lung Biopsy/Pleurodesis
- Lung Resection (W<p></p>
What are 4 indications for lung isolation?
- control of foreign material (lung abcess, hemoptysis, etc)
- airway control (bronchopleural-cutaneous [B-p] fistula)
- surgical exposure (lung resection, VATS, etc.)
- special procedures (lung lavage, differential ventilation)
Things to consider during the preop evaluation for lung isolation procedures. (5)
- Laboratory Tests
- Prescreen for underlying pulmonary infection,
- Tracheal stenosis (positional dyspnea, airway collapse, hypoxemia, anatomic narrowing)
- Review ABG, PFT, CXR, V/Q Scan, CT/MRI (lesion and trachea), angiography
- Coexisting pathology
If a patient is having a lung procedure done and their Hct is < 25%, should they be transfused?
yes, because adequate oxygen carrying capacity is essential.
also, type and cross for 2-4 units of PRBC
Lung cancer patients could potentially have myasthenic syndrome, which means they could have an increased sensitivity to what type of drugs?
nondepolarizing muscle relaxants
GETA with or without a thoracic epidural can be used for lung surgeries. Epidural analgesia reduces VAA requirements, but the epidural anesthesia may create ________ _________ and __________ .
sympathetic blockade
hypotension
What are 3 complications in open thoracic surgery?
- pneumothorax (from opening the chest)
- interference with ventilatory exchange and CV stability d/t manipulation of lung, heart, and major vessels
- alteration of the distribution of blood flow to the lungs d/t lateral decubitus position, exposing the lower lung to danger of contamination by secretions, blood, or fluids
What are 7 risks to open thorax surgery?
- Dysrhythmias #1!!
- DVT/PE/AMI
- Bronchopleural fistula
- Chylothorax
- Subcutaneous emphysema
- Phrenic nerve injury***
- Recurrent laryngeal nerve injury
What is pleurodesis?
Pleurodesis is a procedure used to cause the layers of the lung lining (the pleura) to stick together. A chemical or medication is inserted into the space between the 2 layers of the pleura, causing inflammation that effectively glues the layers together.
What is decortication?
Decortication is a surgical procedure that removes a restrictive layer of fibrous tissue overlying the lung, chest wall, and diaphragm. The aim of decortication is to remove this layer and allow the lung to reexpand. When the peel is removed, compliance in the chest wall returns, the lung is able to expand and deflate, and patient symptoms improve rapidly.
During a lung resection, you want to give the patient as little fluid as possible, preferably less than 1L. Why?
so you don’t fluid overload the right heart and the vascular beds, and to prevent edema.
What two things are air filled, thin walled, bronchogenic or alveolar destructive, and post infective?
lung cysts and bullae
With lung cysts and bullae, you have an increased ventilatory volume with a decreased _________ _______ _____ .
respiratory diffusion area
Can positive pressure ventilation rupture a lung cyst or bullae?
yes.
you want to keep the pressure below 10 cm H2O (a double lumen tube may be helpful to isolate the affected lung)
you also don’t want them coughing on emergence
Should you use N2O with lung cysts and bullae?
NNNOOOOOO!!
Can you use a regular ETT in an emergency to isolate a lung?
yes, just advance it to the unaffected side if using a double lumen tube doesn’t work out.
use the fiberoptic to confirm placement.
Bronchopleural fistula: what is it, what are risks (2).
- abnormal communication between bronchial tree and pleural cavity
- risks: contamination and tension pneumo
Bronchopleural fistula and empyema: what is it; causes (4); risks (2)
- abnormal communication between bronchial tree and pleural cavity with pus
causes:
- pulmonary resection
- bronchus or bullae rupture
- penetrating chest wound
- lung cyst or empyema cavity
risks:
- positive pressure ventilation may contaminate healthy lung
- tension pneumo
Indications (3) and considerations (4) for esophageal surgery.
indications:
- resection of neoplasms
- anti-reflux procedures
- repair of traumatic or congenital lesions
considerations:
- chronic malnutrition r/t cancer illness, swallowing difficulties
- hypovolemia r/t difficulty swallowing
- alcoholism r/t esophageal lesions
- aspiration risk
Should you use a double lumen tube during esophageal surgery?
yes
the location of the lesion will determine which side they will enter from and one lung will need to be put down
What are indications (4) for tracheal resection/reconstruction? What are 3 things that should be done for management of these patients?
indications:
- congenital lesions (agenesis, stenosis)
- neoplasms
- injuries
- infections
management:
- steroids for tracheal edema
- 100% FiO2
- head down position to prevent drainage into lung
What does VATS stand for?
video assisted thoracoscopy
What surgeries can be done with VATS? (4)
- lung biopsy / wedge
- pleurodesis / decortication
- lobectomy, bi-lobectormy, pneumonectormy
- extrapleural (sympathetic denervation)
Complications to a VATS procedure? (3)
- hemorrhage
- access
- surgical times
(the rest of the complications are similar to open thoracotomy)
Indications (2) and considerations (4) for lung transplants.
indications:
- end stage respiratory failure
- cystic fibrosis
considerations:
- emergent procedure –> full stomach??
- antibiotics / immunosuppressants
- peripheral arteriovenous or venovenous bypass oxygenator
- full cardiopulmonary bypass??
5 things to check when positioning the patient in a lateral position.
- Secure tubes and lines, take command of turning procedures
- Proper padding and assessment of pressure points essential
- Head, neck, eyes neutral position
- Padding for axilla and lower extremities
- Reassess breath sounds, vital signs, monitors, arterial and PA lines, IV’s
Prior to an open thorax surgery, a bronchoscopy may be done. What size should the single lumen ETT be?
> 8 mm
the single will be replaced with a double lumen tube after the bronch
If a lumbar epidural was placed and you were going to use lidocaine for the dosing, how much would you use and how often would you redose?
lidocaine 10mL, redosing every 45 minutes
of course he didn’t put the concentration of the lidocaine on the ppt slide
After lung surgery, chest tubes are placed on water seal or 20 cm H2O suction. After a pneumonectomy the chest tube must be on water seal only. Why?
because the suction can potentially cause a displacement of the heart and major vessels.
Postop complications after lung surgery. (6)
- Airway trauma from intubation
- Tracheobronchial rupture
- Positioning injuries related to lateral pressure damage to ear, eye, nose, deltoid muscle, iliac crest
- Structural injuries related to thoracotomy: neurological, thoracic duct, spinal cord, bronchopleural fistula
- Surgical complications: cardiac herniation, tension pneumothorax, bleeding
- Cardiopulmonary complications: pneumonia, supraventricular dysrhythmias, PE
What are 3 cocktails used to bolus an epidural for thoracic surgeries?
- Fentanyl 100 mcg/10ml nss as Bolus
- Bupivacaine 0.1% + Fentanyl 0.001% as Bolus
- Bupivacaine 0.1% + Fentanyl 0.001% as continuous gtt rate 3-10 cc/hr.
(why he put the fentanyl as 0.001% instead of 0.01mg, or even 10mcg is beyond me…..)
Postoperative pain management for thoracic surgeries. (7)
- Neuraxial opioids - epidural or intrathecal
- Parenteral opioids
- Intercostal blocks
- Interpleural analgesia (bupivacaine intra pleural at time of closing)
- Epidural local anesthetics
- Cryoanalgesia (Nerves are frozen inta-op to destroy them)
- Transcutaneous nerve stimulation
