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adv princip II exam 2 (6/13) > anesthesia for selec. proced. 3/3 > Flashcards

anesthesia for selec. proced. 3/3 Flashcards

0
Q

How do you do lung separation on a patient with a difficult airway?

A
  1. awake intubation with FOB (fiber optic bronchoscope) to place DLT, univent or standard ETT
  2. then tube exchanger PLUS direct laryngoscopy
  3. or fogarty embolectomy catheter as a bronchial blocker
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1
Q

what do you do for OLV if the patient has a trach?

A

DLTs are not designed for stomas, try a bronchial blocker passed thru or alongside a conventional or wire reinforced (anode)ETT

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2
Q

what is the rule of thumb for airways post procedure (especially when having to change over a DLT for a standard single ETT)?

A

the airway can alsways change (d/t fluid overload, swelling, facial edema, secretions or laryngeal trauma (from first attempted intubation).

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3
Q
  1. why is a single lumen ETT sometimes used as an effective bridge?
  2. what must you ensure before you attempt the exchange?
A

because the DLT is very stiff, so if you can place a normal ETT, you can exchange it for a DLT with a FOB (or tube exchanger).
2. test to make sure the DLT can pass over the exchanger (and that the surgeon is ok with using an exchanger (boogie is sometimes too big- a cook is usually the right size).

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4
Q

–why are bronchial blockers not to be used for conditions such as pulmonary alveolar proteinosis treatment (unilateral bronchopulmonary lavage) ?
in other words, what are the drawbacks of bronchial blockers?

A
  1. because blockage may not be optimal
  2. can easily dislodge
  3. harder to place properly
  4. unable to suction distall
  5. high pressure/ low volume cuff (greater chance of bronchial damage/ ischemia).
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5
Q

what can you use to place a DLT in a difficult airway?

A

glidescope

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6
Q

can you use a bronchial blocker with a VATS?

A

absolutely NOT!

VATS is an absolute indication because you need a quiet and deflated lung (DLT is necessary).

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7
Q
  1. what lung procedures would you want to leave a patient intubated post surgery?
  2. why?
  3. what can be done if you cannot exchange the tube (for a single ETT) and thus have to leave the patient intubated on a DLT?
A

1a. complex lung resections
- -b. thoracoabdominal esophagectomy
- -c. thoracic aortic aneurysmectomy
- -d. extensive vertebral tumor resection
2. d/t facial edema, secretions and hemoptysis
3. may have to send patient to AICU with a DLT (with the 2 part “Y” piece, extra long suction catheters and instructions and alot of reassurance).

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8
Q
  1. what can you do with a DLT to make it a single ETT?
  2. what is a major drawback?
  3. if you have to replace the DLT, how could it be done?
A

pull it back until the bronchial lumen is above the carina. You can use the bronchial lumen as a single ETT.

  1. it will be hanging out ALOT!!! it can be confusing for staff that is unfamiliar.
  2. If you replace a DLT with a single ETT, do it under direct visualization (glide or DLT).
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9
Q

for a bronchoscopy; what is it vital that you do pre-op?

A

a THOROUGH PATIENT EVALUATION (this procedure can go bad quickly and turn into a thoracotomy or sternotomy)

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10
Q

bronchoscopy:

what type of monitors?

A
  • ecg
  • nibp
  • procordial
  • spo2
  • art line, central line or swan (as needed for patient history/condition)
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11
Q

what should all lung procedures get pre op or at induction?

A

drying agent (robinol)

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12
Q
  1. what are common local anesthetics for bronchoscopy?

2. name some methods by which they are administered:

A
  1. lidocaine, tetracaine
  2. nebulizer
    - viscous lido gargle
    - pledgets in piriform fossa bilat
    - trans tracheal block
    - spray vocal cords under DL
    - precutaneous block of superior laryngeal or glossopharyngeal (mouth)
    - cocaine and neo to nose (nasal intubation)
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13
Q
  1. what must you consider with all local anesthetics?
  2. what must you monitor for with any local to throat?
  3. what should one of the post op orders be?
A
  1. calculate total dose and toxic dose
  2. all of these blocks depress airway protective reflexes (high risk for aspiration post op)
  3. NPO for several hours post op
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14
Q

GENERAL VS. LOCAL

  1. which is better?
  2. advantages of local & general
  3. disadvantages of local & general
A
  1. they are often used in combination
  2. advantages of local: patient is breathing spontaneously, awake, coopertive
    - –advantages of general: controlled ventilation
  3. disadvantages of local: dont tolerate bleeding, sometimes uncoopertive
    - –disadvantages of general: could have exagerated response to NDMR (myasthenic syndrome, eaton lambert)
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15
Q

rigid bronchoscope:

what are 4 way that you get oxygen to the patient?

A
  1. apneic oxygenation
  2. apnea with intermittened ventilation
  3. sanders injection system
  4. mechanical ventilation
  5. HFPPV
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16
Q

apneic oxygenation

  1. how is it accomplished?
  2. what are the disadvantages?
A
  1. apneic oxygenation (you can supply oxygen at 10-15 L/min for up to 30 min without incident)
  2. disadvantages: ACTUALLY should be limited to 5 min d/t arrhythmias and respiratory acidosis from CO2 accumulation
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17
Q
  1. what is apnea with intermittened ventilation?

2. what are disadvantages of this?

A
  1. apnea with intermittened ventilation (once eye piece is closed and surgeon is not exploring) you can ventilate the patient
  2. poor ABG with resp acidosis (if prolonged)
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18
Q

rigid bronchoscopy:

  1. what is the sanders injection system?
  2. what are advantages?
  3. what are the disadvantages?
A
  1. jet ventilation (high pressure oxygen thru a 16-18 g sidearm). creates a “venturi” effect as high pressure oxygen pulls air in with it.
  2. advantages: can add some anesthetic gas in some systems; no barotrauma if proximal end of bronchoscope is left open and fit is loose in trachea
  3. disadvantages: adequacy of ventilation may be poor (and is hard to assess- have to watch chest rise); inspired oxygen concentration is variable; if tight fit, air cannot escape- causes excess peep)
19
Q

rigid bronch:

1. how is mechanical ventilation accomplished?

A

regular PPV with circuit attached to sidearm

20
Q

rigid bronch

HFPPV

A

advantage is that tracheal wall remains motionless

21
Q

what are 7 potential complications of the RIGID bronchoscopy?

A
  1. damage to teeth
  2. hemorrhage
  3. bronchospasm
  4. loss of sponges
  5. perforation of trachea or bronchus
  6. subglottic edema
  7. barotrauma
22
Q

what are 7 potential complications of a FIBEROPTIC bronchoscopy?

A
  1. local anesthesia overdose
  2. insertion trauma
  3. hemorrhage
  4. upper airway obstruction
  5. hypoxia
  6. bronchospasm
23
Q

why do fiberoptic bronch patients need oxygen post op

A

procedure causes hypoxemia with an average decrease in paO2 of 20 mmhg which lasts 1-4 hours post op

24
Q

what size ETT should you use with fiberoptic bronch?

A

largest diameter possible

25
Q

how do you prevent airway obstruction in fiberoptic bronchoscopy?

A

atropine helps

26
Q

3 things that should be done regarding suctioning and post bronch care:

A
  • keep suction brief
  • post procedure chest x ray (rule out pneumo, mediastinal emphysema)
  • patient may need to be intubated post op (if not already) so they can be emerged slowly, suctioned and monitored
27
Q

MEDIASTINOSCOPY:

  1. what is a mediastinoscopy for?
  2. what can a mediastinal mass cause in a patient?
  3. what is the anesthesia and other issues for this procedure?
A
  1. a blunt steel rod/camera is inserted to assess for spread of bronchial carcinoma
  2. obstruction of vena cava, aorta, major airways (which may only become apparent on induction or with position change-can be fatal)
  3. head gets cranked way over, must be paralyzed
28
Q

contraindications for mediastinoscopy

  1. absolute:
  2. relative:
A
  1. absolute contraindications: “one and done”- prior mediastonoscopy means you cannot have another d/t scar tissue
  2. relative contraindications: superior vena cava obstruction, aortic arch aneurysm, tracheal deviation
29
Q

mediastinoscopy:

  1. what specific monitor set up must be present?
  2. what is the most common MAJOR complication?
  3. what must be available?
  4. what are 2nd and 3rd most common complications?
  5. what is another big concern (regarding a vessel and it can lead to what?)
A
  1. arterial line on right and pulse ox on left (monitors blockage of inominate artery vs. cardiac arrest)
  2. bleeding is #1 complication 0.73% (1.5-3% morbidity)
  3. blood MUST be available
  4. pneumo (0.66%); recurrent laryngeal nerve injury (0.34%),
  5. inominate artery compression (can also lead to stroke)
30
Q

what is treatment for bleeding during mediastinoscopy?

A
  1. immediate thoracotomy

2. place large bore iv in lower limb (if SVC syndrome)

31
Q

what are other complcations of mediastinoscopy?

A
  1. acute tracheal collapse
  2. reflex bradycardia (d/t aortic compression)
  3. arrhythmias
  4. hyovolemia
  5. tension ptx or pneumomediastinum
  6. hemothorax or chylothorax (if left side)
32
Q

thoracoscopy

  1. what is it?
  2. used to diagnose what?
  3. used to treat what?
A
  1. insertion of endoscope into thoracic cavity into interpleural space
  2. used to diagnose pleural disease, effusions, infection, staging procedures, pleurodesis and lung biopsy
  3. used to treat spontaneous ptx , treat bullous emphysema, vaporize malignant pleural tumors
33
Q

VATS:

  1. what is it used for?
  2. why is OLV so important with vats?
  3. when should up lung be deflated with vats? why?
  4. what is a good treatment for hypoxemia; when should it be used?
A
  1. diagnose and treat lung carcinomas, pleurodesis, decortication and drainage of empyema, lung resection, pericardial window, esophageal procedures
  2. lung separation is mandatory, lung must be deflated via DLT with vats as opposed to an open thoracotomy where the doctor can manually deflate the lung
  3. as soon as DLT is placed, may take 30 min for lung to deflate
  4. cpap is the best treatment for hypoxemia, but it interferes with lung visualization so it is the last resort (peep to down lung is not as good but is the most frequently used)
34
Q
  1. what are advantages of VATS vs. open thoracotomy?

2. what are disadventages of vats?

A
  1. less pain
    - –beter preserved respiratory function
    - – faster recovery
  2. same incidence of dysrhythmias
    - – if it turns to an open thoracotomy (or lobectomy or pneumonectony d/t positive bx), you dont have an epidural
35
Q

what is the rate and rise of CO2 in an anesthetized patient?

A 
6 mmHg (torr) in first minute
3 mmHg (torr) for each subsequent minute
36
Q

what are complications of VATS?

A
  • dysrhythias
  • bleeding
  • pulmonary edema
  • pneumonia
37
Q

bronchopleural fistula

  1. what is it?
  2. what is the anesthesia priority
  3. what is the most feared consequence? what vent mode will cause this?
  4. what is the best anesthetic management (intubation and ventilation)
A
  1. an abnormal connection between conducting airways and pleural cavity
  2. priority is isolate affected side
  3. tension pneumothorax (especially with positive pressure ventilation)
  4. awake endo tracheal intubation (ETI) with spontaneous ventilation (no PPV) or DLT with bronchial lumen to unaffected side
38
Q

tracheal resection

  1. what is it done for?
  2. what are major potential problems?
  3. what are surgical implications (specific monitors, medications, positioning)?
A
  1. agenesis, stenosis, neoplasm, injury, infection, post intubation injuries
  2. maintaining ventilation during surgery, post op integrity of anastamosis, inominate artey compression
  3. arterial line in right radial, steroids, high fio2, patient positioned in HEAD DOWN position
39
Q

bronchopulmonary lavage

  1. what is it done for?
  2. what type of anesthesia (what test should be done)?
  3. how is patient positioned
  4. major side effect:
A
  1. irrigation of lung in alveolar proteinosis, radioactive dust inhalation, cystic fibrosis, bronchiectasis, asthmatic bronchitis
  2. general anesthesia with DLT (with water leak test to ensure perfect lung separation)
  3. lavaged lung down with HEAD UP
  4. Spillage of lavage into non-affected lung
40
Q

BRONCHOPULMONARY LAVAGE:

what is treatment for spillage of lavage fluid into good lung?

A

STOP LAVAGE and re-ensure proper lung separation

41
Q

MG (myasthenia gravis)

  1. what is the cause? how is it diagnosed?
  2. what gender is it most common in? at what stage of life?
  3. presentation
  4. caution in what meds (just dont use)
  5. how is it cured?
A
  1. decreased number of ACH receptors d/t autoimmune destruction; (usually d/t thymus gland)-
    - -diagnosed by tensilon test:
  2. more common in females usually in 30s (50s for men)
  3. occular issues (ptosis, disconjugate) are first symptoms
    - -bulbar muscles (causes dyspnea and dysphagia)
    - -peripheral (weakness, clumsiness, difficulty walking, holding up head)
  4. NO NONDEPOLARIZERS-very sensitive (nimbex is best, use sux if you MUST HAVE some muscle relaxation and dont have nimbex)
  5. thymectomy is 75% curitive (performed while in remission)
42
Q
  1. how is a tensilon test done?

2. how can you tell difference between cholinergic crisis and myasthenia gravis?

A
  1. A test to diagnose MG vs Cholinergic crisis:
    - -Patient is given between 2 -10 mg dose of edrophonium (d/t its quick onset and short duration -up to 10 minutes)
  2. if patient gets stronger and pupils become less dilated (mydriatic); it is myasthenic crisis; start on anticholinesterase drugs or increase doses
    - -if patient gets weaker with increased cholinergic symptoms (ex. constricted or miotic pupils); it is cholinergic crisis
43
Q

thymectomy for MG

  1. which case of the day?
  2. pre op meds?
  3. what should you tell the patient is a potential post op scenario?
  4. what should you use for relaxation? pain?
  5. what meds should be avoided?
  6. if you must use muscle relaxation, which ones are the best? why?
  7. is a defasiculating dose of NDMR ok if using sux? if you use NDMR, what dose should you use?
A
  1. first case of the day
  2. home meds (mesthenon) usually held- so patient will be weak
  3. may be on vent post op d/t weakness
  4. induction meds and gas should be enough relaxation (d/t pre-existing weakness);
    - nimbex is best, or sux if you need to for cord relaxation.
    - avoid opiates (if possible or reduce dose)d/t already high risk of resp depression
  5. avoid NDMRs and mivacron;
    - avoid reversal if possible (just dont use NDMRs and you wont need reversal;
  6. nimbex is hoffman elimination and sux is plasmacholinesterase)
  7. even a defasciculating dose of NDMR is bad (it is equal to a full dose in a normal person)
    - if you must use NDMR, decrease dose by 80–90%
44
Q

sux in a MG patient:

  1. how are they affected (sensitive or resistant)?
  2. what is the ED 95 for sux in a MG patient compared to normal?
  3. what are the clinical effects seen (in general)
A
  1. more resistant to sux
  2. ED95 is 2.6 x higher than normal
  3. clinically, effects and duration are the same as in normal patients

adv princip II exam 2 (6/13) (5 decks)

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