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Advanced Principles 2 > Anesthesia for Thoracic Surgery 1 > Flashcards

Anesthesia for Thoracic Surgery 1 Flashcards

1
Q

Challenges associated with thoracic surgery include:

A

physiologic derangements caused by lateral decubitus position
problem of an open pneumothorax
surgical manipulations interfering with pulmonary and heart function
risk of rapid, massive bleeding
necessity for one-lung ventilation

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2
Q

The lateral decubitus positioning provides

A

optimal surgical access for many thoracic procedures

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3
Q

The lateral decubitus positioning has the potential for

A

significant alteration in normal respiratory physiology

disrupts ventilation/perfusion relationships

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4
Q

Complications with lateral decubitus positioning includes:

A

brachial plexus & peroneal nerve injury
monocular blindness–> minimize pressure on dependent eye
outer ear ischemia–> flat or in donut
axillary artery compression

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5
Q

Pulmonary & CV complications with lateral decubitus positioning includes:

A

coughing, tachycardia, hypertension during turn to lateral decubitus position
hypotension from blood pooling in dependent portions
V/Q mismatching= hypoxemia
interstitial pulmonary edema of dependent lung

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6
Q

When the table is flexed,

A

ensure position of tube hasn’t moved because if it is tight, it can be pulled out

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7
Q

Describe ventilation and perfusion in the awake patient who is upright, has spontaneous respirations & a closed chest:

A

apex of lungs are maximally dilated
most ventilation occurs at the base of the lungs
perfusion also favors the base of the lungs
V/Q matching is preserved during spontaneous respirations
V/Q matching is best preserved in zone 3

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8
Q

Describe ventilation & perfusion in the lateral decubitus position in the spontaneously breathing, closed chest patient.

A

V/Q matching is preserved
dependent lung receives more ventilation and perfusion than the upper lung (non-dependent lung)
non-dependent lung is now zone 1

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9
Q

Factors that cause diaphragm displacement include:

A

surgical position
paralysis
supine position
induction of anesthesia

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10
Q

Describe the V/Q matching in the anesthetize patient who is in the lateral decubitus position, paralyzed and has a closed chest.

A 
Positive pressure ventilation
decrease in FRC
V/Q mismatching
dependent lung= greater perfusion
non-dependent lung= greater ventilation
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11
Q

Describe the V/Q matching for the anesthetized patient in the lateral decubitus position with an open chest

A

V/Q mismatching
perfusion remains greater in dependent lung
upper lung collapse leads to progressive hypoxemia–> mediastinal shift impedes ventilation to lower lung, paradoxical respirations

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12
Q

Describe V/Q matching of the anesthetized patient in the lateral decubitus position, paralyzed with open chest (2 lung ventilation).

A

Positive pressure ventilation
may worse V/Q mismatching
ventilation greater in non-dependent lung
perfusion greater in dependent lung

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13
Q

The following have an effect on V/Q matching:

A

positioning
open chest- mediastinal shift
anesthesia with paralysis

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14
Q

Describe the V/Q match in the lateral position.

A

non-dependent V> Q

Dependent V

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15
Q

Hypoxic pulmonary vasoconstriction works by

A

diverting blood away from the hypoxic regions of the lung

decrease blood flow to the non-ventilated lung

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16
Q

Hypoxic pulmonary vasoconstriction ________ shunt

A

decreases

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17
Q

Hypoxic pulmonary vasoconstriction helps improve

A

arterial oxygen content improving hypoxemia

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18
Q

Describe blood flow distribution of the nondependent & dependent lungs in the lateral decubitus position.

A

Nondependent: 40%
Dependent: 60%

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19
Q

Factors that inhibit HPV include:

A 
high pulmonary vascular resistance (increased PAP, volume overload, mitral stenosis)
hypocapnia
high or very low mixed venous PO2
vasodilators
pulmonary infection
inhalation anesthetics
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20
Q

Vasodilators that inhibit HPV include

A

nitroglycerin
nitroprusside
beta agonists (dobutamine)
calcium channel blockers

21
Q

1 Mac of anesthetic causes a ________ in shunting

A

5% increase

22
Q

One lung ventilation blood flow with hypoxic pulmonary vasoconstriction is

A

20% in nondependent

80% in dependent

23
Q

1 MAC of isoflurane ______ hypoxic pulmonary vasoconstriction by ____

A

inhibits by 21%

24
Q

One lung anesthesia is beneficial for

A

better operating conditions with collapse of the disease lung
facilitates access to the aorta & esophagus
prevents cross-contamination with abscess, secretions, bblood
prevents loss of anesthetic gases with bronchopleural fistula

25
Q

Relative contraindications for one-lung anesthesia include

A

difficult airway with poor visualization of the larynx

lesion in bronchial airway precluding bronchial intubation

26
Q

Absolute indications for one-lung ventilation include:

A 
pulmonary infection
copious bleeding on one side
bronchopulmonary fistula
bronchial rupture
large lung cyst
bronchopleural lavage
27
Q

Relative indications for one-lung ventilation include

A 
thoracic aortic aneurysm
pneumonectomy
lobectomy
thoracotomy; thoracoscopy
subsegmental resections
esophageal surgery
28
Q

Techniques for achieving one lung ventilation include

A 
double-lumen endotracheal tubes
bronchial blocker (used with standard single-lumen endotracheal tube)
single-lumen endotracheal tube
29
Q

Shared characteristics of double-lumen endotracheal tubes include

A

longer bronchial lumen which enters either the right or left mainstem bronchus
shorter tracheal lumen remaining in the distal trachea
performed curve that allows preferential entry into the left or right side
separate bronchial and tracheal cuffs
tubes specifically designed for L or R side due to differences in anatomy

30
Q

Describe the anatomic considerations of the adult trachea for DLT

A

11-12 cm long
begins at C6 (cricoid cartilage)
bifurcates at the sternomanubrial joint (T5)

31
Q

Describe anatomic considerations for the right bronchus when using the double lumen tube.

A

wider
diverges away from trachea at 20-25 angle
orifice of RUL sits only 1 to 2 cm to carina

32
Q

Describe anatomic considerations for DLT for the left bronchus.

A

narrower
diverges away from trachea at 40-45 degree angle
orifice of LUL sits about 5 cm distal to carina

33
Q

The stylet goes through the ________ of the double lumen tube

A

bronchial side

34
Q

The ______ is more difficult to place for the double lumen tube.

A

the right

35
Q

The best predictor of DLT size is

A

patient height

36
Q

For someone who is 4’6” to 5’3” the size of the DLT is

A

35-37 french

37
Q

For someone who is 5’3” to 5’7”, the DLT size is

A

37 or 39 FR- most commonly used size

38
Q

For someone who is taller than 5’7”, the DLT used is a

A

41 FR

39
Q

Proper size of the DLT allows for

A

1-2 mm smaller than patients left bronchus to allow for space of bronchial cuff

40
Q

Describe the insertion technique of the double lumen tube.

A

laryngoscopy with curved blade provides optimal space to place DLT
DLT is passed with the distal curvature concave anteriorly, then rotated 90 degree towards the size that is to be intubated after the tip enters the larynx
advance DLT until resistances felt
confirm correct placement

41
Q

The average insertion depth of the DLT is

A

28-29 cm at teeth

42
Q

Correct position of the double lumen tube when one tube is clamped includes:

A

ipsilateral breath sounds disappear
ipsilateral hemothorax does not move
no change in moisture
contralateral breath sounds remain
contralateral hemothorax rises & falls
contralateral respiratory gas moisture disappears on inhalation and reappears on exhalation
breathing bag has the expected compliance for one-lung ventilation

43
Q

The protocol for checking placement includes:

A 
inflate tracheal cuff
check for bilateral breath sounds
inflate bronchial cuff
clamp tracheal lumen
check for unilateral LEFT breath sounds
unclamp tracheal lumen & clamp bronchial lumen
check for unilateral RIGHT breath sounds
fiberoptic confirmation (check both supine & after LDP)
44
Q

The tracheal cuff should be inflated to

A

5-10 mL of air

45
Q

The bronchial cuff should be inflated with

A

1-2 mL of air

46
Q

When checking for bilateral breath sounds, if unilateral breath sounds are heard, this indicates

A

tube too far down & tracheal opening is endobronchial

47
Q

When checking for unilateral LEFT breath sounds, persistence of right-sided breath sounds indicate

A

bronchial opening still in trachea & tube should be advanced

48
Q

When checking for unilateral LEFT breath sounds, if unilateral right sided breath sounds are heard instead, this indicates

A

incorrect entry of the tube into right bronchus

Advanced Principles 2 (42 decks)

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