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N934 Adv Principles Fa 21 > Anesthesia for Thoracic Surgery > Flashcards

Anesthesia for Thoracic Surgery Flashcards

1
Q

Positioning for Thoracic Surgery

A

lateral decubitus

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2
Q

complications with positioning

A

coughing, tachycardia, hypertension during turn to lateral
HoTN from blood pooling in dependent portions
VQ mismatching and hypoxemia
interstitial pulmonary edema of dependent lung
brachial plexus and peroneal nerve injury
monocular blindness (dependent eye ischemia)
outer ear ischemia (flat or in donut)
axillary artery compression

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3
Q

ventilatory mechanics of awake and upright spontaneously breathing patient with a closed chest (ventilation and perfusion)

A

apex of lungs are minimally dilated
most Ventilation occurs at the base of the lungs
perfusion also favors the base of the lungs
VQ mismatching is preserved during spontaneous respirations

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4
Q

zone 1 of an upright lung, relationship between alveoli, pulmonary artery, pulmonary vein

A

pA>pa>pv

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5
Q

zone 2 of an upright lung, relationship between alveoli, pulmonary artery, pulmonary vein

A

pa>pA>pv

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6
Q

zone 3 of an upright lung, relationship between alveoli, pulmonary artery, pulmonary vein

A

pa>pv>pA

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7
Q

where is V/Q most efficient in an upright lung

A

zones 2 and 3

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8
Q

ventilatory mechanics of an awake patient in lateral decubitus position with a closed chest and spontaneous respirations

A

VQ matching is preserved

dependent lung receives more ventilation and perfusion than upper lung (non dependent lung)

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9
Q

where do the zones of the lungs lie for a lateral decubitus patient who is awake and spontaneously breathing

A

zone 1 is the top of the nondependent lung, zone 2 is the bottom 2/3 of the nondependent lung and the top 1/3 of the dependent lung, and zone 3 is the bottom 2/3 of the dependent lung

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10
Q

factors that incite progressive cephalad displacement of the diaphragm

A

surgical positioning and displacement, paralysis, induction of anesthesia, supine positioning

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11
Q

ventilatory mechanics and factors affecting an anesthetized patient in lateral decubitus position, paralyzed, with a closed chest and 2 lung ventilation

A

PPV, decrease in FRC, VQ mismatching, dependent lung has greater perfusion while nondependent lung has greater ventilation and Vt

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12
Q

ventilatory mechanics and factors affecting an anesthetized patient in lateral decubitus position with an open chest and 2 lung ventilation

A

PPV helps overcome pneumothorax, VQ mismatching occurring, perfusion remains greater in dependent lung, upper lung collapse leads to progressive hypoxemia via mediastinal shift and resultant paradoxical respirations.
pneumothorax creates loss of negative pressure to open lung

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13
Q

inspiration during a pneumothorax

A

increases pneumothorax size and increases VQ mismatching

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14
Q

VQ mismatch in the non dependent versus dependent regions summary

A

non dependent V>Q, dependent Q>V

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15
Q

what is the big effect of an open chest

A

mediastinal shift

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16
Q

HPV

A

diverts blood away from hypoxic regions of the lung
decreased BF to the non ventilated lung
helps improve arterial oxygen content, improving hypoxemia
decreases shunt

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17
Q

average of both lungs being nondependent: blood flow distribution during two lung ventilation in the lateral position

A

top lung averages at 40% blood flow while bottom lung averages at 60% blood flow

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18
Q

HPV response during one lung ventilation in the lateral decubitus position (no inhalational influence)

A

there is a 50% HPV response in the dependent lung, so BF therefore increases to 80% in the dependent lung and decreases to 20% in the non dependent non ventilated lung

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19
Q

Factors that inhibit HPV (6)

A

high PVR, hypocapnia, high or very low mixed venous pO2, vasodilators, pulmonary infection, inhalation anesthetics

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20
Q

what is capable of increasing PVR (3)

A

high PAP, volume overload, mitral stenosis

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21
Q

vasodilators that inhibit HPV examples (4)

A

nitroglycerin
sodium nitroprusside
beta agonists (dobutamine)
CCB’s

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22
Q

1 MAC of inhalational = ___ increase in VQ shunt via inhibition of HPV by ____

A

4%

21%

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23
Q

which inhalational gases are not as inhibitory of HPV

A

desflurane and sevoflurane are not as inhibitory as isoflurane

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24
Q

1 MAC of isoflurane inhibits HPV by ____% and therefore increases the VQ shunt

A

21%

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25
benefits of one lung anesthesia (4)
better operating conditions with collapse of diseased lung facilitates access to aorta and esophagus prevents cross contamination with abscess, secretions, blood prevents loss of anesthetic gases with bronchopleural fistula
26
relative contraindications for one lung anesthesia (2)
difficult airway with poor visualization of the larynx | lesion in bronchial airway precluding bronchial intubation
27
absolute indications for one lung ventilation (OLV)
``` pulmonary infection copious bleeding on one side bronchopulmonary fistula bronchial rupture large lung cyst bronchopleural lavage ```
28
relative indications for one lung ventilation (6)
``` thoracic aortic aneurysm pneumonectomy lobectomy thoracotomy, thoracoscopy subsegmental resections esophageal surgery ```
29
techniques for achieving one lung ventilation (OLV)
``` double lumen ETT bronchial blocker (used with standard single lumen ETT) single lumen ETT with bronchial blocker built in ```
30
double lumen endotracheal tube (DLT) shared characteristics
longer bronchial lumen which enters the right or left mainstream bronchus shorter tracheal lumen remaining in distal trachea preformed curve that allows preferential entry into the left or right side separate bronchial and tracheal cuffs (with separate balloons) tubes specifically designed for left or right side due to differences in anatomy
31
double lumen tube cuff sizes and stylet considerations
bronchial cuff is 3cc and the tracheal cuff is 6cc. the stylet goes through the bronchial side. the concave portion and the tip face up during initial insertion
32
anatomic considerations of the adult trachea: length, where it begins, where it bifurcates
11-12cm in length, begins at C6 (cricoid cartilage), bifurcates at the sternomanubrial joint (T5)
33
anatomic considerations of right bronchus: width, angle, orifice of RUL in relation to carina
wider, diverges away from trachea at 20-25 degree angle, orifice of RUL sits only 1-2cm to carina
34
anatomic considerations of left bronchus: width, angle, orifice of LUL in relation to carina
narrower, diverges away from trachea at 40-45 degree angle, orifice of LUL sits about 5cm distal to carina
35
big difference in right versus left double lumen tube?
right sided tube has murphys eye for the RUL
36
what is the best predictor of DLT size?
height
37
what size DLT for women and what size DLT for men usually?
35-37 women 37-39 men (tall, 41fr available)
38
insertion technique for DLT
laryngoscopy with curved blade provides optimal space to place DLT (mac>miller) DLT is passed with distal curvature concave anteriorly, then rotated 90 degrees towards the right side that is to be intubated after the tip enters the larynx (or rotate once bronchial cuff is at cords) advance DLT until resistance is felt confirm correct placement via bronchoscopy
39
average insertion depth of DLT
28-29 cm at teeth
40
how to listen for correct positioning
clamp left bronchial side, hear breath sounds on both. clamp tracheal lumen, BS on left
41
protocol for checking placement?
inflate tracheal cuff (5-10mL of air) and check for bilateral breath sounds inflate bronchial cuff (1-2mL of air) and clamp tracheal lumen. check for unilateral LEFT breath sounds unclamp tracheal lumen and clamp bronchial lumen. check for unilateral right breath sounds fiberoptic confirmation (both supine and after LDP)
42
if you inflate the tracheal cuff to check for bilateral breath sounds and only hear unilateral breath sounds, what can you assume
tube is too far down and tracheal opening is endobronchial
43
if you check for unilateral left breath sounds and hear persistent right sided breath sounds on a DLT, what can you assume?
bronchial opening still in trachea and tube should be advanced.
44
common problems with DLT placement include (3)
in too far, not far enough, wrong side
45
most common problem encountered with positioning a left endobronchial tube?
inserting too deeply, excluding right lung from ventilation
46
most common problem encountered when positioning a right endobronchial tube?
excluding the RUL from ventilation
47
what are left endobronchial tubes used for?
right sided thoracotomy. tracheal lumen is clamped and left lung is ventilated though bronchial lumen. used also for left sided thoracotomy. bronchial lumen is clamped and right lung is ventilated through tracheal lumen
48
if surgeon needs to clamp the left mainstem of a left endobronchial tube for a pneumonectomy
move bronchial lumen into the trachea and then use a standard ETT
49
indications for a right DLT include
resection of a thoracic aortic aneurysm tumor in left mainstem bronchus left lung transplantation or left pneumonectomy (not absolute) left sided tracheo bronchial disruption
50
explain bronchial blockers
inflatable devices passed alongside or though a single lumen ETT to selectively occlude a bronchial orifice
51
what is a univent tube
single lumen ETT with built in side channel for retractable bronchial blocker
52
how to use regular ett with bronchial blocker
regular ett is used with inflatable catheter (fogarty catheter), guide wire used for placement
53
explain how to insert a bronchial blocker
must be advanced, positioned, and inflated under direct visualization via a flexible bronchoscope. adapter still allows you to ventilate during placement
54
"major advantage" to bronchial blockers
patient who requires intubation postoperatively-do not have to redo their laryngoscopy and change out ETT
55
"major disadvantage" to bronchial blockers
blocked lung collapses slowly (due to lumen size) and sometimes incompletely
56
how to insert univent bronchial blocker
ETT is placed with blocker fully retracted ETT is then turned 90 degrees towards the operative side bronchial blocker is pushed to the mainstream bronchus under direct visualization with fiberoptic scope
57
describe ventilation during insertion of univent bronchial blocker with a fiberoptic scope
fiberoptic scope passed through adapter with self sealing diaphragm allowing uninterrupted ventilation
58
what can the channel on the univent bronchial blocker be used for
suctioning, deflating, insufflating
59
describe the utilization of a fogarty catheter
used with standard ETT, guide wire in catheter is used to facilitate placement through ETT does not allow suctioning or ventilation of isolated lung. (same as clot plasty balloon thing)
60
indications for a lung resection
diagnosis and tx of pulmonary tumors necrotizing pulmonary infections bronchiectasis
61
preoperative testing for lung resection
``` CXR/CT EKG/cardiac studies ABG PFT's VQ tests, especially important in lung that will be left to pick up the slack ```
62
risk assessment based on FEV1
FEV1>2L or 80% predicts low risk | FEV1<2L or 40% predicts high risk
63
risk assessment for pneumonectomy: ABG
PaCO2 >45mmHg on RA or PaO2 <50mmHg
64
risk assessment for pneumonectomy: FEV1/FVC
<50% of predicted
65
risk assessment for pneumonectomy: VO2
<10mL/kg/min
66
risk assessment for pnuemonectomy: maximum voluntary ventilation
<50% of predicted
67
preoperative evaluation for pneumonectomy: describe split lung function tests
- uses ratio labeled albumin to calculate the predicted pulmonary function, postoperative outcome, and survival after pneumonectomy. - predicts FEV1 of an isolated lung if the other lung is removed - minimal predicted postoperative FEV1 necessary for long term survival 800-1000mL
68
formula for predicted postoperative FEV1?
preoperative total FEV1X % BF to remaining lung
69
which chemotherapeutic agents can be responsible for cardiomyopathy and would prompt the need for a preoperative echocardiogram? (2)
doxorubicin (Adriamycin) | Cyclophosphamide (Cytoxan)
70
which chemotherapeutic agents can be responsible for pulmonary toxicity? (3)
bleomycin (pulmonary toxicity with high FiO2) mitomycin c cyclophosphamide
71
which chemotherapeutic agents can be responsible for bone marrow suppression and therefore warrant a preoperative CBC
most chemotherapeutic agents-check platelets, RBC's, WBC's
72
what paraneoplastic syndromes can small cell lung carcinoma be responsible for? (3)
SIADH LEMS Carcinoid Syndrome
73
Oat Cell Carcinoma (Small Cell Lung Carcinoma) may cause
``` low UOP hypervolemia hyponatremia CHF Pedema ```
74
what paraneoplastic syndrome is non small cell lung carcinoma responsible for?
ectopic parathyroid hormone
75
Assessment of patients with lung cancer: 4 M's
mass effects metabolic effects metastasis (brain, liver, bone, adrenals) medications (chemo induced lung/cardiac changes)
76
describe "mass effects" assessment of patients with lung cancer (5)
obstructive PNA, SVC syndrome, tracheobronchial distortion, RLN or phrenic nerve paresis
77
describe "metabolic effects" assessment of patients with lung cancer
LEMS, hypercalcemia, hyponatremia, cushings syndrome
78
patient preparation: premedication to consider
bronchodilators | anticholinergics (secretions, also increases HR to counteract vagus nerve stimulation when pleura is opened)
79
monitoring equipment to consider during a one lung ventilation case
``` arterial line (everyone gets one. place on dependent limb) CVP: not necessary, but desirable to guide fluid managment PA cath: LV dysfunction or severe pHTN ```
80
airway equipment to consider having available during one lung ventilation case
multiple sized DLT's, standard ETT available | pedes FOB, difficult AW card
81
what can you consider for postoperative pain mangement
thoracic epidural
82
positioning considerations for one lung ventilation
properly placed axillary roll to protect brachial plexus. check tube with bronchoscope after positioning
83
fluid management considerations during one lung ventilation
2 large bore PIV's, avoid over hydration have blood warmer and rapid infusion device available T&C and PRBC's
84
one lung ventilation management after induction and before pleura is opened
get baseline ABG prior to OLV | maintain 2 lung ventilation until pleura is opened
85
one lung ventilation surgery management: during first incision to get to pleura opening
need maximum depth of anesthesia with chest opening and rib splitting
86
initiation of one lung ventilation during surgery: management and considerations
100% O2 to dependent lung obtain ABG 15 minutes after OLV is initiated, guide therapy to maintain near baseline major adjustments in ventilation usually not necessary
87
greatest risk of one lung ventilation
hypoxemia
88
what do you do if you have high peak pressures during one lung ventilation
check ETT position, reduce VT and increase RRR to maintain minute ventilation
89
ventilation of dependent lung: FiO2/Vt/RR/PEEP
FiO2: 100%, can decrease after ABG obtained Vt 5-6mL/kg, not necessary to change with OLV RR 12-15 to keep PaCO2 35-45mmHg (or close to preop value) PEEP 0-5mmHg
90
PEEP and patients with COPD during OLV
dont add PEEP
91
how much does EtCO2 increase during OLV
1-3mmHg
92
which mode is suggested for OLV
pressure control
93
if the patient experiences hypoxemia during OLV, these are the suggested steps
confirm tube placement and increase FiO2 to 100% check hemodynamic status adjust Vt/RR add 2-10cmH2O CPAP to collapsed lung periodically inflate collapsed lung with 100% O2 add 5-10cmH2O PEEP to dependent lung continuous insufflation to collapsed lung with 100% O2 early ligation/clamping of ipsilateral pulmonary artery (if doing pneumonectomy). BF goes to other lung
94
complications from thoracic anesthesia: hypoxemia and respiratory acidosis causes
atelectasis and shallow breathing (splinting) due to incisional pain gravity dependent transudation of fluid into dependent lung
95
complications from thoracic anesthesia: postoperative hemorrhage signs
(associated with 20% mortality) | signs: chest tube drainage >200mL/min, hypotension, tachycardia, decreasing HCT
96
complications from thoracic anesthesia: 4 others (not including hypoxemia and postoperative hemorrhage)
arrhtyhmias bronchial rupture (due to excessive cuff inflation of bronchial tube) acute RV failure (low CO, elevated CVP, oliguria) positioning injuries

N934 Adv Principles Fa 21 (23 decks)

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