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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
Q

benefits of one lung anesthesia (4)

A

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

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26
Q

relative contraindications for one lung anesthesia (2)

A

difficult airway with poor visualization of the larynx

lesion in bronchial airway precluding bronchial intubation

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27
Q

absolute indications for one lung ventilation (OLV)

A 
pulmonary infection
copious bleeding on one side
bronchopulmonary fistula
bronchial rupture
large lung cyst
bronchopleural lavage
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28
Q

relative indications for one lung ventilation (6)

A 
thoracic aortic aneurysm
pneumonectomy
lobectomy
thoracotomy, thoracoscopy
subsegmental resections
esophageal surgery
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29
Q

techniques for achieving one lung ventilation (OLV)

A 
double lumen ETT
bronchial blocker (used with standard single lumen ETT)
single lumen ETT with bronchial blocker built in
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30
Q

double lumen endotracheal tube (DLT) shared characteristics

A

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

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31
Q

double lumen tube cuff sizes and stylet considerations

A

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

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32
Q

anatomic considerations of the adult trachea: length, where it begins, where it bifurcates

A

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

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33
Q

anatomic considerations of right bronchus: width, angle, orifice of RUL in relation to carina

A

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

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34
Q

anatomic considerations of left bronchus: width, angle, orifice of LUL in relation to carina

A

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

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35
Q

big difference in right versus left double lumen tube?

A

right sided tube has murphys eye for the RUL

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36
Q

what is the best predictor of DLT size?

A

height

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37
Q

what size DLT for women and what size DLT for men usually?

A

35-37 women
37-39 men
(tall, 41fr available)

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38
Q

insertion technique for DLT

A

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

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39
Q

average insertion depth of DLT

A

28-29 cm at teeth

40
Q

how to listen for correct positioning

A

clamp left bronchial side, hear breath sounds on both. clamp tracheal lumen, BS on left

41
Q

protocol for checking placement?

A

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
Q

if you inflate the tracheal cuff to check for bilateral breath sounds and only hear unilateral breath sounds, what can you assume

A

tube is too far down and tracheal opening is endobronchial

43
Q

if you check for unilateral left breath sounds and hear persistent right sided breath sounds on a DLT, what can you assume?

A

bronchial opening still in trachea and tube should be advanced.

44
Q

common problems with DLT placement include (3)

A

in too far, not far enough, wrong side

45
Q

most common problem encountered with positioning a left endobronchial tube?

A

inserting too deeply, excluding right lung from ventilation

46
Q

most common problem encountered when positioning a right endobronchial tube?

A

excluding the RUL from ventilation

47
Q

what are left endobronchial tubes used for?

A

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
Q

if surgeon needs to clamp the left mainstem of a left endobronchial tube for a pneumonectomy

A

move bronchial lumen into the trachea and then use a standard ETT

49
Q

indications for a right DLT include

A

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
Q

explain bronchial blockers

A

inflatable devices passed alongside or though a single lumen ETT to selectively occlude a bronchial orifice

51
Q

what is a univent tube

A

single lumen ETT with built in side channel for retractable bronchial blocker

52
Q

how to use regular ett with bronchial blocker

A

regular ett is used with inflatable catheter (fogarty catheter), guide wire used for placement

53
Q

explain how to insert a bronchial blocker

A

must be advanced, positioned, and inflated under direct visualization via a flexible bronchoscope. adapter still allows you to ventilate during placement

54
Q

“major advantage” to bronchial blockers

A

patient who requires intubation postoperatively-do not have to redo their laryngoscopy and change out ETT

55
Q

“major disadvantage” to bronchial blockers

A

blocked lung collapses slowly (due to lumen size) and sometimes incompletely

56
Q

how to insert univent bronchial blocker

A

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
Q

describe ventilation during insertion of univent bronchial blocker with a fiberoptic scope

A

fiberoptic scope passed through adapter with self sealing diaphragm allowing uninterrupted ventilation

58
Q

what can the channel on the univent bronchial blocker be used for

A

suctioning, deflating, insufflating

59
Q

describe the utilization of a fogarty catheter

A

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
Q

indications for a lung resection

A

diagnosis and tx of pulmonary tumors
necrotizing pulmonary infections
bronchiectasis

61
Q

preoperative testing for lung resection

A 
CXR/CT
EKG/cardiac studies
ABG
PFT's
VQ tests, especially important in lung that will be left to pick up the slack
62
Q

risk assessment based on FEV1

A

FEV1>2L or 80% predicts low risk

FEV1<2L or 40% predicts high risk

63
Q

risk assessment for pneumonectomy: ABG

A

PaCO2 >45mmHg on RA or PaO2 <50mmHg

64
Q

risk assessment for pneumonectomy: FEV1/FVC

A

<50% of predicted

65
Q

risk assessment for pneumonectomy: VO2

A

<10mL/kg/min

66
Q

risk assessment for pnuemonectomy: maximum voluntary ventilation

A

<50% of predicted

67
Q

preoperative evaluation for pneumonectomy: describe split lung function tests

A
  • 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
Q

formula for predicted postoperative FEV1?

A

preoperative total FEV1X % BF to remaining lung

69
Q

which chemotherapeutic agents can be responsible for cardiomyopathy and would prompt the need for a preoperative echocardiogram? (2)

A

doxorubicin (Adriamycin)

Cyclophosphamide (Cytoxan)

70
Q

which chemotherapeutic agents can be responsible for pulmonary toxicity? (3)

A

bleomycin (pulmonary toxicity with high FiO2)
mitomycin c
cyclophosphamide

71
Q

which chemotherapeutic agents can be responsible for bone marrow suppression and therefore warrant a preoperative CBC

A

most chemotherapeutic agents-check platelets, RBC’s, WBC’s

72
Q

what paraneoplastic syndromes can small cell lung carcinoma be responsible for? (3)

A

SIADH
LEMS
Carcinoid Syndrome

73
Q

Oat Cell Carcinoma (Small Cell Lung Carcinoma) may cause

A 
low UOP
hypervolemia
hyponatremia
CHF
Pedema
74
Q

what paraneoplastic syndrome is non small cell lung carcinoma responsible for?

A

ectopic parathyroid hormone

75
Q

Assessment of patients with lung cancer: 4 M’s

A

mass effects
metabolic effects
metastasis (brain, liver, bone, adrenals)
medications (chemo induced lung/cardiac changes)

76
Q

describe “mass effects” assessment of patients with lung cancer (5)

A

obstructive PNA, SVC syndrome, tracheobronchial distortion, RLN or phrenic nerve paresis

77
Q

describe “metabolic effects” assessment of patients with lung cancer

A

LEMS, hypercalcemia, hyponatremia, cushings syndrome

78
Q

patient preparation: premedication to consider

A

bronchodilators

anticholinergics (secretions, also increases HR to counteract vagus nerve stimulation when pleura is opened)

79
Q

monitoring equipment to consider during a one lung ventilation case

A 
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
Q

airway equipment to consider having available during one lung ventilation case

A

multiple sized DLT’s, standard ETT available

pedes FOB, difficult AW card

81
Q

what can you consider for postoperative pain mangement

A

thoracic epidural

82
Q

positioning considerations for one lung ventilation

A

properly placed axillary roll to protect brachial plexus. check tube with bronchoscope after positioning

83
Q

fluid management considerations during one lung ventilation

A

2 large bore PIV’s, avoid over hydration
have blood warmer and rapid infusion device available
T&C and PRBC’s

84
Q

one lung ventilation management after induction and before pleura is opened

A

get baseline ABG prior to OLV

maintain 2 lung ventilation until pleura is opened

85
Q

one lung ventilation surgery management: during first incision to get to pleura opening

A

need maximum depth of anesthesia with chest opening and rib splitting

86
Q

initiation of one lung ventilation during surgery: management and considerations

A

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
Q

greatest risk of one lung ventilation

A

hypoxemia

88
Q

what do you do if you have high peak pressures during one lung ventilation

A

check ETT position, reduce VT and increase RRR to maintain minute ventilation

89
Q

ventilation of dependent lung: FiO2/Vt/RR/PEEP

A

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
Q

PEEP and patients with COPD during OLV

A

dont add PEEP

91
Q

how much does EtCO2 increase during OLV

A

1-3mmHg

92
Q

which mode is suggested for OLV

A

pressure control

93
Q

if the patient experiences hypoxemia during OLV, these are the suggested steps

A

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
Q

complications from thoracic anesthesia: hypoxemia and respiratory acidosis causes

A

atelectasis and shallow breathing (splinting) due to incisional pain
gravity dependent transudation of fluid into dependent lung

95
Q

complications from thoracic anesthesia: postoperative hemorrhage signs

A

(associated with 20% mortality)

signs: chest tube drainage >200mL/min, hypotension, tachycardia, decreasing HCT

96
Q

complications from thoracic anesthesia: 4 others (not including hypoxemia and postoperative hemorrhage)

A

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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