Anesthesia for thoracic surgery 2

Question 1

Correct placement of a double lumen tube includes

Answer 1

no herniation of the cuff over the carina

Question 2

Problems with DLT placement include:

Answer 2

in too far
not far enough
wrong side

Question 3

The most common problem encountered when positioning a LEFT endobronchial tube is

Answer 3

inserting too deeply, excluding right lung from ventilation

Question 4

The most common problem encountered when positioning a RIGHT endobronchial tube is

Answer 4

excluding the right upper lobe from ventilation

Question 5

Left endobronchial tubes may be used for:

Answer 5

right-sided thoracotomy

left-sided thoracotomy

Question 6

When using a left endobronchial tube for a right-sided thoracotomy, the ______ lumen

Answer 6

tracheal lumen is clamped and left lung ventilated through bronchial lumen

Question 7

When using a left endobronchial tube for a left-sided thoracotomy, the ____ lumen is clamped

Answer 7

bronchial lumen is clamped and right lung is ventilated through tracheal lumen

Question 8

When using a left endobronchial tube for a left-sided thoracotomy, if the surgeon needs to clamp the left mainstem for pneumonectomy,

Answer 8

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

Question 9

Indications for using a right double lumen tube include

Answer 9

resection of a thoracic aortic aneurysm
tumor in left mainstem bronchus
left lung transplantation or left pneumonectomy (not absolute)
left-sided tracheo-bronchial disruption

Question 10

A bronchial blocker is an

Answer 10

inflatable device passed alongside or through a single-lumen ETT to selectively occlude a bronchial orifice

Question 11

A univent tube is a

Answer 11

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

Question 12

A regular ETT can be used as a bronchial blocker when

Answer 12

an inflatable catheter is used and a guide wire is used for placement

Question 13

A bronchial blocker must be advanced, positioned, and inflated under

Answer 13

direct visualization via flexible bronchoscope

Question 14

A major advantage of a bronchial blocker is

Answer 14

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

Question 15

A major disadvantage of a bronchial blocker is

Answer 15

blocked lung collapses slowly & sometimes incompletely due to small size of channel within the blocker

Question 16

Placing a univent bronchial blocker includes

Answer 16

ETT is placed with blocker fully retracted
ETT is then turned 90 degrees towards the operative side
bronchial blocker is pushed to the mainstem bronchus under direct visualization with fiberoptic scope

Question 17

The cuff of the univent bronchial blocker is

Answer 17

high pressure-low volume cuff so use minimum volume to prevent leak

Question 18

The channel within the univent bronchial blocker allows lungs

Answer 18

to slowly deflate

-channel can also be used for suctioning or insufflating oxygen

Question 19

A fogarty catheter is

Answer 19

not used commonly anymore
used with standard ETT
guide wire in catheter is used to facilitate placement through ETT
does not allow suctioning or ventilation of the isolated lung

Question 20

Indications for lung resection include

Answer 20

diagnosis & treatment of pulmonary tumors
necrotizing pulmonary infections
bronchiectasis

Question 21

Preoperative preparation must consider:

Answer 21

does the risk of potential postop complications preclude performing the surgery?
will postop pulmonary function be sufficient to allow reasonable quality of life?

Question 22

Preoperative testing includes:

Answer 22

CXR/ chest CT
EKG
ABG
PFTs
Ventilation-perfusion tests

Question 23

Many patients undergoing a thoracic surgery will have

Answer 23

CAD combined with lung problems so consider appropriate cardiac diagnostics

Question 24

Describe low risk & high risk PFTs.

Answer 24

FEV1 >2L or 80% predicted: low risk

FEV1 <2L or 40% predicted: high risk

Question 25

A risk assessment for pneumonectomy takes into account:

Answer 25

``` arterial blood gas FEV1 FEV1/FVC maximum O2 uptake (VO2) maximum voluntary ventilation ```

Question 26

Describe a high risk patient for a pneumonectomy based on arterial blood gas.

Answer 26

PaCO2> 45 mmHg (on room air) | PaO2 < 50 mmHg

Question 27

Describe a high risk patient for a pneumonectomy based on FEV1.

Answer 27

<2L or <50% of predicted

Question 28

Describe a high risk patient for pneumonectomy based on FEV1/FVC

Answer 28

<50% of predicted

Question 29

Describe a high risk patient for pneumonectomy based on maximum O2 uptake (VO2).

Answer 29

<10 mL/kg/min

Question 30

Describe a high risk patient for pneumonectomy based on maximum voluntary ventilation.

Answer 30

<50% of predicted

Question 31

A split-lung function test uses

Answer 31

radio-labeled albumin to calculate the predicted pulmonary function, postoperative outcome, & survival after pneumonectomy

Question 32

The minimal predicted postoperative FEV1 necessary for long-term survival is

Answer 32

800-1000 mL

Question 33

A split-lung function test predicts FEV1 of

Answer 33

an isolated lung if the other lung is removed | -predicted postop FEV1= preop total FEV1 x % blood flow to remaining lung

Question 34

Concerns with preoperative chemotherapy include

Answer 34

cardiomyopathy pulmonary toxicity bone marrow suppression

Question 35

Chemotherapy induced cardiomyopathy may be the result of

Answer 35

doxorubicin cyclophosphamide -check preop echo

Question 36

Chemotherapy induced pulmonary toxicity may be the result of

Answer 36

bleomycin (pulmonary toxicity with high FiO2) mitomycin-C cyclophosphamide

Question 37

Chemotherapy induced bone marrow suppression is the result of

Answer 37

most chemotherapeutic agents | check platelets, RBCs, WBCs

Question 38

Non-small cell lung carcinoma is the result of

Answer 38

ectopic parathyroid hormone

Question 39

Small cell lung carcinoma may be the result of

Answer 39

SIADH lambert-eaton myasthenic syndrome carcinoid syndrome

Question 40

SIADH oat cell carcinoma of the lung may cause

Answer 40

low urine output, hypervolemia, hyponatremia, CHF, & pulmonary edema

Question 41

Lambert Eaton myasthenic syndrome is associated with

Answer 41

small cell lung CA | increased muscle weakness due to decreased calcium levels at neuromuscular junction

Question 42

Management of one lung ventilation includes always

Answer 42

getting baseline ABG prior to instituting OLV; this is your reference point

Question 43

With chest opening and rib splitting,

Answer 43

maximum depth of anethesia is necessary

Question 44

It is important to maintain______ until pleura is opened

Answer 44

two-lung ventilation

Question 45

During one-lung ventilation when the operative lung is deflated,

Answer 45

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

Question 46

The greatest risk during one lung ventilation management is

Answer 46

hypoxemia!

Question 47

If you experience high peak inspiratory pressures during one lung ventilation

Answer 47

check ETT position | reduce Vt & increase RR to maintain minute ventilation

Question 48

Describe how to ventilate the dependent lung.

Answer 48

Fio2 100%; can decrease after ABG obtained Vt 5-6 mL/kg- not necessary to change with OLV PEEP 0-5 mmHg RR 12-15 to keep PaCO2 35-45 mmHg (or close to preoperative value)

Question 49

The recommended mode of ventilation for one lung ventilation is

Answer 49

volume or pressure control | -pressure control for patients at risk of lung injury (e.g. bullae, pneumonectomy, post lung transplantation)

Question 50

The following steps should be taken if hypoxemia is experienced during OLV

Answer 50

confirm tube placement & increase fiO2 to 100% check hemodynamic status adjust TV &/or RR add 2-10 cmH2O CPAP to collapsed lung periodically inflate collapsed lung with 100% oxygen (inform surgeon) add 5-10 cmH2O PEEP to dependent lung continuous insufflation to collapsed lung with 100% O2 early ligation/clamping of the ipsilateral pulmonary artery (if doing pneumonectomy)

Question 51

Alternatives to one lung ventilation includes:

Answer 51

stopping ventilation for short periods & employing use of 100% O2 insufflated at a rate greater than O2 consumption HFJV- low volumes, high pressure

Question 52

Apneic oxygenation is

Answer 52

useful for 10-20 minutes | can cause progressive respiratory acidosis: PaCO2 rises 6 mmHg first minute, 3-4 mmHg each subsequent minute

Question 53

Emergence with one lung ventilation may include

Answer 53

inflate lung to 30 cmH2O pressure/may request valsava thoracotomy tubes may be placed standard extubation criteria for patients you anticipate extubating at end of procedure

Question 54

If the patient is to remain intubated,

Answer 54

must change out to single-lumen ETT prior to transporting to unit

Question 55

A valsava may be used to

Answer 55

check for leaks if stapling bronchus | check for microbleeding to re-inflate collapsed lung

Question 56

Complications from thoracic anesthesia may include:

Answer 56

``` hypoxemia/respiratory acidosis (#1 complication) postoperative hemorrhage arrhythmias bronchial rupture acute right ventricular failure positioning injuries ```

Question 57

Hypoxemia/respiratory acidosis may result from

Answer 57

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

Question 58

Postoperative hemorrhage signs include

Answer 58

chest tube drainage >200 mL/min. hypotension, tachycardia, decreasing Hct associated with 20% mortality

Question 59

The most common arrhythmia from thoracic anesthesia is

Answer 59

atrial fibrillation

Question 60

Acute right ventricular failure may present as

Answer 60

low CO, elevated CVP, oliguria

Question 61

Bronchial rupture may be the result of

Answer 61

excessive cuff inflation of the bronchial tube