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Advanced Principles 2 > Anesthesia for thoracic surgery 2 > Flashcards

Anesthesia for thoracic surgery 2 Flashcards

1
Q

Correct placement of a double lumen tube includes

A

no herniation of the cuff over the carina

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2
Q

Problems with DLT placement include:

A

in too far
not far enough
wrong side

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3
Q

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

A

inserting too deeply, excluding right lung from ventilation

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4
Q

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

A

excluding the right upper lobe from ventilation

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5
Q

Left endobronchial tubes may be used for:

A

right-sided thoracotomy

left-sided thoracotomy

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6
Q

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

A

tracheal lumen is clamped and left lung ventilated through bronchial lumen

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7
Q

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

A

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

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8
Q

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

A

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

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9
Q

Indications for using a right double lumen tube 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

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10
Q

A bronchial blocker is an

A

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

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11
Q

A univent tube is a

A

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

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12
Q

A regular ETT can be used as a bronchial blocker when

A

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

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13
Q

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

A

direct visualization via flexible bronchoscope

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14
Q

A major advantage of a bronchial blocker is

A

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

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15
Q

A major disadvantage of a bronchial blocker is

A

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

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16
Q

Placing a univent bronchial blocker includes

A

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

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17
Q

The cuff of the univent bronchial blocker is

A

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

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18
Q

The channel within the univent bronchial blocker allows lungs

A

to slowly deflate

-channel can also be used for suctioning or insufflating oxygen

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19
Q

A fogarty catheter is

A

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

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20
Q

Indications for lung resection include

A

diagnosis & treatment of pulmonary tumors
necrotizing pulmonary infections
bronchiectasis

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21
Q

Preoperative preparation must consider:

A

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

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22
Q

Preoperative testing includes:

A 
CXR/ chest CT
EKG
ABG
PFTs
Ventilation-perfusion tests
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23
Q

Many patients undergoing a thoracic surgery will have

A

CAD combined with lung problems so consider appropriate cardiac diagnostics

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24
Q

Describe low risk & high risk PFTs.

A

FEV1 >2L or 80% predicted: low risk

FEV1 <2L or 40% predicted: high risk

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25
Q

A risk assessment for pneumonectomy takes into account:

A 
arterial blood gas
FEV1
FEV1/FVC
maximum O2 uptake (VO2)
maximum voluntary ventilation
26
Q

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

A

PaCO2> 45 mmHg (on room air)

PaO2 < 50 mmHg

27
Q

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

A

<2L or <50% of predicted

28
Q

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

A

<50% of predicted

29
Q

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

A

<10 mL/kg/min

30
Q

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

A

<50% of predicted

31
Q

A split-lung function test uses

A

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

32
Q

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

A

800-1000 mL

33
Q

A split-lung function test predicts FEV1 of

A

an isolated lung if the other lung is removed

-predicted postop FEV1= preop total FEV1 x % blood flow to remaining lung

34
Q

Concerns with preoperative chemotherapy include

A

cardiomyopathy
pulmonary toxicity
bone marrow suppression

35
Q

Chemotherapy induced cardiomyopathy may be the result of

A

doxorubicin
cyclophosphamide
-check preop echo

36
Q

Chemotherapy induced pulmonary toxicity may be the result of

A

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

37
Q

Chemotherapy induced bone marrow suppression is the result of

A

most chemotherapeutic agents

check platelets, RBCs, WBCs

38
Q

Non-small cell lung carcinoma is the result of

A

ectopic parathyroid hormone

39
Q

Small cell lung carcinoma may be the result of

A

SIADH
lambert-eaton myasthenic syndrome
carcinoid syndrome

40
Q

SIADH oat cell carcinoma of the lung may cause

A

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

41
Q

Lambert Eaton myasthenic syndrome is associated with

A

small cell lung CA

increased muscle weakness due to decreased calcium levels at neuromuscular junction

42
Q

Management of one lung ventilation includes always

A

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

43
Q

With chest opening and rib splitting,

A

maximum depth of anethesia is necessary

44
Q

It is important to maintain______ until pleura is opened

A

two-lung ventilation

45
Q

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

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

46
Q

The greatest risk during one lung ventilation management is

A

hypoxemia!

47
Q

If you experience high peak inspiratory pressures during one lung ventilation

A

check ETT position

reduce Vt & increase RR to maintain minute ventilation

48
Q

Describe how to ventilate the dependent lung.

A

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)

49
Q

The recommended mode of ventilation for one lung ventilation is

A

volume or pressure control

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

50
Q

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

A

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)

51
Q

Alternatives to one lung ventilation includes:

A

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

52
Q

Apneic oxygenation is

A

useful for 10-20 minutes

can cause progressive respiratory acidosis: PaCO2 rises 6 mmHg first minute, 3-4 mmHg each subsequent minute

53
Q

Emergence with one lung ventilation may include

A

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

54
Q

If the patient is to remain intubated,

A

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

55
Q

A valsava may be used to

A

check for leaks if stapling bronchus

check for microbleeding to re-inflate collapsed lung

56
Q

Complications from thoracic anesthesia may include:

A 
hypoxemia/respiratory acidosis (#1 complication)
postoperative hemorrhage
arrhythmias
bronchial rupture
acute right ventricular failure
positioning injuries
57
Q

Hypoxemia/respiratory acidosis may result from

A

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

58
Q

Postoperative hemorrhage signs include

A

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

59
Q

The most common arrhythmia from thoracic anesthesia is

A

atrial fibrillation

60
Q

Acute right ventricular failure may present as

A

low CO, elevated CVP, oliguria

61
Q

Bronchial rupture may be the result of

A

excessive cuff inflation of the bronchial tube

Advanced Principles 2 (42 decks)

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