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Advanced Principles 2 > Anesthesia for thoracic surgery 3 > Flashcards

Anesthesia for thoracic surgery 3 Flashcards

1
Q

The use of video camera and surgical instruments inserted through ports in the thoracic wall; usually 3-5 ports are used

A

Video-assisted thorascopic surgery (VATS)

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2
Q

Indications for thoracoscopic procedures include

A 
lung biopsy
wedge resection
biopsy of hilar & mediastinal masses
esophageal & pleural biopsy
pericardiectomy
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3
Q

Advantages of VATs over thoracotomy

A

smaller incision; no intraoperative rib spreading; less postoperative pain
less risk of postoperative hypoxemia
faster recovery & discharge from hospital

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4
Q

Thoracoscopic surgery can be performed under

A

local, regional, or general anesthesia with two-lung ventilation or OLV

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5
Q

Preoperative evaluation and planning

A

discuss pain management options with patient

  • PCA (for chest tube pain) & NSAIDs are usual after thoracoscopy
  • consult with surgeon about likelihood of proceeding to thoracotomy
  • otherwise same as with thoracotomy
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6
Q

Intraoperative considerations for thoracoscopic procedures include

A

GA/OLV with DLT or bronchial blocker is common
infiltration with local anesthesia by surgeon prior to placement of ports
lateral decubitus position
routine monitors
minimum one large bore PIV
a-line usually placed
end of procedure- lung is suctioned & gently re-inflated- change DLT to standard ETT if patient cannot be extubated
chest tube placed prior to closing

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7
Q

Intraoperative complications for thoracoscopic procedures include

A

CO2 insufflated used to improve surgical visualization- gas embolism & hemodynamic compromise
tension pneumothorax (rare)
hemorrhage (rare)
perforation of diaphragm or other organs (rare)
complications related to positioning and DLT

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8
Q

A mediastinoscopy is a

A

procedure is usually performed with lymph node or tissue biopsy to either establish a diagnosis (carcinoma of the lung, thymoma, or lymphoma), or to determine resectabilty of an intrathoracic tumor

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9
Q

Mediastinoscopy is performed through

A

small transverse incision just above suprasternal notch

blunt dissection along pre-tracheal fascia permits biopsy of paratracheal lymph nodes to the level of the carina

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10
Q

Compression to the innominate artery during a mediastinoscopy can

A

cause poor flow to right carotid artery and the right arm resulting in poor cerebral perfusion

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11
Q

Central airway obstruction may occur during mediastinoscopy due to

A

compression of the trachea during induction or manipulation of the mediastinoscope near the trachea

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12
Q

The technique for mediastinoscopy is

A

GA with ETT

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13
Q

Monitors for mediastinoscopy include

A

monitor a-line/pulse ox on RIGHT arm- if absent waveform ask surgeon to reposition mediastinoscope
BP on left

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14
Q

Pathology of mediastinal tumors includes

A 
neurogenic tumors
thymomas
lymphomas
cysts
vascular masses
esophageal lesions
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15
Q

90% of lymph node masses in the middle mediastinum result from

A

metastatic spread of malignancies

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16
Q

Signs & symptoms associated with mediastinal masses typically include

A

most are asymptomatic and discovered incidentally on CXR
symptomatic masses are usually malignant and are larger with extensive involvement- airway obstruction, impaired cerebral circulation, distortion of anatomy

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17
Q

Mediastinal tumors are frequently associated with the following systemic syndromes:

A 
myasthenia gravis
cushing's syndrome
hypercalcemia
hypertension
myasthenic syndrome
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18
Q

Other signs & symptoms of mediastinal tumors include

A

cough, dyspnea, stridor, jugular distention, exaggerated changes in BP associated with postural changes

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19
Q

Progressive mediastinal tumor growth may result in compression of the SVC which leads to

A

obstruction of venous drainage in the upper thorax

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20
Q

Clinical manifestations of SVC syndrome include

A

Caval obstruction
edema of the face, conjunctiva, neck & upper chest
edema of the mouth, larynx, and airway obstruction
cyanosis
decreased cardiac output
increased ICP
venous backflow into upper extremity IV lines

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21
Q

Describe how caval obstruction occurs.

A

venous distension in the neck, thorax, & upper extremities

22
Q

Describe why cyanosis occurs with SVC syndrome

A

mucosal edema & direct compression can severely compromise airflow in trachea

23
Q

Describe why cardiac output is impacted with SVC syndrome.

A

may be severely depressed due to impeded venous return from upper body or by direct mechanical compression on the heart from tumor

24
Q

Relative contraindications to mediastinoscopy include

A 
SVC syndrome
previous mediastinoscoy
obstruction & distortion of airway
impaired cerebral circulation 
myasthenic syndrome
25
Q

Absolute contraindications to mediastinoscopy include

A

inoperability
coagulopathy
thoracic aortic aneurysm

26
Q

Preoperative consideration for mediastinoscopy includes assessing for evidence of

A

airway compromise: dyspnea, tachypnea, tracheal compression or deviation

27
Q

____________ are essential to assess size & location of tumor & to evaluate tracheal distortion or compression

A

preoperative CXR & CT scan

28
Q

If airway compression is present in patients presenting for mediastinoscopy, obtain

A

PFTs in upright & supine positions: flow-volume loops detect airway obstruction

29
Q

Many patients presenting for mediastinoscopy will favor the _________ position

A

upright

30
Q

Worsening of symptoms of mediastinal mass may be precipitated by

A

muscle relaxants, coughing, breath holding & position changes

31
Q

Monitoring for mediastinoscopy includes

A

large bore PIV x 2- may need to place in LE’s if s/s of SVC syndrome
monitor right radial pulse: doppler, arterial pressure line, pulse ox on right hand
blood pressure cuff monitoring in left arm
peripheral nerve stimulator

32
Q

Complications of mediastinoscopy include:

A 
acute airway obstruction
difficulties with intubation & ventilation
venous air embolism
mediastinal hemorrhage (most common complication)
33
Q

Describe the complication of acute airway obstruction.

A

long-standing tumors may cause tracheal malasia leading to tracheal collapse
GA with reinforced ETT

34
Q

Describe the complication of difficult intubation and ventilation

A

have different ETT sizes available
establish ability to ventilate BEFORE muscle relaxation
muscle relaxation intraop to prevent coughing or straining

35
Q

Describe the complication of venous air embolism.

A

HOB often 30 degrees elevation

36
Q

Describe the complication of mediastinal hemorrhage.

A

surgical bleeding more likely in patients with increased CVP

do not over hydrate patient, especially those with SVC syndrome

37
Q

If airway obstruction or SVC obstruction occurs, place the patient in

A

lateral, reverse trendelenburg, prone or high-Fowlers position–> may cause mass to shift away from trachea or SVC and relieve the obstruction

38
Q

Describe anesthesia for mediastinoscopy.

A

deep anesthesia to blunt autonomic reflexes

vagally mediated reflex bradycardia from compression of trachea or great vessels

39
Q

When managing anesthesia for mediastinoscopy, monitor for

A

instrument pressure against innominate, right subclavian, or right carotid arteries- loss of distal pulse, postoperative neurologic deficits

40
Q

It is important to observe postoperative respiratory status closely for mediastinoscopy because

A

injury to recurrent laryngeal nerve (3rd most common injury) may result in hoarseness, vocal cord paralysis
injury to phrenic nerve

41
Q

Describe emergence for mediastinoscopy.

A

prior to extubation- full TOF, full return of airway reflexes, patients with SVC syndrome must be fully awake as they can easily obstruct
postoperative CXR on all patients to rule out pneumothorax

42
Q

Major complications of mediastinoscopy include:

A 
hemorrhage
pneumothorax
RLN injury
phrenic nerve injury/left hemiparesis
esophageal injury
air embolism
dysrhythmias
43
Q

The ability to perform________ and a detailed knowledge of ______ are necessary to provide reliable lung isolation

A

fiberoptic bronchoscopy & a detailed knowledge of bronchial anatomy

44
Q

The standard method of providing lung isolation in adults is use of

A

double-lumen endobronchial tubes

-bronchial blockers are a reasonable alternative for lung isolation in patients with abnormal upper or lower airways

45
Q

Patients undergoing pulmonary resection should have a preoperative assessment of their

A

respiratory function in three areas: lung mechanical function, pulmonary parenchymal function & cardiopulmonary reserve

46
Q

Interventions that have been shown to decrease the incidence of respiratory complications in high-risk patients undergoing thoracic surgery include

A

cessation of smoking, physiotherapy, & thoracic epidural anesthesia

47
Q

Geriatric patients are at a high risk for _____ after large pulmonary resections

A

cardiac complications, particularly arrhythmias

48
Q

The best predictor of post-thoracotomy outcome in the elderly includes

A

preoperative exercise capacity

49
Q

The use of large tidal volumes during OLV, can contribute to

A

acute lung injury, particularly in patients at increased respiratory risk such as after pneumonectomies

50
Q

With the use of intravenous anesthetic techniques or volatile anesthetics at less than or equal to 1 MAC doses,

A

hypoxemia during one-lung ventilation occurs infrequently
-the use of CPAP or PEEP as treatment for hypoxemia during OLV should be guided by the individual patient’s lung mechanics

Advanced Principles 2 (42 decks)

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