Anesthesia for thoracic surgery 3

Question 1

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

Answer 1

Video-assisted thorascopic surgery (VATS)

Question 2

Indications for thoracoscopic procedures include

Answer 2

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

Question 3

Advantages of VATs over thoracotomy

Answer 3

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

Question 4

Thoracoscopic surgery can be performed under

Answer 4

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

Question 5

Preoperative evaluation and planning

Answer 5

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

Question 6

Intraoperative considerations for thoracoscopic procedures include

Answer 6

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

Question 7

Intraoperative complications for thoracoscopic procedures include

Answer 7

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

Question 8

A mediastinoscopy is a

Answer 8

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

Question 9

Mediastinoscopy is performed through

Answer 9

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

Question 10

Compression to the innominate artery during a mediastinoscopy can

Answer 10

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

Question 11

Central airway obstruction may occur during mediastinoscopy due to

Answer 11

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

Question 12

The technique for mediastinoscopy is

Answer 12

GA with ETT

Question 13

Monitors for mediastinoscopy include

Answer 13

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

Question 14

Pathology of mediastinal tumors includes

Answer 14

neurogenic tumors
thymomas
lymphomas
cysts
vascular masses
esophageal lesions

Question 15

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

Answer 15

metastatic spread of malignancies

Question 16

Signs & symptoms associated with mediastinal masses typically include

Answer 16

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

Question 17

Mediastinal tumors are frequently associated with the following systemic syndromes:

Answer 17

myasthenia gravis
cushing's syndrome
hypercalcemia
hypertension
myasthenic syndrome

Question 18

Other signs & symptoms of mediastinal tumors include

Answer 18

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

Question 19

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

Answer 19

obstruction of venous drainage in the upper thorax

Question 20

Clinical manifestations of SVC syndrome include

Answer 20

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

Question 21

Describe how caval obstruction occurs.

Answer 21

venous distension in the neck, thorax, & upper extremities

Question 22

Describe why cyanosis occurs with SVC syndrome

Answer 22

mucosal edema & direct compression can severely compromise airflow in trachea

Question 23

Describe why cardiac output is impacted with SVC syndrome.

Answer 23

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

Question 24

Relative contraindications to mediastinoscopy include

Answer 24

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

Question 25

Absolute contraindications to mediastinoscopy include

Answer 25

inoperability coagulopathy thoracic aortic aneurysm

Question 26

Preoperative consideration for mediastinoscopy includes assessing for evidence of

Answer 26

airway compromise: dyspnea, tachypnea, tracheal compression or deviation

Question 27

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

Answer 27

preoperative CXR & CT scan

Question 28

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

Answer 28

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

Question 29

Many patients presenting for mediastinoscopy will favor the _________ position

Answer 29

upright

Question 30

Worsening of symptoms of mediastinal mass may be precipitated by

Answer 30

muscle relaxants, coughing, breath holding & position changes

Question 31

Monitoring for mediastinoscopy includes

Answer 31

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

Question 32

Complications of mediastinoscopy include:

Answer 32

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

Question 33

Describe the complication of acute airway obstruction.

Answer 33

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

Question 34

Describe the complication of difficult intubation and ventilation

Answer 34

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

Question 35

Describe the complication of venous air embolism.

Answer 35

HOB often 30 degrees elevation

Question 36

Describe the complication of mediastinal hemorrhage.

Answer 36

surgical bleeding more likely in patients with increased CVP | do not over hydrate patient, especially those with SVC syndrome

Question 37

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

Answer 37

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

Question 38

Describe anesthesia for mediastinoscopy.

Answer 38

deep anesthesia to blunt autonomic reflexes | vagally mediated reflex bradycardia from compression of trachea or great vessels

Question 39

When managing anesthesia for mediastinoscopy, monitor for

Answer 39

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

Question 40

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

Answer 40

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

Question 41

Describe emergence for mediastinoscopy.

Answer 41

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

Question 42

Major complications of mediastinoscopy include:

Answer 42

``` hemorrhage pneumothorax RLN injury phrenic nerve injury/left hemiparesis esophageal injury air embolism dysrhythmias ```

Question 43

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

Answer 43

fiberoptic bronchoscopy & a detailed knowledge of bronchial anatomy

Question 44

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

Answer 44

double-lumen endobronchial tubes | -bronchial blockers are a reasonable alternative for lung isolation in patients with abnormal upper or lower airways

Question 45

Patients undergoing pulmonary resection should have a preoperative assessment of their

Answer 45

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

Question 46

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

Answer 46

cessation of smoking, physiotherapy, & thoracic epidural anesthesia

Question 47

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

Answer 47

cardiac complications, particularly arrhythmias

Question 48

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

Answer 48

preoperative exercise capacity

Question 49

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

Answer 49

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

Question 50

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

Answer 50

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