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AP Summer > Anesthesia for Thoracic Surgery > Flashcards

Anesthesia for Thoracic Surgery Flashcards

1
Q

What are some possible preoperative symptoms associated with thoracic surgery?

A 
Coughing/wheezing
Hemoptysis
Weight loss (advanced cancer)
Dyspnea
Pleuritic chest pain (problem spread to pleura)
Horner syndrome 
Hoarseness (RLN Damage)
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2
Q

What is Horner’s syndrome?

A

Also known as oculocephalic palsy it is the combination of ptosis, meiosis and anhydrosis on the ipsilateral side.
Ptosis = drooping eyelid
Meiosis = pupil construction
Anhydrosis = lack of sweating

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3
Q

What are some preoperative tests that may provide important information for patients undergoing thoracic surgery?

A

PFTs
Radiologic imaging
Cardiac assessment
Baseline ABG on RA

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4
Q

If a patient appears for thoracic surgery that has a Cushing’s appearance they may also have what syndrome?

A

Paraneoplastic syndrome

-Hormonal or other secretions from a tumor

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5
Q

What is the difference between resectability and operability?

A

Resectability refers to the tumor stage.

Operability refers to the patient’s health

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6
Q

Most thoracic surgical procedures are done under what type of anesthetic?

A

General

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7
Q

Why is positioning particularly important for patients undergoing thoracic procedures?

A

Surgical access
Ease of ventilation (VQ Mismatch)
Potential for pneumothorax
Possibility of nerve damage

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8
Q

What is VATS?

A

Video assisted thoracoscopic surgery

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9
Q

How does ventilation change between and anesthetized and the awake patient in the lateral decubitus position?

A

In the awake (spontaneous ventilation) patient VQ matching is normal

In the anesthetized patient VQ mismatching occurs at the upper lung is ventilated more and the lower lung is less compliant

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10
Q

When the chest cavity is open what happens to pleural pressure?

A

Normal negative pleural pressure is lost and the lung will normally collapse

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11
Q

Spontaneous ventilation with an open pneumothorax in the lateral position results in what two negative phenomena?

A

Mediastinal shift

Paradoxical respirations

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12
Q

How can we overcome mediastinal shift and paradoxical respiration?

A

By positive pressure ventilation during general anesthesia and thoracotomy

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13
Q

Paradoxical respirations and mediastinal shift can cause what to progressive problems?

A

Hypoxemia and hypercapnia

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14
Q

Intentional collapse of the lung on the operative side facilitates most thoracic procedures, but greatly complicates anesthetic management. Why?

A

When the collapsed lung continues to be perfused and is deliberately no longer ventilated the patient can develop a large right to left intrapulmonary shunt

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15
Q

What effect does one lung ventilation have on the alveolar to arterial oxygen gradient?
What is the end result?

A

It widens the alveolar to arterial oxygen gradient which often results in hypoxemia

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16
Q

How is this alveolar to arterial gradient difference overcome naturally by the body?

A

Blood flow to the non-ventilated lung is decreased by Hypoxic pulmonary vasoconstriction (HPV)

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17
Q

What factors are known to inhibit HPV and thus worsen the right to left shunt?

A 
Hypocapnia
Vasodilators & Ca2+ Channel Blockers
Inhalational anesthetics
PEEP
High PVR (Pulmonary infection)
Hypothermia
Extremes of mixed venous PO2
Extremes of PA pressures
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18
Q

What would a decrease in blood flow to the ventilated lung cause?

A

It would counteract the effect of HPV by indirectly increasing blood flow to the collapsed lung

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19
Q

What factors could possibly decrease blood flow to the ventilated lung?

A
  1. High mean airway pressures due to increased PEEP
  2. Low FiO2
  3. Vasoconstrictors (greater effect on normoxic than hypoxic vessels)
  4. Intrinsic PEEP that develops due to inadequate expiratory times.
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20
Q

What is the “3-legged stool?”

A

A pre-thoracotomy respiratory assessment that includes:

  1. Respiratory mechanics
  2. Cardiopulmonary reserve
  3. Long parenchymal function
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21
Q

When assessing respiratory mechanics the general cut off for success is a PPO greater than what percent?

A

PPO > 40%

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22
Q

What is a normal PPO?

A

80 to 100% predicted

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23
Q

What is FEV1?

A

Forced expiratory volume (1 sec)

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24
Q

What is the difference between volume and capacity?

A 
Volume = directly measured
Capacity = Some of 2+ volumes
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25
Q

What are some absolute indications for one lung ventilation?

A
  1. Contamination
  2. Control of distribution of ventilation
    - Airway fistula
    - Need for differential ventilation
  3. Bronchoalveolar lavage
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26
Q

What are some relative indications for one lung ventilation?

A 
Thoracic aneurysm
Pneumonectomy
Upper lobe procedures
Thoracoscopic surgery (usually requires)
Esophagectomy (Iver Louis)
Other lung resections
Transplant (Bilateral vs single)
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27
Q

How can one lung ventilation lead to hypoxemia?

A 
Hypoventilation
Shunt
Diffusion
Inadequate FiO2
VQ mismatch
Anemia
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28
Q

What can we do to manage hypoxemia with one lung ventilation?

A
  1. Maintain minute ventilation
    - Decreased tidal volume
    - Increased respiratory rate
  2. CPAP to non-ventilated lung
  3. PEEP to ventilated lung (avoid auto-PEEP)

Extreme: Have surgeon clamp pulmonary artery or reinstate two lung ventilation

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29
Q

In general, thoracic procedures are better tolerated on which side?

A

Left sided procedures because the right lung is bigger

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30
Q

What are three techniques used to facilitate one lung ventilation?

A
  1. Double lumen bronchial tube (R vs L)
  2. Use of a single lumen tracheal tube with a bronchial blocker
  3. Endobronchial intubation with a single lumen tube
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31
Q

Sizing of double lumen tubes depends on what?

A

Patient’s height

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32
Q

What are some advantages to double lumen tubes?

A

Relative ease of use
Ability to suction the non-ventilated lung
Ability to reposition
Ability to use CPAP

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33
Q

What are some disadvantages to double lumen tubes?

A
  • Can be challenging to place
  • Size limitations
  • Need to exchange if post-op ventilation is required
34
Q

What are some common sizes of double lumen tubes for men and women?

A 
Men = 39F (occ. 41)
Women = 37F (occ. 35)
35
Q

At what point during placement is the double lumen tube rotated?

A

DLT is rotated once the bronchial cough is past the cords

36
Q

What color is the bronchial cuff normally?

A

Bronchial = Blue

37
Q

How is proper placement of a DLT verified?

A

With a (pediatric) fiberoptic scope

38
Q

What is the average depth of a DLT?

A

29cm

39
Q

Which sided tubes are used most often?

A

Left (easier placement)

40
Q

All double lumen tube’s share what characteristics?

A
  1. A longer bronchial lumen
  2. Shorter tracheal lumen
  3. Preformed curve that allows preferential entry into the bronchus
  4. A bronchial and tracheal cuff
41
Q

The average adult trachea is how long?

A

11 to 13 cm

42
Q

What must a right-sided bronchial tube have?

A

A slit in the bronchial cuff for ventilating the right upper lobe

43
Q

After proper tube placement is confirmed and the patient is repositioned for surgery what must then be done?

A

Reconfirm tube position

44
Q

Malpositioning of a double lumen tube is usually indicated by what?

A

Poor lung compliance and low exhaled tidal volumes

45
Q

A problem with left sided DLT placement is usually related to what three possibilities?

A

The tube is too deep
Not deep enough
It entered the wrong bronchus

46
Q

What is the maximum amount of air that should be inflated into a bronchial cuff?

A

2cc of air

47
Q

When confirming placement of a DLT where should FFOB be placed first?

A

In the tracheal lumen

48
Q

What are some advantages of bronchial blockers?

A
  • *1. No need for tube exchange
    2. Easier intubation
    3. Some tubes can enable use of CPAP
49
Q

What is the major disadvantage of a bronchial blocker?

A

The “blocked” lung collapses slowly and sometimes incompletely

50
Q

When a DLT is in the correct position what can you expect to see on the ipsilateral and contralateral sides when the bronchial tube is clamped?

A

Ipsilateral (side clamped):

  • Breath sounds disappear
  • Hemithorax does not move
  • No moisture exchange in tube

Contralateral (ventilated side):

  • Breath sounds remain
  • Hemithorax rises and falls
  • Changes in respiratory gas moisture
  • Bag compliance expected for one lung ventilation
51
Q

In what patient population is endobronchial intubation most often used for one lung ventilation?

A

Pediatrics

52
Q

What are the ventilation goals for one lung ventilation?

A
  • 6 to 8 mL/kg to ventilated lung
  • aim for peak pressure < 25 cmH2O
  • Typically use PC
  • (+/-) PEEP
53
Q

What are some major complications of DLT’s?

A
  1. Hypoxemia
  2. Traumatic laryngitis
  3. Tracheobronchial rupture from over inflation of the bronchial cuff
  4. Inadvertent suture and of the tube to a bronchus during surgery
54
Q

What is the ratio of fractional blood flow between the dependent and non-dependent lungs in two lung ventilation vs one lung ventilation?

A

Two-Lung:
Dependent = 60. Non-dependent = 40

One-Lung:
Dependent = 77.5 Non-dependent = 22.5

55
Q

Lung resections are usually carried out for the diagnosis and treatment of what three causes?

A
  1. Lung tumors (most common)
  2. Pulmonary infections
  3. Bronchiectasis
56
Q

What are some examples of procedures that can be done as VATS?

A

Lung resection
Pericardial window
Esophageal surgery
Pleurodesis

57
Q

What two factors increase the incidence of arrhythmias during thoracic procedures?

A

Increased age

Increased amount of pulmonary resection

58
Q

What is post pneumonectomy syndrome?

A

Mediastinal shift which results in stretching and compression of tracheobronchial tree and esophagus following pneumonectomy

  • Shortness of breath (main symptom)
  • More common after left pneumonectomy
  • Treated with saline filled implants in vacant hemithorax
59
Q

When gaining central venous access during a thoracotomy the central venous line is preferentially placed on which side?

A

The side of the thoracotomy

60
Q

Post pneumonectomy pulmonary edema is most common when….

A
  • A right pneumonectomy was performed

- Aggressive periop Fluid resuscitation

61
Q

What happens to venous return when the chest is opened?

A

Venous return decreases when the chest is open because negative pleural (intrathoracic) pressure is lost on the operative side

62
Q

Excessive fluid administration in the lateral decubitus position may promote what syndrome?

A

Lower lung syndrome

63
Q

What is lower lung syndrome?

A

Gravity dependent transudation of fluid into the dependant lung

  • Increases intrapulmonary shunting
  • Promotes hypoxemia
  • Collapsed lung is prone to edema following reexpansion
64
Q

The greatest risk of one lung ventilation is _____

A

Hypoxemia

65
Q

What to post operative effects are common following atelectasis from surgical compression of the lungs and shallow breathing due to incisional pain?

A

Hypoxemia and respiratory acidosis

66
Q

What is the presentation of a bronchopleural fistula?

A

Sudden large airleak from the chest tube that may be associated with an increasing pneumothorax and partial lung collapse

67
Q

Acute herniation of the heart into the operative hemithorax can occur following a radical pneumonectomy. How will this present on the left versus the right?

A

Herniation into the LEFT hemithorax:

  • hypotension
  • ischemia
  • infarction

Herniation into the RIGHT hemithorax:

  • hypotension
  • elevated CVP
68
Q

How is massive hemoptysis usually defined for patients undergoing lung resection?

A

> 500-600 mL blood loss from tracheobronchial tree within 24hrs

69
Q

Tracheal resections are commonly performed for what reasons?

A

Tracheal stenosis
Tracheal mass/tumor
Extrinsic airway compression
Rarely congenital abnormalities

70
Q

What is the most valuable preoperative assessment for patients undergoing tracheal resection?

A

Flow volume loops confirm the location of the obstruction and aid the clinician in evaluating the severity of the lesion

71
Q

What type of anesthetic is usually necessary for patients undergoing a tracheal resection?

A

TIVA

Jet or cross-table ventilation

72
Q

What is the goal of lung volume reduction surgery (LVRS)?

A

To remove severely emphysematous lung tissue

73
Q

Where should the pulse ox and blood pressure cuff be placed for a patient undergoing a mediastinoscopy?

A

BP Cuff = Left

Pulse-Ox = Right

74
Q

Why must the pulse ox be placed on the right side and the blood pressure cuff on the left for patients undergoing a mediastinoscopy?

A

Compression of the Innominate artery

75
Q

What is another name for mediastinoscopy?

A

Chamberlain procedure

76
Q

What are some potential complications associated with the Chamberlain procedure?

A
  1. Reflex bradycardia
  2. Excessive hemorrhage
  3. Cerebral ischemia (compression of Innominate)
  4. Pneumothorax
  5. Air embolism
  6. RLN or Phrenic nerve damage
77
Q

When is lung transplantation indicated?

A

End stage lung disease or pulmonary hypertension

78
Q

What are some common comorbidities associated with end-stage lung disease?

A 
Liver disease (Alpha-1 antitrypsin deficiency)
Right heart failure
79
Q

What is important to remember in terms of PA and arterial pressures during lung transplantation?

A

Yellow can’t be > Red

Pulmonary Artery pressure should not exceed Arterial pressure

80
Q

What are some important considerations for postoperative analgesia?

A
  • Epidurals are important as part of pain control after major thoracic surgery (esp with chronic pain pts)
  • Multimodal analgesia (attack it from different angles) (IV narcotics, NSAIDs, Local)
81
Q

What two factors will necessitate cardiopulmonary bypass during transplantation of one lung?

A

Persistent arterial hypoxemia (SpO2 <88%)

Sudden increase in PA pressures

82
Q

What is superior vena cava syndrome?

A

The result of progressive enlargement of a mediastinal mass and compression of mediastinal structures particularly the vena cava.

-Associated with severe airway obstruction and CV collapse on induction

AP Summer (24 decks)

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