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NUNA 692 Principles III > Exam II Anesthesia For Thoracic Surgery > Flashcards

Exam II Anesthesia For Thoracic Surgery Flashcards

1
Q

Leading cause of cancer deaths in the US

A

Bronchogenic cancer

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2
Q

Better prognosis with _____ than with ____ or _____

A

Resection
Chemo
Radiation

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3
Q

COPD patients ___ ____ ____ to get lung cancer

A

4x more likely

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4
Q

Bronchogenic cancer has ____ ____ d/t aging population and co-morbidities

A

Increasing morbidity

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5
Q

___ needing resections are disqualified d/t ____ ____ ____

A

40%
Poor pulmonary function

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6
Q

____-_____ ____ ____ has led to a decrease in postop complications such as dysrhythmias, MI, PE, PNA, and emphysema

A

Video-assisted thoracic surgery (VATS)

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7
Q

Bronchogenic cancer risk factors: (3)

A
  • smoking
  • air pollution
  • industrial chemicals
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8
Q

Smokers need evaluation for ____ or ___ ___ ___

A

HTN
Ischemic heart disease

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9
Q

____ history needs stress testing

A

COPD

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10
Q

Continue ____ ____ throughout perioperative course

A

Beta blockers

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11
Q

Consider ___ ___ ____ if coronary bypass needed

A

6-week delay

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12
Q

Radiographic airway evaluation for ______ _____

A

Mediastinal masses

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13
Q

Endocrine evaluation - rule out _____ _____ caused by some lung tumors

A

Paraneoplastic syndromes

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14
Q

Neuroendocrine tumors can cause ____ _____

A

Carcinoid syndrome

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15
Q

_____ occurs in up to 25% of lung cancer pts

A

Hypercalcemia

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16
Q

Hypercalcemia symptoms: (6)

A
  • polyuria
  • polydipsia
  • confusion
  • vomiting
  • abdominal cramping
  • bradycardia
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17
Q

COPD symptoms: (4)

A
  • paradoxical breathing
  • tympanic chest percussion
  • rhonchi
  • wheezing
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18
Q

cor pulmonale symptoms: (4)

A
  • jugular vein distention
  • peripheral edema
  • split S2
  • rales
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19
Q

Need a CXR in pre-op to test for:
[Pre-op Testing]

A
  • airway eval
  • CHF
  • PTX
  • tracheal shift
  • PA enlargement (sign of increased PVR)
    -Eval for airway infringement
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20
Q

EKG: tall R in V1 =

A

RVH

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21
Q

EKG: biphasic P in V1 =

A

R atrial hypertrophy

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22
Q

EKG: look for (3)

A
  • ST depression
  • BBBs
  • T inversion
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23
Q

EKG: Pathologie Q waves + LVH =

A

Increased risk of ischemia/infarction

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24
Q

Best initial tool for pulmonary HTN but higher level studies may need to follow

A

Echo

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25
Q

Labs to check for COPD patients: (5)

A
  • room air ABG to check for CO2 retention (>45 = poor function)
  • SpO2 < 90% = increased risk of complications
  • albumin < 3.6 g/dL (common) = 2.5x higher risk
  • BUN > 22 mg/dL = increased risk
  • renal fxn labs (esp with chemo)
  • lytes (esp Na, K, Ca)
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26
Q

PFTs: significant improvement = ____ increase in ____ after bronchodilators

A

12% increase in FEV1

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27
Q

PFTs: ___ ____ test is a good predictor. ___-____ testing is best

A

No single
Multi-modal

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28
Q

PFTs: general cutoffs for increased risk: ____, _____, and _____ < 40%

A

PPO (predicted post op)
FEV1 (forced expiratory volume/1 second)
DLCO (diffusion in the lung of carbon monoxide)

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29
Q

PFTs: general cutoffs for increased risk: ____ ____ < 15(10) mL/kg/min

A

VO2 max (ability to climb 5 flights of stairs = > 20, inability to climb 1 flight = < 10)

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30
Q

Non CV surgeries:
____ of smokers have complications
____ of past smokers have complications
____ non-smokers have complications

A

22%
13%
5%

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31
Q

Lung cancer patients: ___ are smokers

A

87%

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32
Q

With lung cancer, smokers have a ____ ____

A

1.5% mortality

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33
Q

With lung cancer, non-smokers have ____ ____

A

0.4% mortality

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34
Q

Pack-year index = ____/____x____

A

Packs / day x years

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35
Q

____ = increased complications over moderate smokers

A

> 20

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36
Q

Smoking cessation ____ ____ ____ = NO difference in outcomes or possibly worse d/t increased _____ _____

A

< 4 weeks
Mucus production

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37
Q

_____ drops and _____ _____ improves in 1-2 weeks but NO difference in outcomes

A

Carboxyhemoglobin
Mucociliary clearance

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38
Q

Some improvement in ___ ____ but more at ___ ____

A

4 weeks
8 weeks

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39
Q

Smoking is difficult to successfully intervene d/t ___ ____ of treating ____ ____

A

Urgent nature
Lung cancer

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40
Q

_____ monitoring

A

Standard

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41
Q

___ ___ best for dysrhythmias

A

Lead II

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42
Q

____ is best for ischemia

A

V5

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43
Q

Consistent findings: ____ ____ significantly most effective

A

Lead combo (lead II and V5)

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44
Q

Arterial line should be placed in the _____ arm

A

Dependent

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45
Q

____ optional

A

Foley

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46
Q

PAC evidence: (3)

A
  • NO improvement in outcomes
  • frequent inaccurate measurements
  • caution in vessels that could be clamped or ligated
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47
Q

____ for complex cases with large fluid shifts. Caution with ____. Insert _____ on _____ side

A

CVP
EJs (easily kinked in lateral position)
Subclavian
Operative

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48
Q

Insert subclavian CVP on operative side why?

A

Don’t want a double pneumo

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49
Q

Trachea:
__-__ cm long
Begins at ____
Bifurcates at ____

A

11-12 cm long
C6 (cricoid cartilage)
T5 (sternomanubrial joint)

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50
Q

R mainstem bronchus:
Wider
Angles ____ from trachea at ____
Divides into ____ lobar branches
Orifice of right upper lobe __ to ___ cm from carina

A

Away from trachea at 20 degrees
3 (upper, middle, lower)
1-2 cm from carina

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51
Q

L mainstem bronchus:
Narrower
Angles ____ from trachea at ____
Divides into ___ lobar branches
Orifice of left upper lobe ___ cm from carina

A

Away from trachea at 45 degrees
2 (upper, lower)
5 cm from carina

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52
Q

Perfusion (Q): increases from ___ to ____ with awake, spontaneous ventilation

A

Apex to base

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53
Q

Ventilation (V): increases from ____ to ____. More ____ pressure in the apices keeps alveoli _____.

A

Apex to base
Negative
Distended

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54
Q

Alveoli in bases less _____, more _____, so most tidal breathing (air movement) distributed to the _____.

A

Distended
Compliant
Bases

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55
Q

V/Q not being perfectly correlated net result is…

A

V/Q matching well enough for efficient gas exchange

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56
Q

More _____ pressure in the apices keeps alveoli _____

A

Negative
Distended

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57
Q

Alveoli in bases less _____, more _____, so most tidal breathing is distributed to ____

A

Less distended
More compliant
Distributed to bases

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58
Q

Lateral Awake: _____ displacement of diaphragm on DEPENDENT side

A

Cephalad

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59
Q

Lateral Awake: So, during inspiration, diaphragm can contract further leading to better ventilation of _____ lung

A

Dependent

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60
Q

Lateral Awake: Perfusion _____ in _____ lung (gravity)

A

Higher
Dependent

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61
Q

Lateral Awake: Net result of V/Q and gas exchange

A

Net result of V/Q - no significant change
Gas exchange is efficient

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62
Q

Lateral, anesthetized, spont vent, chest closed: induction leads to decreased ____ ____ ____

A

Functional residual capacity (FRC)

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63
Q

Lateral, anesthetized, spont vent, chest closed: Cephalad diaphragm displacement leads to ____ _____

A

Decreased FRC

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64
Q

Lateral, anesthetized, spont vent, chest closed: ______ lung is more compliant leading to _____ ventilation

A

NonDependent
Increased

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65
Q

Lateral, anesthetized, spont vent, chest closed: _____ lung is more _____ (gravity)

A

Dependent
Perfused

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66
Q

Lateral, anesthetized, spont vent, chest closed: V/Q net result

A

Mismatched

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67
Q

Lateral, paralyzed, mech vent, chest closed: with mech vent, diaphragm no longer helps maintain ____ leading to further decrease in ventilation in _____ lung and increased vent in ______ lung and ____ V/Q mismatch

A

FRC
Dependent
NonDependent
More

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68
Q

Lateral, paralyzed, mech vent, chest closed: PEEP ____ ____ leading to ____ V/Q mismatch

A

Improves FRC
Less

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69
Q

Lateral, anesthetized, chest open: huge reduction in resistance in ______ lung leading to increased ventilation in _____ lung and further decreased vent in ______ lung

A

NonDependent
NonDependent
Dependent

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70
Q

Lateral, anesthetized, chest open: Mediastinum shifts _____ d/t loss of _____ _____ pressure

A

Downward
Negative intrathoracic pressure

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71
Q

Lateral, anesthetized, chest open: Vessels can be _____ leading to decreased ____ ____

A

Compressed
Cardiac output

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72
Q

Lateral, anesthetized, chest open: With spontaneous vent (theoretically) leads to _____, _____ exchange. Air from the open-chest _____ lung moves into the ______ lung

A

Paradoxical, inefficient
NonDependent
Dependent

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73
Q

Paradoxical Respiration: during inspiration, air from the open-chest ______ lung moves into the ______ lung

A

NonDependent
Dependent

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74
Q

Paradoxical Respiration: During expiration, air moves from ____ lung to the open-chest _____ lung

A

Dependent
NonDependent

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75
Q

Paradoxical Respiration: _____ ventilation helps, but ______ lung is much better ventilated. ______ lung is much better perfused. (Gravity)

A

Mechanical
NonDependent
Dependent

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76
Q

Paradoxical Respiration: Net result - major ____ _____ in dependent lung

A

Physiologic shunt

reminder that this is theoretical and should NOT occur

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77
Q

With mechanical (positive pressure) ventilation, Paradoxical Respiration and Mediastinal shift are _____. But _____ compliance of the NonDependent lung in open chest leads to ____ _____ _____

A

Reduced
High
HUGE V/Q mismatch

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78
Q

What situation has the worst V/Q mismatch? And why do you care?

A

Lateral, anesthetized, paralyzed, open-chest patient

We care bc we have to deal with this exact situation for the duration of the surgery

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79
Q

Lateral, open-chest, one-lung ventilation (OLV): ____ resistance, _____ compliance of NonDependent lung which leads to ____ ventilation

A

Low
High
High

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80
Q

Lateral, open-chest, one-lung ventilation (OLV): _____ in dependent lung leads to ____ perfusion

A

Gravity
High

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81
Q

Lateral, open-chest, one-lung ventilation (OLV): When vent stops in NonDependent lung, all _____ is diverted to _____ lung

A

Ventilation
Dependent

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82
Q

Lateral, open-chest, one-lung ventilation (OLV): Perfusion to ______ lung now creates a ______

A

NonDependent
Shunt

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83
Q

Lateral, open-chest, one-lung ventilation (OLV): BUT HPV in ______ lung diverts perfusion to ______ lung and decreases the ______ effect

A

NonDependent
Dependent
Shunt

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84
Q

Lateral, open-chest, one-lung ventilation (OLV): Net result - ____ V/Q mismatch (clinical picture ____ when _____ lung is clamped)

A

Less
Improves
NonDependent

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85
Q

Patient Related (isolation) indications for Lateral, open-chest, one-lung ventilation (OLV): (6)

A
  • lung abscess
  • copious bleeding on one side
  • bronchopulmonary fistula
  • bronchial rupture
  • large lung cyst
  • bronchopleural lavage
86
Q

Procedure Related (exposure) Indications for Lateral, open-chest, one-lung ventilation (OLV): (7)

A
  • thoracic aortic aneurysm
  • pneumonectomy
  • upper lobectomy
  • thoracostomy/thoracoscopy
  • lower/middle lobectomies
  • sub-segmental resections
  • esophageal surgery
87
Q

Double-Lumen EBTs: ____ tube, _____ lumen

A

Single
Double

88
Q

Double-Lumen EBTs: __ or __ available

A

L or R

89
Q

Double-Lumen EBTs: Right DLTs designed to ventilate ____

A

RUL

90
Q

Double-Lumen EBTs: ____ almost never used d/t missed ____ if not positioned perfectly

A

R DLT
RUL

91
Q

Double-Lumen EBTs:
External French sizes -
Internal sizes -

A

External - 26, 28, 35, 37, 39, 41
Internal - 3.4 - 6.6 mm

92
Q

Double-Lumen EBTs: Sizing based on ____

A

Height

93
Q

Double-Lumen EBTs: Usual sizing ___, ___ in females, and ___, ___ in males

A

35, 37
39, 41

94
Q

Double-Lumen EBTs:
35 French DLT = ____ mm (ID)
41 French DLT = ____ mm (ID)

A

5.5
6.5

95
Q

Double-Lumen EBTs: Have ____ outer diameters. Ex 37 Fr DLT has outer diameter equivalent to ____ mm ID standard ETT

A

Larger
11

96
Q

Contraindications for L DLT (indications for R DLT): (5)

A
  • distorted L main bronchus d/t mass
  • compression of L main bronchus d/t aortic aneurysm
  • left-sided pneumonectomy
  • left-sided single lung transplantation
  • left-sided sleeve resection
97
Q

Most common DLT complication:

A

Malposition

98
Q

Other common DLT complications: (5)

A
  • thoracic aneurysm rupture with L DLT
  • vocal cord damage from carinal hook, or hook breaking off
  • bronchial cuff rupture d/t over-inflation
  • barotrauma if DLT inserted too deeply
  • inadvertent suturing of DLT to bronchus
99
Q

Insertion of DLT: stylet through the _____ lumen, _____ blade, _____ DLT

A

Bronchial
Mac
Lube

100
Q

Insertion of DLT: Insert with _____ curve, through ____ ____, remove _____

A

Anterior curve (over and under shotgun)
Vocal cords
Stylet

101
Q

Insertion of DLT: Turn ___ ____ toward R (or L) bronchus and advance until _____.
(Male approx. ____ cm, female approx. ____ cm)

A

90 degrees
Resistance

29
27

102
Q

Insertion of DLT: Inflate ____ cuff, verify ____, inflate ____ cuff

A

Tracheal
BBS
Bronchial

103
Q

Insertion of DLT: Auscultate per _____

A

Protocol

104
Q

Insertion of DLT: _____ ____ to verify. (Up to ____ of DLTs are malpositioned when verified by _____ ____)

A

Fiberoptic scope
80%
Auscultation only

105
Q

Insertion of DLT: Position patient into _____ position and then then _____ with _____

A

Lateral
Re-verify
FOB

106
Q

Insertion of L DLT: (7 steps)

A
  1. Inflate tracheal cuff (5-10 mL)
  2. Check for BBS (unilateral = too deep)
  3. Inflate bronchial cuff (1-2 mL)
  4. Clamp tracheal lumen
  5. Check for unilateral L BS
  6. Unclamp tracheal lumen, clamp bronchial lumen
  7. Check for unilateral R BS. If absent or weak R BS, DLT is too shallow, occluding the distal trachea
107
Q

Insertion of L DLT: after clamping tracheal lumen, you check for unilateral L BS. However, if you hear
- R BS also
- Unilateral R BS
- No R BS, no LUL BS
It means:

A
  • R BS also means: bronchial lumen is in trachea, Advance the DLT into L side.
  • Unilateral R BS means: DLT in R bronchus
  • No R BS, no LUL BS means: DLT too deep into L side
108
Q

Bronchial Blockers: catheter with ______ ______ to block _____ lung bronchus

A

Inflatable balloon
Operative

109
Q

Bronchial Blockers: Types (2)

A
  • side-channel (Univent)
  • separate devices through or outside of regular ETT
110
Q

Bronchial Blockers: Place with ____ guidance

A

F/O

111
Q

Bronchial Blockers: May be better with _____ airways than _____

A

Difficult
DLTs

112
Q

Bronchial Blockers: Use when ____ _____ is risky

A

ETT change

113
Q

Bronchial Blockers: Can be used in _____

A

Children

114
Q

Bronchial Blockers: Higher incidence than DLT of _____

A

Malposition

115
Q

Bronchial Blockers: Lung deflation ____ _____ than DLT

A

Less effective

116
Q

Bronchial Blockers: No ability to _____ below balloon

A

Suction

117
Q

Bronchial Blockers: Caution with removal on _____ lung cases

A

“Dirty”

118
Q

Bronchial Blockers: Same problem as DLT with missing ____. Usually only used for ___ ___ surgery

A

RUL
Left side surgery

119
Q

During OLV, NonDependent (deflated) lung becomes ___ ___ leading to decreased ____

A

Shunt flow
PaO2

120
Q

Hypoxia pulm vasoconstriction: lungs compensate by increasing _____ _____ in _____ areas which diverts perfusion to areas with better ______. (_____ phenomenon from general circulation)

A

Vascular resistance
Hypoxic
Ventilation
Reverse

121
Q

HPV is caused by ____ hypoxia, NOT ____ hypoxemia

A

Alveolar
Arterial

122
Q

HPV and OLV net result

A

Pulm blood flow matched to better oxygenated areas of the lung (improved VQ matching)

123
Q

W/O HPV, approx ___ ___ would result

A

40% shunt

124
Q

HPV occurs within seconds of _____, max effect in a few mins, can be maintained for ____ ____

A

Hypoxia
Long periods

125
Q

HPV improves SaO2 during __-__ lung hypoxia which is the ____ ____ present with OLV

A

20-80%
Usual condition

126
Q

We can facilitate the effectiveness of HPV by AVOIDING: (7)

A

AVOIDING
- alkalosis/hypocapnea
- excessive PIP, TV, or PEEP
- hemodilution/hypervolemia (L atrial pressure > 25 mmHg)
- prostacyclins
- hypothermia
- vasodilators, PDE inhibitors, CCBs
- > 1.5 MAC of volatiles

127
Q

Anesthetic agents: ____ are a good choice because they are ______, allow for high FiO2, ____ elimination for emergence

A

Volatiles
Bronchodilators
Rapid

128
Q

Anesthetic agents: ____ ____ does NOT inhibit HPV

A

<1.5 MAC volatile

129
Q

Anesthetic agents: ____ do not inhibit HPV. But ___ ____ in outcomes when compared to volatiles

A

TIVAs
No difference

130
Q

Anesthetic agents: Use ___/___ mix

A

Air/O2

131
Q

Anesthetic agents: Avoid ____. It increases ____ and moves into ____ and _____

A

N2O
PVR
Bullae and cysts

132
Q

Anesthetic agents: Avoid potential ____ ____. Can be deadly.

A

Residual blockade

133
Q

Anesthetic agents: Use _____ relaxants, _____, antagonize.

A

Intermediate
MONITOR

134
Q

Regional Anesthesia: ____ required for open lung case but ____ good choice for post-op pain control

A

GA
Regional

135
Q

Regional Anesthesia: ______ from epidural, ______ does not appear to affect local HPV

A

Vasodilation
Sympathectomy

136
Q

Regional Anesthesia: ____ can cause same response as heavy opioids: decreased _____ ____, ____, _____

A

Pain
Respiratory effort, hypoxemia, acidosis

137
Q

Regional Anesthesia: Good choices (5)

A
  • IV PCA
  • thoracic epidural (T6-T8)
  • paravertebral nerve block
  • ketamine
  • NSAIDs
138
Q

____ of thoracotomy patients have pain ___ ___ out. 1/3 have pain at ____ ____ out.

A

50%
1 year
4 years

139
Q

Primary goals of anesthetic management: maintain adequate ____, protect ____, provide favorable ____ ____

A

Oxygenation
Lungs
Surgical field

140
Q

Protective ventilation strategies: physiologic VT of ____ (____ needed on the left)

A

6-8 mL/kg
Less

141
Q

Protective ventilation strategies: PEEP as low as possible to _____ lung

A

Dependent

142
Q

Protective ventilation strategies: Limit PiPs to ___-___

A

20-25 cm H2O

143
Q

Protective ventilation strategies: Permissive ______ (____) to support HPV

A

Hypercapnia (< 60 mmHg)

144
Q

Protective ventilation strategies: ___/___ mix at lowest level that maintains _____. (But ____ ____ frequently needed)

A

Air/O2
PaO2
100% O2

145
Q

Protective ventilation strategies: ____ limiting ventilation modes

A

Pressure

146
Q

___ lung is larger than ___ lung so hypoxemia will be worse in ___ ____ procedures

A

Right
Left
R-side

147
Q

____ can be predictive of intraoperative shunting

A

EtCO2

148
Q

the degree of drop in EtCO2 when shifting to OLV is proportionate to _____ of the ______ lung

A

Perfusion
NonDependent

149
Q

The greater the initial drop in EtCO2, the ____ chance of ____ during OLV

A

Greater
Hypoxia

150
Q

Causes of OLV hypoxia: (6)

A
  • tube Malposition (check first)
  • bronchospasm
  • drop in cardiac output
  • hypoventilation
  • low FiO2
  • PTX of dependent lung (the only good lung)
151
Q

If still hypoxic, ____ to NonDependent lung. Start at ___ ____ and use the lowest possible ____

A

CPAP
2 cmH2O
Pressure

152
Q

Too much CPAP inflates the lung causing a ____ ____ ____

A

Surgical exposure problem

153
Q

For CPAP, can use _____ system or CPAP _____

A

Breathing
Valve

154
Q

Can use ___ ___ O2 via catheter insufflated through ______ circuit limb

A

Low flow
NonDependent

155
Q

Can ____ ventilate _____ lung with very small TV

A

Hand
NonDependent

156
Q

PEEP can be delivered to _____ lung

A

Dependent

157
Q

PEEP produces alveolar _____, increases ____ ____ and _____

A

Recruitment
Lung compliance and FRC

158
Q

High PEEP leads to decreased ____ ____

A

Cardiac output

159
Q

____ + ____ = auto PEEP effect with CO2 retention and lung ____

A

PEEP + fast rate
Trauma

160
Q

____ _____ of NonDependent lung, this is where communication with surgeon is vital

A

Intermittent reinflation

161
Q

______ to NonDependent lung (can cause movement and ____ ____)

A

HFJV
CO2 retention

162
Q

Selective oxygenation of non-operative lobes of ______ lung with _____ _____ or _____

A

NonDependent
Bronchial blocker
FOB

163
Q

Early _____ of pulm artery for ______

A

Ligation
Pneumonectomies

164
Q

After procedure, ____ NonDependent (operative side)

A

Unclamp

165
Q

After procedure, use PiP of ___-___ cm H2O to _____ NonDependent lung

A

30-40 cm H2O
Reinflate

166
Q

After procedure, ____ bronchial cuff

A

Deflate

167
Q

Inhaled selective pulm vasodilators such as ____ ____ and _____ can help with perfusion

A

Nitric oxide (NO)
Prostacyclin

168
Q

New research: _____ to NonDependent lung with ____ to dependent lung (100% increases PaO2)

A

Almitrine
NO

169
Q

Almitrine promotes ____ in NonDependent lung. (____ ____ ____ agonist)

A

HPV
Carotid body chemoreceptor

170
Q

NO is _____, _____, requires complex ____-___ independent of anesthesia machine with dedicated RT.

A

Expensive, toxic, requires complex set-up

171
Q

Most mediastinal masses are _____

A

Asymptomatic

172
Q

Symptomatic masses are usually ____ (larger with extensive involvement)

A

Malignant

173
Q

Mediastinal tumors are frequently associated with systemic syndromes which include: (6)

A
  • MG (thymoma)
  • cushing’s syndrome (thymoma, carcinoid)
  • hypercalcemia (parathyroid adenoma)
  • HTN
  • myasthenic syndrome (lung cancer)
  • cough, dyspnea, stridor, jugular distention, exaggerated postural changes in BP
174
Q

Mediastinal mass: Problematic with _____ position; VERY problematic with _____/_____

A

Supine
Induction/anesthesia

175
Q

Mediastinal mass: Loss of _____ vent leads to potential airway collapse

A

Spontaneous

176
Q

Mediastinal mass: If distal to ETT, ventilation can be _____. Have ___/___ _____ available before induction.

A

Impossible
ENT/rigid bronchoscope

177
Q

Mediastinal mass: Mass encroaching on ___, ____, or ____ ____ can cause potential CV collapse. ____ would need to be initiated immediately.

A

Heart, aorta, or vena cava
CP bypass

178
Q

Mediastinal mass: Pre-op eval - ___, ___, ____, ____, ____, to determine size, location, compression effects

A

CXR, CT, MRI, TEE, PFTs

179
Q

Mediastinal mass: ____ to shrink mass before surgery

A

Radiate

180
Q

Mediastinal mass: ____ ____ ____ ____ - venous distention of thorax and neck, redness/edema of face, neck, torso, airway, conjunctiva, SOB, HA, confusion. Place PIVs in ____ _____

A

Superior vena cava syndrome
Lower extremities

181
Q

Mediastinal mass: Major goal

A

Maintain spontaneous ventilation

182
Q

Mediastinal mass: Biopsy with LA in ____ position if possible

A

Sitting

183
Q

Mediastinal mass: Biphasic positive airway pressure (BiPAP) supports airway during _____ _____ with _____

A

Spontaneous ventilation with sedation

184
Q

Mediastinal mass: _____ to shrink mass before surgery

A

Radiate

185
Q

Mediastinal mass: ____ ____ is good choice for intubation

A

Awake FOB

186
Q

Mediastinal mass: Avoid ____ ____ until ability to ventilate confirmed

A

Muscle relaxants

187
Q

Mediastinal mass: ____/____ mixture (____) to minimize turbulence

A

Helium/O2
Heliox

188
Q

Mediastinoscopy: incision above ____ ____, scope passed between ____ and ____ ____, near L common carotid, L subclavian, and innominate arteries, innominate veins, L ____ ____ nerve, thoracic duct, superior vena cava and aortic arch

A

Sternal notch
Trachea and thoracic aorta
Recurrent laryngeal nerve

189
Q

Complications with mediastinoscopy: (9)

A
  • hemorrhage
  • PTX
  • dysrhythmias
  • bronchospasm
  • laryngeal nerve damage
  • tracheal or esophageal rupture
  • chylothorax
  • air embolus
  • DEATH
190
Q

Mediastinoscopy: monitor ___ arm (d/t pressure on _____ artery)

A

Right
Innominate

191
Q

Mediastinoscopy must haves: (2)

A
  • good IV access
  • cross matched blood available
192
Q

VATS replaces ____ ____

A

Open thoracotomy

193
Q

VATS most common technique

A

GA with DLT

194
Q

VATS usual monitoring

A

Arterial line

195
Q

VATS can be done with ____, ____, ____ _____ for patients with poor pulmonary function

A

Epidural, sedation, spontaneous ventilation (although not commonly done)

196
Q

Bullectomy: For ____ patients with bullae. (Prone to ____ leading to ____ PTX)

A

COPD
Rupture
Tension

197
Q

Bullectomy: ____ approach

A

VATS

198
Q

Bullectomy: Spont vent until chest ____ to decrease risk of ____

A

Open
Rupture

199
Q

Bullectomy: Vent settings (4)

A
  • low TV
  • high RR
  • 100% O2
  • PiP < 20 cmH2O
200
Q

Bullectomy: Epidural?

A

Try your very best to do GA unless you think it’s going to kill them. Then maybe epidural

201
Q

Bullectomy: AVOID ____

A

N2O

202
Q

Complications Post-Thoracotomy: Highest risk factors- (5)

A
  • > 80 years old
  • PPO FEV1 or DLCO < 40%
  • ASA status > or equal to 3
  • > 80 mins surgery time
  • hemorrhage
203
Q

Most Common Complications Post-Thoracotomy: (4)

A
  • resp failure
  • dysrhythmias
  • cardiac failure
  • acute lung injury (ALI)
204
Q

Highest risk factors for ALI: (4)

A
  • R pneumonectomy
  • overhydration
  • high PiPs during OLV
  • pre-op ETOH abuse
205
Q

Complications Post-Thoracotomy: Chest tube drainage should not exceed ____ mL/day. ____ mL/hr calls for ____ _____

A

500 mL/day
200 mL/hr
Surgical exploration

206
Q

Complications Post-Thoracotomy: Lung resection leads to increased ____ leading to ___ failure. Increased risk with _____, hyper____, _____

A

PVR
RV
Pneumonia
Hypercarbia
Acidosis

207
Q

Complications Post-Thoracotomy: _____ dysrhythmias common.

A

Supraventricular

208
Q

Complications Post-Thoracotomy: Morbidity ___, ___ death in 1st 30 post-op days. Treat aggressively with ____ _____.

A

High
25%
Beta blockers

209
Q

Complications Post-Thoracotomy: ___ or ___ nerve damage

A

Phrenic or laryngeal

210
Q

Complications Post-Thoracotomy: SCI if ____ artery damaged, _____ hematoma, positioning injury (____ ____)

A

Radicular
Epidural
Lateral decubitus

NUNA 692 Principles III (20 decks)

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