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SRNA3CoExisting > ExtraThoracic Surgery > Flashcards

ExtraThoracic Surgery Flashcards

1
Q

Different types of Extrathoracic Surgery

A 
Breast biopsy/lumpectomy
Sentinel lymph node biopsy
Mastectomy
Mastectomy with reconstruction
Clavicle repair
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2
Q

Breast biopsy/lumpectomy Terminology

A
  • Excisional biopsy = benign

* Lumpectomy = cancerous lesion

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3
Q
  • Patient population
  • Lumpectomy =_____(age)
  • wire-localized breast biopsy =___(age)
  • Mainly what sex (M/F)
A

> 15 yr ; 25-90 yr; female

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4
Q

Palpable lesions characterized by

A

masses, nodules, asymmetric thickening

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5
Q

•Breast biopsy/lumpectomy manifestations

A

edema, redness, brawny discoloration, ulceration

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6
Q

• Bloody/pathological nipple discharge

A
  • Usually benign intraductal papilloma

* Rarely carcinoma

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7
Q

Percutaneous Hookwires in breast Using 2 imaging studies? Explain

A

MRI and breast US.
Radiologist places Percutaenous hook-wires close to lesion
Surgeon removes breast tissue surrounding wire
Confirm removal of wire and target lesion with radiography and ultrasound

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8
Q

Paravertebral block put at risk for

A

pneumothorax

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9
Q

Block for lumpectomy

• Factors to pick a block

A

• Paravertebral block
• With MAC or GA
• Pectoral nerve block type II
size, location, quantity, trajectory of wires, patient preferences

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10
Q

ABT breast surgery

A

Antibiotics optional, cefazolin 1 g IV (dose: < 80 kg =

1 g, > 80 kg = 2 g)

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11
Q

Breast surgery closing

A

Closing specimen radiograph result must be

obtained

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12
Q

Breast surgery approx time

Pain

A

Time 0.5-1.5 h

2-5

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13
Q

M and M of breast surgery

A

M/M seroma, ecchymosis, hematoma, infection

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14
Q

Sentinel lymph node biopsy

Most likely node?

A

Invasive breast cancer without pathologic lymph nodes
• Most likely node to FIRST harbor metastatic tumor cells
• No metastasis means no cells = other lymph nodes
negative for CANCER

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15
Q

• SNL =

A

first node to drain afferent lymphatics from a particular region of breast. Therefore

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16
Q

Lymphatic mapping

What should surgeon tell anesthesiologist?

A

• Dyes
• Drops SpO2 (2-5% 20-25 min after injection)
Injected (clock plane , 6, 12, 9, 3)

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17
Q

Sentinel node biopsy

A

No paralyzing, no muscle relaxants.

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18
Q

Technetium sulfur colloid (TSC)

A

Low radiactive tracer

No additional protection required

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19
Q

Unique considerations BP

A

BP cuff cannot be an operative side, ask about muscle relaxation.

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20
Q

SNL antibiotics

A

Cefazolin 1g

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21
Q

SNL EBL, SNL timing

A

Minimal
10-30 min but up to 1.5 h with axillary lymph node
dissections

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22
Q

M and M with SNL

A

Allergic reaction to dyes

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23
Q

Anesthesia considerations for breast biopsy/SNL

Pre-Op

A

• Anxious, require midazolam, lab testing not always necessary (except HCG if child-bearing age)

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24
Q

Anesthesia considerations for breast biopsy/SNL

Intra-OP

A

MAC: Propofol 25-100 mcg/kg/min, supplement with fentanyl/remi and midazolam, titrate to effect
REMI bolus: 0.5-1mcg/kg 90 seconds prior to initial incision with local anesthesia
Consider HIGH Propofol

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25
Q

If concerns about HR for Breast biopsy

A

Give Glycopyrrolate (Robinul)

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26
Q

• GA:

A

may mask or LMA if appropriate • Standard induction,
maintenance, emergence • Isosulfran dye reaction =
pruritus, localized swelling, blue hives • Diphenhydramine 10 -50mg IV, epi if BP ↓

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27
Q

• Postoperative •

A

Urine, emesis, or stool might be blue for 24 -48h

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28
Q

• Immediate breast reconstruction

2 types

A 
• Usually not if postop
chest radiation needed
 Two types:
• Prosthetic reconstruction
• Autologous myocutaneous flap
29
Q

Position for mastectomy , total and lumpectomy

A

Supine, ipsilateral arm abducted

30
Q

Mastectomy time

A

1.3- 3 hours long

31
Q

EBL mastectomy

A

150-500ml lumpectomy is 25-100ml

32
Q

Morbidity and mortality

A

LYMPHADEMA
SEROMA
INFECTION
Nerve damage

33
Q

Axillary part of the surgery consideration

A

NO PARALYTICS

34
Q

Antibiotics for modified radical, lumpectomy and total

A

Cefazolin 2g IV

35
Q

• Preop Mastectomy
• Resp:
•

A

hx radiation therapy to chest = compromise;

CXR if any pulmonary signs

36
Q

Preop Mastectomy Cardio:

A

Chemo agents can cause cardiomyopathy,

order diagnostic studies if presentation indicates

37
Q

Preop mastectomy Neuro:

A

breast CA can mets to CNS (focal neuro deficits, ↑ICP, AMS)

38
Q

Preop Mastectomy Hem:

A

Anemia/thrombocytopenia associated with chemo

39
Q

Doxorubicin associated with

A

CARDIOMYOPATHY

40
Q

Post op Emergence =

A

may require binder in sitting position = keep them asleep through this process

41
Q

Post op considerations: ASk about

A

Binder (keep asleep till then)

42
Q

Multilevel paravertebral blocks level MASTECTOMY

A

T1- T6

43
Q

How many ml per level

A

• 4-5 mL/leve

44
Q

2 local anesthetics you can use for mastectomy

A

Bupivacaine :0.5%

Ropivacaine 0.5%

45
Q

Contraindications to regional anesthesia

A

Contraindications: patient refusal, local
anesthetic allergy, pathology or anatomical
distortion of paravertebral space, infection at site

46
Q

Anesthetic considerations Post Op complications

and symptoms

A 
Complications: pneumothorax
• Symptoms?
• Others (2° PNB)
**** Failed block (10%)
****Pleural puncture
**** Pneumothorax (PIP goes up, CO2 goes down) 
**** Horner’s syndrome
• Accidental epidural spread of local anesthetic
• PONV
47
Q

Pneumothorax interventions

A

O2 100 FiO2
Chest Xray
Remove Positive pressure ventilation

48
Q

Signs of Pneumothorax

A

breath sounds decreased on one side

Avoid Positive pressure ventilation

49
Q

Horner’s syndrome

A

Ptosis, myosis droops on side LA was injected.

50
Q

Tips for breast surgery

A

Know local anesthesia toxicity levels
• OR table may be angled/turned sideways (Disconnect ET before moving)
• Breast biopsies can turn into mastectomy

51
Q

LA toxicity

A

Serum levels , LA in tissue doesn’t always transfer to vessels.

52
Q

Lidocaine with epi

A

7mg/kg

53
Q

Lidocaine without epi

A

4mg/kg

54
Q

LTA (laryngotracheal Topical Anesthesia)

A

4ml 4%

55
Q

Lidocaine and marcaine

A

Additive effects, Consider both can increase toxicity

56
Q

Interscalene Block

A

Clavicle

57
Q

Clavicle repair

Position

A

Beach chair or supine, head turned away from
surgical field, bump placed behind affected
shoulder (ANNOYING)
HOLD HEAD entire time

58
Q

Unique considerations

A
  • RSI if trauma
  • ISB will NOT help cover proximal clavicular pain
  • IV/cuff on nonoperative side
59
Q

Clavicle repair GETA or

A

GETA or GLMAA

• Tape tube on one side opposite of surgical field

60
Q

Clavicle repair

A

Surgeon may require SBP < 100 mm Hg to prevent

bleeding

61
Q

Complications of clavicle repair

A

Complications: brachial plexus or subclavian artery

injury

62
Q

Eye protection is important

A 
• Tape eyes closed, place pads over eyes,
consider goggles (DON’T)
63
Q

• Perform a thorough distal neuro assessment on

A

the affected arm both pre/post

• Circulation, sensation, motor function

64
Q

For beach chair Carefully stabilize

A

head in beach chair position
• Tape the ETT or LMA SEVERELY
• Head will be under drapes

65
Q

Ductoscopy

A

Give surgeon clear view between diseased and healthy breast tissues (camera into milk duct)

66
Q

If unable to find SNL

A

conventional axillary dissection level I and II

67
Q

Lumpectomy, axillary LND pain score and Morbidity

Post op care if no morbidity

A

4-8PACU → 2 d hospitalization

PACU–> Home

68
Q

Lumpectomy, axillary LND pain score and Morbidity

Post op care if no morbidity

A

4-8PACU → 2 d hospitalization

PACU–> Home

SRNA3CoExisting (16 decks)

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