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8361 Exam 4 > Mod XI: ANESTHETIC MANAGEMENT DURING THORACIC SURGERY > Flashcards

Mod XI: ANESTHETIC MANAGEMENT DURING THORACIC SURGERY Flashcards

1
Q

ANESTHETIC MANAGEMENT DURING THORACIC SURGERY

General anesthesia

A

Standard induction expected for most thoracic procedures

Any deviation to be discussed with each procedure

Adequate preoxygenation is key!

Standard intravenous induction

Surgeon may want to perform a diagnostic bronchoscopy

If this is the case, place size 8-9 ETT or LMA if flexible bronchoscopy is planned prior to surgery

Traded for DLT at the conclusion of diagnostic bronchoscopy

A bronchoscopy can also be performed at the end of the case

Is the is the plan, the DLT will be replaced with either and ET tube or an LMA

After that, if there is no indication for prolonged ventilatory support, the pt can be extubated

This is why it’s important to communicate with the surgical team prior to starting the procedure, so that if a bronchoscopy is to be performed, adequate preparation can occur

Inhalation anesthetic are typically used for these cases

TIVA can also be used

There are some benefits of using Inhalation anesthetic over TIVA

inhalation agent have a brondilatory function, and they can be rapidly removed at the end of the case

Remember, clinical doses of inhalation agents do not significantly alter HPV

No N2O!

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2
Q

ANESTHETIC MANAGEMENT DURING THORACIC SURGERY

Total Intravenous Anesthesia

A

TIVA can be used effectively as a technique that does not inhibit HPV

IV anesthetics do not inhibit HPV

No benefit over 1 MAC of volatile agent and no difference in M&M between two choices

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3
Q

ANESTHETIC MANAGEMENT DURING THORACIC SURGERY

Maintenance

A

Adequate analgesia is imperative

Monitor fluid administration b/c excessive fluid administration has been a/w acute lung injury in the post op period

Can also cause a gravity dependent accumulation of fluid in the dependent lung, which can exacerbate shunting and hypoxemia during OLV

Muscle relaxant facilitates rib spreading

Risk of postoperative residual neuromuscular blockade

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4
Q

ANALGESIA FOR THORACIC SURGERY

Thoracotomy one of the most painful surgeries - Pain primarily caused by

A

Resection of thoracic tissue and

Bone for surgical exposure

Places pts at High risk for atelectasis and pneumonia d/t shallow breathing

Goal = balance between comfort and respiratory depression

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5
Q

ANALGESIA FOR THORACIC SURGERY

Pain after thoracic surgery leads to:

A

Splinting

Decreased resp effort

Hypoxemia

Respiratory acidosis

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6
Q

ANALGESIA FOR THORACIC SURGERY

Hollistic multimodal approach should be used to reduce post op pain - This can be done by

A

IV patient-controlled analgesia (PCA), coupled with

Thoracic epidural, or

Paravertebral block

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7
Q

ANALGESIA FOR THORACIC SURGERY

Thoracic epidural

A

Placed prior to induction

Catheter placed at T6-T8

Cautious use of IV narcotics if narcotics placed in epidural

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8
Q

ANALGESIA FOR THORACIC SURGERY

Paravertebral block

A

Placed at level of incision, plus 1-2 intercostal interspaces above and below

Provides good short-term pain relief

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9
Q

POSITIONING FOR THORACIC SURGERY

After induction of anesthesia and confirmation of correct tube placement, the pt is placed in which position?

A

Lateral Decubitus position with the surgical side up

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10
Q

POSITIONING FOR THORACIC SURGERY

After the Lateral Decubitus position is assumed a roll is placed caudal to axilla - What is it called? what’s its purpose?

A

Axillary roll placed caudal to axilla

Purpose it to keep the pt weight off the brachial plexus and the axillary fascia

Eventhough this roll is called the Axillary roll, it should never be positioned into the axilla b/c doing so may cause neurovascular compression

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11
Q

POSITIONING FOR THORACIC SURGERY

Positioning the Arms:

A

Arms padded and extended forward on arm boards

Support nondependent arm with pillows, Mayo stand or double arm boards

Be careful not to abduct the shoulder more than 90 degrees, or flex or extend pass the neutral point

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12
Q

POSITIONING FOR THORACIC SURGERY

Head support:

A

Head support on pillows to maintain head and neck alignment with spine

Lateral flexion can cause compression of neck vessels compromising cerebral perfusion

Careful not to compress dependent ear, pad with foam doughnut pillow to prevent pressure from the head

Careful not to place pressure on dependent eye to prevent corneal abarasion and retinal ischemia

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13
Q

POSITIONING FOR THORACIC SURGERY

Potential nerve injuries:

A

Brachial plexus most common!!! b/c it has two points of potential compression or stretch

Common peroneal nerve & Suprascapular nerve also have the potential for injury

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14
Q

ANESTHETIC MANAGEMENT DURING THORACIC SURGERY

Emergence

A

OLV or bronchial blocker will be discontinued

Remember to deflate bronchial cuff to reduce pressure on the bronchial mucosa, and to help prevent injury when removing the DLT

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15
Q

ANESTHETIC MANAGEMENT DURING THORACIC SURGERY

Re-expansion of the operative lung

A

The operative will then be re-expanded under direct visualization, so that the surgeon can look atelectatic areas, and for air leaks

Lungs inflated 20-30 cmH2O to reinflate atelectatic areas and to check for air leaks

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16
Q

ANESTHETIC MANAGEMENT DURING THORACIC SURGERY

Placement of chest tube:

A

Chest tube placed to facilitate removal of fluid in the pleura cavity, and to aid in lung re-expansion

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17
Q

ANESTHETIC MANAGEMENT DURING THORACIC SURGERY

Extubation:

A

Patients typically extubated in OR unless contraindicated

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18
Q

ANESTHETIC MANAGEMENT DURING THORACIC SURGERY

Post op ventilatory support:

A

If postoperative ventilatory support needed, DLT swapped for single lumen ETT

Done under direct vizualisation with a laryngoscope blade or

Glidescope (great idea)

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19
Q

ANESTHETIC MANAGEMENT FOR BRONCHOSCOPY (FLEXIBLE & RIGID)

Purpose of Bronchoscopy (Flexible & Rigid):

A

To vizualise the upper airway as well as distal anatomies in the trachea and bronchi

Flexible => flexible scope

Rigid => Stiff scope like

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20
Q

ANESTHETIC MANAGEMENT FOR BRONCHOSCOPY

Flexible BRONCHOSCOPY:

A

Diagnostic procedure

Commonly performed prior to lung resection to reconfirm diagnosis, or to determine the invasion or obstruction of the distal airway

Allows for distal airway examination

Awake versus General

General with ETT or LMA

Oral versus nasal

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21
Q

ANESTHETIC MANAGEMENT FOR BRONCHOSCOPY

Rigid BRONCHOSCOPY

A

Diagnostic procedure

Procedure of choice for tracheal stenosis (tracheal dilation), airway obstruction, foreign body removal, and massive hemoptysis

General anesthesia

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22
Q

ANESTHETIC CONSIDERAATIONS FOR BRONCHOSCOPY: FLEXIBLE

Routes:

A

Oral or nasal approach

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23
Q

ANESTHETIC CONSIDERAATIONS FOR BRONCHOSCOPY: FLEXIBLE

Anesthetic technique:

A

Awake bronchoscopy

With or without sedation

Topical anesthesia via nebulizer, aerosol, or soaked pledgets

Laryngeal or glossopharyngeal nerve block

“Spray as you go” technique

General

LMA or ETT

Spontaneous vs. positive pressure ventilation

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24
Q

ANESTHETIC CONSIDERAATIONS FOR BRONCHOSCOPY: FLEXIBLE

Potential complications:

A

Dental/tissue damage

Airway rupture

Pneumothorax

Airway bleeding

Airway edema

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25
Q

ANESTHETIC CONSIDERATIONS FOR RIGID BRONCHOSCOPY

Procedure of choice for:

A

Dilation of tracheal stenosis

Assessment of airway obstructions involving trachea

Therapy for massive hemoptysis

Foreign body removal

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26
Q

ANESTHETIC CONSIDERATIONS FOR RIGID BRONCHOSCOPY

Typically requires general anesthesia, but four different techniques:

A

Spontaneous ventilation

with addition of either a topical anesthetic or a nerve block

Apneic oxygenation

where ventilation if held for 2 to 3 minutes while the surgeon performs the bronchoscopy

Positive-pressure ventilation via a ventilating bronchoscope

Uses a standard anesthesia machine to ventilate around the bronchoscope

Jet ventilation

Which is performed through a hand held injector, with a high frequency ventilator

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27
Q

ANESTHETIC CONSIDERATIONS FOR RIGID BRONCHOSCOPY

These cases causes the most anx for the anesthesia provider - why?

A

b/c we are sharing an unsecured airway with the surgeon

So there is a high risk for aspiration, especially if the pt is at increased risk

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28
Q

ANESTHETIC CONSIDERATIONS FOR RIGID BRONCHOSCOPY

Beside the sharing of an unsecured airway with the surgeon, other Potential complications of rigid bronch include:

A

Same as Flexible bronch plus…

Airway is never completely secure

Airway perforation

Mucosal damage

Hemorrhage

Airway edema

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29
Q

ANESTHETIC CONSIDERAATIONS FOR BRONCHOSCOPY (FLEXIBLE & RIGID)

Special Considerations: Patient’s position

A

Patients are supine for these procedures

(Not in the lateral decubitus position)

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30
Q

ANESTHETIC CONSIDERAATIONS FOR BRONCHOSCOPY (FLEXIBLE & RIGID)

Management of secretions:

A

Anticholinergic agent to reduce secretions

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31
Q

ANESTHETIC CONSIDERAATIONS FOR BRONCHOSCOPY (FLEXIBLE & RIGID)

FiO2 use if laser is used:

A

If laser used (Yttrium Aluminum Garnet ”YAG”),

Use lowest possible FiO2, preferably < 30%

This is to reduce the chance of airway fire

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32
Q

ANESTHETIC CONSIDERAATIONS FOR BRONCHOSCOPY (FLEXIBLE & RIGID)

Why should Suctioning be kept at a minimum?

A

Suctioning will remove an average of 14L/min of air

Decreased FiO2, PaO2, and FRC –> hypoxemia

Keep suctioning brief

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33
Q

MEDIASTINOSCOPY

Used for

A

Access to mediastinal lymph nodes

Diagnosis of anterior/superior mediastinal masses

The scope is passed anterior to the trachea and posterior to the thoracic aorta

Patient in supine position

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34
Q

MEDIASTINOSCOPY

Most common diagnostic procedure

A

Cervical mediastinoscopy

In which the surgeon wil make a small transverse incision, midline at the lower neck

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35
Q

MEDIASTINOSCOPY

Most commonly performed under which anesthetic technique?

A

General anesthesia with NMB, and placement of a SLT

Can be performed under MAC

High risk of coughing and moving

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36
Q

MEDIASTINOSCOPY

Arterial line:

A

Arterial line not necessary for this procedure

however pulse must be monitored on right side (with either arterial line or SpO2)

b/c there is a possibility that the innominate artery could be occluded by mediastinoscope

Why is this important?

Impaired cerebral and right arm blood flow

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37
Q

ANESTHETIC CONSIDERATIONS FOR MEDIASTINOSCOPY

Possible complications - Mediastinal hemorrhage

A

Occurs as a result of disruption of a major blood vessel

Could be difficult to recognize and treat, and would require emergency strenotomy and thoracotomy

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38
Q

ANESTHETIC CONSIDERATIONS FOR MEDIASTINOSCOPY

Possible complications - Compression of the trachea or bronchi

A

Compression of the trachea or bronchi in pts with mediastinal masses

This would increase resistance to flow

Can be more profound after induction of general anesthesia

Could lead to collapse of the airway or total airway obstruction

PPV could be rendered impossible, even w/ the ET tube properly placed, if the mass involves the airway distal to the ET tube

To anticipate this, a rigid bronchoscopy should be readily available

In pts who have severe vessel compression by masses, and have itt confirmed diagnostically femoral cannulation for cardiopulmonary bypass may be needed

Which position change could help alleviate?

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39
Q

ANESTHETIC CONSIDERATIONS FOR MEDIASTINOSCOPY

Possible complications - Compression of the trachea or bronchi

Which position change could help alleviate?

A

Prone or supine

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40
Q

ANESTHETIC CONSIDERATIONS FOR MEDIASTINOSCOPY

Possible complications - Pneumothorax

A

Pneumothorax (infrequent)

Would require chest tube to be placed

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41
Q

ANESTHETIC CONSIDERATIONS FOR MEDIASTINOSCOPY

Possible complications - nerve injury

A

Recurrent laryngeal nerve injury

(permanent in 50% of patients)

If injury is suscpected, the vocal cords should be visualized during spontaneous breathing

If the do not move or are in midline, post op laryngeal obstruction should be considered

This is typically not a problem for ectubation inless both are injured

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42
Q

ANESTHETIC CONSIDERATIONS FOR MEDIASTINOSCOPY

Possible complications - Venous air embolism

A

Venous air embolism is a possible complication from mediastinoscopy

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43
Q

ANESTHETIC CONSIDERATIONS FOR MEDIASTINOSCOPY

Why is Previous mediastinoscopy is considered a contraindication to repeat mediastinoscopy?

A

Scaring

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44
Q

Anesthetic Management of Mediastinoscopy Hemorrhage

A
  1. Stop surgery and pack the wound. There is a serious risk that the patient will approach the point of hemodynamic collapse if the surgery-anesthesia team does not realize soon enough that there is a problem.
  2. Begin the resuscitation and call for help, both anesthetic and surgical.
  3. Obtain large-bore vascular access in the lower limbs.
  4. Place an arterial line (if not placed at induction).
  5. Prepare for massive hemorrhage with blood warmers and rapid infusers.
  6. Obtain cross-matched blood in the operating room.
  7. Place a double-lumen tube or bronchial blocker if the surgeon believes that thoracotomy is a possibility.
  8. Once the patient is stabilized and all preparations are made, the surgeon can reexplore the cervical incision.
  9. Convert to sternotomy or thoracotomy if indicated.
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45
Q

ANESTHETIC CONSIDERATIONS FOR TRACHEAL RESECTIONS

TRACHEAL RESECTIONS are most commonly performed for

A

Tracheal stenosis

Tumors

Congenital abnormalities

You will most commonly performed on pts after they have had long term tracheostomy tube and have developed tracheal stenosis

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46
Q

ANESTHETIC CONSIDERATIONS FOR TRACHEAL RESECTIONS

least difficult and the least invasive TRACHEAL RESECTIONS are

A

Stenosis that is confined to the cervical tracheal ring are the least difficult and the least invasive

Accessibility of the cervical tracheal rings= least invasive

More inferiorly directed lesions may require an approach via sternotomy or right thoracotomy

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47
Q

ANESTHETIC CONSIDERATIONS FOR TRACHEAL RESECTIONS

Induction of anesthesia

A

Awake fiberoptic intubation vs IV induction

An Emergency plan should be in place

Pt usually received with a tracheostomy tube already in place

There may be some pt who present without a secured airway

Considerations must be take as to whether to perform and Awake fiberoptic intubation vs IV induction

If the pt does not already have a trach in place, they are typically intubated w/ an ET tube that is small enough to pass the stenotic area

If possible, you also want to keep the pt spontaneously ventilating to reduce the chance of airway collapse

Endotracheal tube placed above and below resection

Placing the endotracheal tube below the level of the stenosis ensures that the airway is not lost during resection

May have elective tracheostomy placed below level of resection

Consider maintaining spontaneous ventilation if severe stenosis present

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48
Q

ANESTHETIC CONSIDERATIONS FOR TRACHEAL RESECTIONS

Use of anticholinergic to dry secretions controversial - why?

A

Doing so can increase the risk for secretions becoming too dry and thick for expulsion

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49
Q

ANESTHETIC CONSIDERATIONS FOR TRACHEAL RESECTIONS

Patient’s position:

A

Supine

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50
Q

ANESTHETIC CONSIDERATIONS FOR TRACHEAL RESECTIONS

Why is Spontaneous ventilation preffered over positive-pressure ventilation?

A

PPV tends to place pressure on suture lines

Spontaneous ventilation ideal to reduce chance of airway collapse

Spontaneous ventilation better than positive-pressure ventilation

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51
Q

ANESTHETIC CONSIDERATIONS FOR TRACHEAL RESECTIONS

extubation:

A

Plan for extubation at end of case or

for re-placement of the pt’s original tracheostomy

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52
Q

ANESTHETIC CONSIDERATIONS FOR TRACHEAL RESECTIONS

Head position after the procedure?

A

Head should remain flexed after procedure

to reduce the pressure one the suture lines

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53
Q

ANESTHETIC CONSIDERATIONS FOR THORACOTOMY PROCEDURES

THORACOTOMY PROCEDURES are mainstay treatment for

A

Curable carcinomas of the lung

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54
Q

ANESTHETIC CONSIDERATIONS FOR THORACOTOMY PROCEDURES

Less common indications:

A

Infection

Trauma

Conversion to open from laparoscopic technique

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55
Q

ANESTHETIC CONSIDERATIONS FOR THORACOTOMY PROCEDURES

THORACOTOMY PROCEDURES are Partial or complete removal of lung tissue that are performed via which approaches?

A

Open approach

Thoracoscopy

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56
Q

ANESTHETIC CONSIDERATIONS FOR THORACOTOMY PROCEDURES

Open approach

A

Reserved for more complex procedures

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57
Q

ANESTHETIC CONSIDERATIONS FOR THORACOTOMY PROCEDURES

Position during the procedure

A

(A) Posterolateral thoracotomy in lateral position

(B) Median sternotomy in supine position

(C) Anterior thoracotomy in supine position

58
Q

ANESTHETIC CONSIDERATIONS FOR THORACOTOMY PROCEDURES

Monitors:

A

Standard monitors

(+/-) Central line

If the procedure is expected to be complex, or there is a possibility of blood loss

(+/-) arterial line on dependent side

59
Q

ANESTHETIC CONSIDERATIONS FOR THORACOTOMY PROCEDURES

Lung isolation technque:

A

May use single and bronchial blocker or DLT

Nondependent lung collapsed to allow for visualization

Bronchial blocker use in situations when OLV was not initially planned for

60
Q

ANESTHETIC CONSIDERATIONS FOR THORACOTOMY PROCEDURES

Open procedures have been almost entirely replaced by

A

Thoracoscopic approaches

61
Q

ANESTHETIC CONSIDERATIONS FOR THORACOTOMY PROCEDURES

Open procedure are still reserved for

A

Emergency situations, or

Massive bleeding

62
Q

ANESTHETIC CONSIDERATIONS FOR THORACOSCOPY

Insertion of an endoscope into the thoracic cavity and pleural space to diagnose pleural diseases, effusions, infectious diseases, to stage cancer and take biopsies if is known as:

A

Thoracoscopy

Least invasive compared to open approach

63
Q

ANESTHETIC CONSIDERATIONS FOR THORACOSCOPY

A Thoracoscopy in which a video camera and surgical instruments are inserted via “trocars” into chest is also known as:

A

Video-assisted Thoracoscopic Surgery (VATS)

Done for visualization and manipulation of thoracic structures

VATS are Less invasive compared to open approach

VATS have become the procedure of choice for manipulation and dx of dz of the pleura

Can be done with thoracoscopy only or as robotic surgery

Robotic surgery has been considered the “logical advancement” of VATS b/c it provides 3D views and increases the surgeon range of motion w/in the chest cavity

64
Q

ANESTHETIC CONSIDERATIONS FOR THORACOSCOPY

Thoracoscopies Can be performed for minor diagnostic procedures - options for the anesthetic technique will depend on

A

the invasiveness of the procedure

Can range from Under local, regional, or general anesthesia

65
Q

ANESTHETIC CONSIDERATIONS FOR THORACOSCOPY

GETA considerations for thoracoscopy procedures

A

Standard monitors, (+/-) arterial line on dependent side

May use SLT and bronchial blocker or DLT

Lateral position

Nondependent lung collapsed to allow for visualization

Can take up to 30 min for the non dependent lung to fully collapse - so OLV should be instituted as soon as the pt is placed in the lateral position

CO2 insufflation is diffused into pleural cavity to aid in visualization of thoracic structures

CO2 insufflation pressures should be kept < 15 mmHg b/c higher pressures can cause mediastinal shift and hemodynamic compromise

May need art-line and ABG for longer cases

66
Q

PULMONARY RESECTIONS

Removal of a lung mass with 1 cm margins is known as:

A

Wedge resection

Wedge resection removal of a lung mass with 1 cm margins

Done in a manner that does not remove an entire anatomical segment

Indicated For patients with peripheral non-small-cell tumors

Indicated for those with limited pulmonary reserve unable to tolerate lobectomy

67
Q

PULMONARY RESECTIONS

The removal of one anatomic lobe of the lung is known as:

A

Lobectomy

Recall that the right lung has 3 lobes and the left lung has 2

Standard operation for the management of lung cancer

68
Q

PULMONARY RESECTIONS

The removal of an entire lung with ligation of the pulmonary artery and the bronchi is also known as:

A

Pneumonectomy

This is required when a lobectomy is not adequate to remove the local dz

69
Q

ANESTHETIC CONSIDERATIONS FOR WEDGE RESECTIONS

Position and lung isolation technique used for WEDGE RESECTIONS

A

Best performed in lateral position with OLV

can also be performed in the supine postion w/ Two-lung ventilation if necessary

70
Q

ANESTHETIC CONSIDERATIONS FOR WEDGE RESECTIONS

Induction and maintenance for WEDGE RESECTIONS

A

Standard induction and maintenance

Similar to that of all other thoracic cases

71
Q

ANESTHETIC CONSIDERATIONS FOR WEDGE RESECTIONS

Emergence for WEDGE RESECTIONS - what should ensure prior to emergence?

A

Ensure complete recruitment of operative lung prior to emergence

This is to reduce the incidence of post op atelectasis

Chest tube placed postoperatively prior to closure

Post op pain management can be achieved w/ epidural, or intercostal blocks

Patients can be extubated in the operating room

72
Q

ANESTHETIC CONSIDERATIONS FOR LOBECTOMY

Position and ventilation FOR LOBECTOMY:

A

Commonly performed in lateral position with OLV

73
Q

ANESTHETIC CONSIDERATIONS FOR LOBECTOMY

Snduction and maintenance FOR LOBECTOMY

A

Standard induction and maintenance

74
Q

ANESTHETIC CONSIDERATIONS FOR LOBECTOMY

Surgical procedure

A

Once OLV has been achieved, the lobe and its blood vessels are isolated, mobilzed and dissected

Retraction of the hilum and its structures can cause arrhythmias

Following ressection of the lobe, the surgeon will resquest a Test maneuver performed to ensure remaining lobes inflate appropriately

Bronchial stump tested with 30 cmH2O positive pressure to ensure that there are No major air leaks

Chest tube placed

75
Q

ANESTHETIC CONSIDERATIONS FOR LOBECTOMY

Emergence and post op pain control:

A

Ensure complete recruitment of operative lung prior to emergence

Multi-modal technique! Painful

IV pain control, epidural, or intercostal blocks

Patients can be extubated in the operating room

76
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Monitoring

A

CVP

Consider placement of CVP for monitoring intravascular volume

77
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Induction and maintenance

A

Standard induction and maintenance

78
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Positioning and ventilation

A

Commonly performed in lateral position with OLV

79
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Surgical procedure

A

Stapling of bronchus on the surgical side and excision of entire lung

80
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Stapling of bronchus on the surgical side and excision of entire lung - Monitor for arrhythmias during this time b/c

A

Retraction of the hilum and its structures can cause arrhythmias

81
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Difference between lobectomy and pneumonectomy

A

Management of the post-pneumonectomy space is a big concern

Pneumonectomy is a/w a high incidence of mediastinal shift since all of the lung tissue is removed on the operative side

82
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Normal post pneumonectomy physiologic changes:

A

Air fills post pneumonectomy space

Elevation of the hemidiaphragm

Hyperinflation of the remaining lung

Shifting of the mediastinum towards pneumonectomy side

Mediastinal shift of thoracic structures can cause hemodynamic collapse

This must be prevented or attenuated

83
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Mediastinal shift of thoracic structures can cause hemodynamic collapse - This must be prevented or attenuated - There is still no concensus among thoracic surgeons on how to best achieve this Standard chest tubes cannot be applied to empty hemithorax - why not?

A

Could cause ubstantial mediastinal shift

Which could result in hemodynamic collapse

Air-filled space immediately after surgery will eventually become a fluid-filled space

84
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Post pneumonectomy, Some surgeons may ellect to use what system to balance the mediastinum

A

Specifically designed Chest drainage system

85
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Postoperative chest x-ray

A

Following surgery, a Postoperative chest x-ray is mandatory!

Serial chest x-rays will also be performed

86
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Post Pneumonectomy POD #1

A

Post Pneumonectomy POD #1

Trachea is midline

Pneumothorax is present in the post pneumonectomy space

87
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Post Pneumonectomy POD #2

A

Post Pneumonectomy POD #2

Fluid accumulation can be seen in the lower 1/3 of the post pneumonectomy space

w/in 24hr. the ipsilateral hemidiaphragm becomes slighty elevated

The mediastinum will slightly shift towards the surgical side

Fluid starts to accumulate in the post pneumonectomy space

Fluid will accumulate on an everage rate of 1 to 2 intercostal spaces per day in the immediate post op period

The median time to 75% opacification is 3 days, and after two weeks, 80 to 90% of the space is filled with fluid

There should not be a rapid accumulation of fluid in this space

If there is, hemorrhage should sucspected

88
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Post Pneumonectomy POD #14

A

Post Pneumonectomy POD #14

Air-fluid level has risen

The median time to 75% opacification is 3 days, and after two weeks, 80 to 90% of the space is filled with fluid

There should not be a rapid accumulation of fluid in this space

If there is, hemorrhage should sucspected

89
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Post Pneumonectomy POD #30

A

Post Pneumonectomy POD #30

Shows total opacifictaion of the post pneumonectomy space

The median time to 75% opacification is 3 days, and after two weeks, 80 to 90% of the space is filled with fluid

There should not be a rapid accumulation of fluid in this space

If there is, hemorrhage should sucspected

90
Q

PNEUMONECTOMY CHEST DRAINAGE SYSTEM

What’s the normal intrapleural pressure

A

-4 to -6 cmH2O

91
Q

PNEUMONECTOMY CHEST DRAINAGE SYSTEM

The Balanced chest-drainage system is composed of three chambers

A
  1. Positive pressure chamber at +1 cm H2O
  2. Negative pressure chamber at -13 cmH2O
  3. Drainage chamber
92
Q

PNEUMONECTOMY CHEST DRAINAGE SYSTEM

How does the Balanced chest-drainage system balances the mediastinum?

A

Has high pressure and low pressure under water release valves that balance the mediastinum

Maintains the pt’s intracavity pressures between +1 cm H2O and -13 cmH2O, with an average of -6 cmH2O, which is at physiologic norme

Helps to establish normal intra-thoracic pressure and avoid significant mediastinal shifts

93
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

The leading cause of M&M post-pneumonectomy is:

A

Respiratory failure

Research has correlated this w/ the use of higher TVs

Low tidal volumes (5 ml/kg) significantly reduce incidence of respiratory failure, ALI and inflammatory responses

94
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Multimodal pain management is important in this patient population, including IV and epidural analegesia - why?

A

Pneumonectomies are extremely painful

The guarding and shallow beathing can lead to atelectasis, pneumonia and respiratory failure

95
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Pneumonectomy has significant impact on right ventricular function - This manifest as:

A

Increase in right heart afterload by up to 50% to 60%

Increase in PAP and PVR which can increase the risk for RV failure and pulmonary edema

Increased pressure in pulmonary veins

Increased risk for pulmonary edema

96
Q

ANESTHETIC CONSIDERATIONS FOR PNEUMONECTOMY

Pneumonectomy has significant impact on right ventricular function - How can this be minimized and managed?

A

Restrict postoperative intravascular fluids

Keep as neutral or negative as possible

97
Q

ESOPHAGECTOMY

ESOPHAGECTOMY May be indicated d/t

A

neoplasm,

reflux disease,

traumatic, or

congenital malformations

98
Q

ESOPHAGECTOMY

Ventilation for ESOPHAGECTOMY:

A

OLV may or may not be required depending on the surgical exposure necessary

99
Q

ESOPHAGECTOMY

The Three surgical approaches for ESOPHAGECTOMY include:

A

Transthoracic approach

Transhiatal approach

Minimally invasive surgery

(Could Thoracoscopic or Robotic surgery)

100
Q

ESOPHAGECTOMY

What’s the most commonly used ESOPHAGECTOMY approach

A

Minimally invasive Robotic surgery

101
Q

ANESTHETIC CONSIDERATIONS FOR ESOPHAGECTOMY PROCEDUES

M&M

A

HIGH

Associated with high M&M (10-15%)

Regardless of the approach used

Anastomotic healing is one of the most important factor in reducing morbidity following this procedure

102
Q

ANESTHETIC CONSIDERATIONS FOR ESOPHAGECTOMY PROCEDUES

most important factor in reducing morbidity following this procedur

A

Anastomotic healing

103
Q

ANESTHETIC CONSIDERATIONS FOR ESOPHAGECTOMY PROCEDUES

Anastomotic leakage/dehiscence (5-26%) in prevalence - Causes are multifactorial; most important are

A

Vasopressor administration

Fluid status

104
Q

ANESTHETIC CONSIDERATIONS FOR ESOPHAGECTOMY PROCEDUES

Research has shown a direct correlation between Anastomotic failure and the use of vasopressor such as levophed for low BP - What causes low BP? How can it be managed?

A

This is d/t to reduced blood flow to the Anastomotic area

Small doses of phenylephrine shown to be more tolerable

Also recommended that large fluid administration be avoided in these pts

105
Q

ANESTHETIC CONSIDERATIONS FOR ESOPHAGECTOMY PROCEDUES

Ventilation

A

OLV

106
Q

ANESTHETIC CONSIDERATIONS FOR ESOPHAGECTOMY PROCEDUES

Monitoring:

A

Standard lines with radial arterial line,

+/- central line

107
Q

ANESTHETIC CONSIDERATIONS FOR ESOPHAGECTOMY PROCEDUES

Complications

A

Respiratory (18-26%)

Anastomotic leakage/dehiscence (5-26%)

Stenosis (12-40%)

108
Q

ANESTHETIC CONSIDERATIONS FOR ESOPHAGECTOMY PROCEDUES

•Improved outcomes with

A

multimodal anesthetic approaches,

early extubation,

fluid restrictions, and

cautious vasopressor/inotropic infusions

109
Q

ENDOBRONCHIAL ULTRASOUND-GUIDED BIOPSY

What’s involved?

A

Use of a radial probe that is inserted thhrough a channel of the bronchoscope probe for identification of mediastinal and hilar lymph nodes

Fine-needle aspiration for mediastinal staging

110
Q

ENDOBRONCHIAL ULTRASOUND-GUIDED BIOPSY

Management typically done in (location)?

A

Bronchoscopy facility (endoscopy center) or

CT suite

111
Q

ENDOBRONCHIAL ULTRASOUND-GUIDED BIOPSY

Anesthetic technique

A

Patients can be managed with moderate anesthesia care

Local anesthesia or MAC

112
Q

An abnormal communication between the bronchial tree and pleural cavity is known as:

A

BRONCHOPLEURAL FISTULA (BPF)

Most common occur after pulmonary resection for carcinoma

Can also occur d/t Rupture of lung abscess, bronchus, bulla, cyst, or parenchymal tissue into pleural space

Pneumonectomy patients have incidence ranging from 2% to 11%

113
Q

BRONCHOPLEURAL FISTULA (BPF)

Diagnosis

A

Diagnosis usually made clinically, and includes

SOB and expectoration of purulent sputum

Diagnosis confirmed by bronchoscopic examination, injection of methelyne blue into pleural space and recover of the indicator from sputum

114
Q

BRONCHOPLEURAL FISTULA (BPF)

Presentation Post pneumonectomy:

A

Dyspnea

Subcutaneous emphysema

Contralateral tracheal deviation

Decreased fluid level on serial chest x-ray

115
Q

BRONCHOPLEURAL FISTULA (BPF)

Presentation Post lobectomy:

A

Persistent air leak

Purulent drainage

Expectoration of purulent matter

116
Q

BRONCHOPLEURAL FISTULA (BPF) AND EMPYEMA

Anesthetic mgt for (BPF) can be complicated by (Three concerns):

A

Protection of healthy lung regions (There is a risk of contamination)

Risk for tension pneumothorax

Inadequate ventilation secondary to large air-leak caused by fistula

117
Q

BRONCHOPLEURAL FISTULA (BPF) AND EMPYEMA

How can the risk of tension pneumothorax be reduced?

A

Insert Chest tube in prior to induction

118
Q

BRONCHOPLEURAL FISTULA (BPF) AND EMPYEMA

ventilation:

A

Double-lumen tube = best choice for positive-pressure ventilation

Bronchial lumen towards healthy lung

Lung isolation before initiation of positive-pressure ventilation

119
Q

BRONCHOPLEURAL FISTULA (BPF) AND EMPYEMA

Which may decrease the air-leak across the fistula?

A

High-frequency jet ventilation

120
Q

BRONCHOPLEURAL FISTULA (BPF) AND EMPYEMA

Extubation:

A

Extubation as soon as possible

121
Q

OTHER THORACIC PROCEDURES

Subpleural collection of air under the visceral pleura caused by a ruptured alveolus are known as:

A

Blebs

Air enlarges to form bubble on the surface of lung

Most commonly occur at the apices of the lung

If rupture, cause pneumothorax

Pneumothorax can usually be managed with chest-tube

Resection of bleb for recurrent pneumothorax

122
Q

OTHER THORACIC PROCEDURES - Blebs​

Anesthetic considerations - Often treated with:

A

VATS

123
Q

OTHER THORACIC PROCEDURES - Blebs​​

Anesthetic considerations - Consider small tidal volumes, and low airway pressures ( <10-20 cmH2O) - why?

A

Positive pressure ventilation could lead to pneumothorax

Protective lunch maneuvers for blebs and bullae

Blebs have an increased compliance, which makes them more susceptible to rupture

If you were to deliver a large tidal volume to a lung with a bleb, because of its increased compliance, most of the tidal volume would preferentially expand the bleb, increasing its risk of rupture and pneumothorax

Lower tidal volumes and low PIP reduce the chance of this occurring.

124
Q

OTHER THORACIC PROCEDURES - Blebs​​​

Anesthetic considerations - Avoid Nitrous oxide - why?

A

May diffuse into the blebs,

Cause it to expand and possibly rupture

This could cause a pneumothorax

125
Q

OTHER THORACIC PROCEDURES

Thin-walled, air-filled lung spaces caused by the loss of alveolar structural tissue are also known as:

A

Bullae or Pulmonary cyst

Typically a/w COPD pts

Can also occur in isolation

Result from destruction of alveolar tissue

Can act as though they have a one-way valve, enlarging and compressing surrounding lung, which can impair ventilation

126
Q

OTHER THORACIC PROCEDURES - Bullae or Pulmonary cyst

Anesthetic considerations - when is surgery considered?

A

When dyspnea becomes incapacitating

When bullae are expanding and compressing surrounding lung tissue

When the pt suffers from repeated pneumos

127
Q

OTHER THORACIC PROCEDURES - Bullae or Pulmonary cyst

When do bullae become more compliant and likely to rupture?

A

With larger TVs

In fact, much of the larger TV will fill the compliant bullae

For this reason, small tidal volumes with low airway pressures should be used

128
Q

OTHER THORACIC PROCEDURES - Bullae or Pulmonary cyst

Surgical approach:

A

Traditional sternotomy or VATS

129
Q

OTHER THORACIC PROCEDURES - Bullae or Pulmonary cyst

Anesthetic considerations - Consider maintaining spontaneous ventilation until the lung or lobe with bullae is isolated - Otherwise, small tidal volumes with low airway pressures - why?

A

Positive pressure ventilation could lead to tension pneumothorax

130
Q

OTHER THORACIC PROCEDURES - Bullae or Pulmonary cyst

Nitrous oxide:

A

AVOID!!!

Nitrous oxide should be avoided

131
Q

The Chronic autoimmune disorder of the neuromuscular junction, tha causes reduced number of postsynaptic acetylcholine receptors at motor end plate is known as:

A

MYASTHENIA GRAVIS

Characterized by skeletal muscle weakness, fatigability on effort, partial restoration of function after rest

Occurs in 25 to 125 of every 1 million people globally

In those < 50 years of age, women > men

Can begin spontaneously at any age, onset may be either slow or abrupt with periods of exacerbation and remission

Most commonly affects eyes, especially at the dz onset

It’s restricted to occular muscles in about 20% of pts

If localized to eyes x2 years, the likelihood of progression is slow

132
Q

MYASTHENIA GRAVIS

System used to classify MG

A

Ossermann Scale

Classifies MG according to symptoms

Divides MG into five classes to aid in the management of pts undergoing tx

As the pt progresses into each stage, the prognosis becomes worse and the response to drug therapy is reduced

Types III & IV are associated with a high mortality rate

133
Q

MYASTHENIA GRAVIS

A
134
Q

The small gland that lies in the front part of the chest, beneath breast bone is known as

A

Thymus

Responsible for making T-cells that travel through the body to fight infectious dz

135
Q

Tumors of the Thymus gland are known as:

A

THYMOMA

Could be benign or malignant

Derived from thymic epithelia cells

Epithelia cells cause Hyperplasia, and express cross reactivity with skeletal muscle proteins such as Ach-receptors

Hyperplasia leads to development of AcH receptor antibodies

When the AcH receptor anitbodies attack the Ach-receptors, they cause destruction or inactivation of the Ach-receptors

This leads to muscle weakness and fatiguability

As many as 80% of functioning AcH receptors can be lost

While only 15% of patients with MG have a thymoma, 50% of patients with thymomas have MG

136
Q

THYMOMA

Why is the thymus gland often removed in pts with MG?

A

Removal of thymus gland, regardless of presence or not of thymoma will improve patient’s MG symptoms

137
Q

ANESTHETIC CONSIDERATIONS: THYMECTOMY FOR MYASTHENIA GRAVIS

Procedure frequently performed to induce clinical remission of MG, even in the absence of thymoma

A

THYMECTOMY

138
Q

ANESTHETIC CONSIDERATIONS: THYMECTOMY FOR MYASTHENIA GRAVIS

Surgical procedure:

A

May be performed via full/partial sternotomy, or

minimally invasive approach

If no tumor present => minimally invasive approach with VATS ok

If thymoma present => sternotomy

139
Q

ANESTHETIC CONSIDERATIONS: THYMECTOMY FOR MYASTHENIA GRAVIS

Induction with Propofol and topical anesthesia without use or with minimal use of muscle relaxants - why?

A

MG have Increased sensitivity to non-depolarizing agents, and are essentially resistant to Sux

140
Q

ANESTHETIC CONSIDERATIONS: THYMECTOMY FOR MYASTHENIA GRAVIS

Muscle relaxation:

A

If muscle relaxants used, 1/10 to 1/20 of usual dose

Cisatracurium & Atracurium best d/t Hoffmann Elimination

Resistance to succinylcholine - Not clinically significant, can still use

141
Q

ANESTHETIC CONSIDERATIONS: THYMECTOMY FOR MYASTHENIA GRAVIS

Which non-relaxant techniques can be used?

A

↑ inhalation agent

Inhalation and narcotic

Propofol, narcotic &/or inhalation agent

142
Q

ANESTHETIC CONSIDERATIONS: THYMECTOMY FOR MYASTHENIA GRAVIS

If muscle relaxation is used, what are important interventions prior to extubation?

A

Assess patient for weakness prior to extubation

Able to lift head, negative inspiratory pressure > -20 cm H2O

Patients may require IV doses of Neostigmine until they are able to resume oral intake of their usual Pyridostigmine dose

8361 Exam 4 (16 decks)

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