PreTest Surgery: Cardiothoracic Problems

Question 1

______________ is the best indicator of pulmonary reserve for preoperative evaluation.

Answer 1

FEV

Greater than 60% predicted is an acceptable range for surgery.

Question 2

Organized, chronic empyema needs to be treated with ________________.

Answer 2

thoracotomy with decortication followed by antibiotics

The organized empyema has a “fibrin rind” that needs to be scraped off to heal.

Question 3

Most cases of SVC syndrome (~70%) are due to ______________.

Answer 3

bronchogenic carcinoma

Question 4

Describe the management of perforated esophagus with air in the mediastinum.

Answer 4

• For cases with cancer, a motility disorder, or a stricture: esophagectomy
• For cases without the above or diagnosed late: spit fistula

Question 5

How should lung abscesses be treated?

Answer 5

• First, trial antibiotics directed at the causative agent.

* Second, if antibiotics fail, then go to percutaneous or surgical drainage.

Question 6

In a hemodynamically stable patient with an aortic dissection, you should first _____________.

Answer 6

initiate a beta-blocker to slow the rate of change of blood pressure (which would stress the dissection)

Question 7

How will the manometry of someone with DES differ from achalasia? How do you treat them?

Answer 7

• In DES, the spasm is throughout the body of the esophagus –not localized to the LES as in achalasia.
• Myotomy along the length of the contraction is the standard treatment.

Question 8

Review the three treatment tiers for spontaneous pneumothorax.

Answer 8

• Mild: observation
• Moderate/severe: tube thoracostomy
• Recurrent: thoracotomy with excision of subpleural blebs

Question 9

A young person has an MVC with sternal fracture and suspected myocardial contusion. What is the recommended treatment plan?

Answer 9

Though no one plan is agreed upon for management of myocardial contusions, observation on telemetry is the standard. The greatest danger is arrhythmia or compromised ventricular contraction (both of which could be medically managed should they arise during observation).

Question 10

How are chylothoraces managed?

Answer 10

• If noticed during the operation, ligate the defect. Sometimes this is not possible due to the fragility of the duct.
• If noticed later, have the patient eat a low-fat diet and monitor for healing.

Question 11

Cardiac myxomas are often attached to the ______________ and produce a murmur that mimics _____________.

Answer 11

fossa ovalis; mitral stenosis

Question 12

In repairing an aortic aneurysm, what maneuvers have been shown to reduce the risk of paraplegia?

Answer 12

• Decrease ischemic time by progressively moving the aortic clamp forward.
• Operative hypothermia
• CSF drainage (decreases opposing pressure so improves perfusion)

Question 13

The surgical treatment of Zenker diverticulum is ___________________.

Answer 13

excision of the diverticulum with myotomy of the cricopharyngeal muscle

Zenker’s is thought to arise from failure of the cricopharyngeal muscles to relax.

Question 14

CABG shows superior outcomes in _____________ disease, compared to PCI.

Answer 14

left-main vessel

Question 15

Review the treatment of thoracic outlet syndrome.

Answer 15

• First, recommend physical therapy to strengthen shoulder girdle muscles (to avoid shoulder droop).
• Second, if PT fails then do a first rib dissection to widen the thoracic outlet.

Question 16

Describe the management of a chylothorax.

Answer 16

• First, recommend bowel rest, avoidance of fatty foods, and TPN.
• If the chest tube continues to drain greater than 500 mL/day, then do a thoracotomy with ligation of the thoracic duct.

Question 17

You’re given a vignette saying a person has a connective tissue benign lung tumor. How can you use location to decide what type it is?

Answer 17

• Peripheral: hamartoma

* Parenchymal or bronchial: fibroma

Question 18

Review the three types of fundoplication.

Answer 18

• 180º anterior: Dor
• 180º posterior: Troupet
• 360º: Nissen

(You knock on DOoRs from the front and you need a TOUPÉe for your posterior bald spot.)

Question 19

The best treatment for achalasia is ___________________.

Answer 19

Heller myotomy with Dor fundoplication

Botox is temporary and balloon dilation carries a risk of perforation.

Question 20

What ophthalmologic condition can result from extremely elevated venous pressure (such as from tricuspid regurgitation)?

Answer 20

Exophthalmos

Question 21

Review the roles of these medications in shock: 
•Norepinephrine: 
•Dopamine:
* Epinephrine:
•Phenylephrine: 
• Dobutamine: 
• Nitroprusside: 
•Nitroglycerin:

Answer 21

•Norepinephrine: first-line for septic shock
•Dopamine: first-line for septic shock
* Epinephrine:
•Phenylephrine: first-line for neurogenic shock or second-line agent for hypotension when the first-line agents (dopamine and norepinephrine) cannot be given due to tachycardia
• Dobutamine: cardiogenic shock
• Nitroprusside: can be used to relieve afterload in severe cardiogenic shock with hypertension
•Nitroglycerin: myocardial ischemia