Thoracic

Question 1

Absolute indications for DLT

Answer 1

Lavage
Bronchopulmonary fistula
Abscess
Hemorrhage

Question 2

Tx for desaturation on OLV

Answer 2

Check other vitals
100%
Check DLT position
CPAP non-dependent lung
PEEP to ventilated lung
Go back to two lung ventilation

Question 3

How would you induce a patient with a mediastinal mass

Answer 3

Confirm with surgeon that rigid bronchoscope is avilable
Availability of sternal saw and CPB in case of airway compromise

Maintain spontaneous ventilation
Awake fiberoptic intubation
If he refuses AFOI - reassure then inhalational w/ sevo and spontaneously ventilating

Question 4

Suddenly lose etCO2 (or pulse ox) after ETT secured. What do you do?

Answer 4

Manually ventilate to assess compliance
Suspect mass compression
Try to pass rigid scope
Lateral or prone position to alleviate compression
CPB

Question 5

Relevance of facial and UL swelling during mediastinoscopy

Answer 5

SVC syndrome

• reduced preload and CO
• ensure adequate preload prior to induction
• large IV in lower extremities
• avoid PPv is able due to dec CO

Question 6

DDx for hypoNa, esp with lung CA

Answer 6

SIADH - normovolemia, high urine osm, high urine Na
HCTZ - hypovolemia, high urine Na

<130 risk for cerebral edema

Question 7

Considerations with carotid disease in mediastinoscopy

Answer 7

Inadequate cerebral perfusion from rightward shift cerebral autoreg

Dec BF from innominate compression

Right radial arterial line to monitor for compression

Question 8

Tear in SVC during mediastinoscopy

Answer 8

Call for help
Prepare for sternotomy, compress vessel
Get blood
IV in lower extremity

Question 9

Hypotension following mediastinoscopy DDx

Answer 9

Massive hemorrhage

Tamponade

Question 10

How might hypocapnia contribute to hypoxia?

Answer 10

hypocapnia would increase shunt and worsen hypoxia by inc vascular resistance in dependent lung and inhibiting HPV in non-dependent lung (hypocarbia induced vasodilation)

Question 11

Why are patients at risk for developing post-thoracotomy supraventricular tachycardia?

Answer 11

Underlying cardiac disease
Increased RV after load from reduction in pulmonary vascular bed
Pain induced sympathetic stimulation
cardiac manipulation

Question 12

The patient is placed in lateral decubitus position. What effect of ventilation does this position have?

Answer 12

Greater V/Q mismatch

• blood directed to dependent lung
• oxygenation preferentially directed to non-dependent lung