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Concepts 2 > Thoracic Anesthesia (Hall and Lorette) > Flashcards

Thoracic Anesthesia (Hall and Lorette) Flashcards

1
Q

Endobronchial Ultrasound (EBUS) - indications and evaluation

A

Indications: Transbronchial needle aspiration, Staging of Non small cell lung cancer, Planning for surgical resection
Evaluation: Mediastinal lesions, Mediastinal Lymph node needle biopsy, Intrapulmonary nodules, Endobronchial lesions

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2
Q

anesthesia for an ebus

A

Sedation and LA
Nebulizing 1% or 2% lidocaine
1% or 2% lidocaine installed via bronchoscope
GA/TIVA
ETT – size 8 - 9
LMA/IGel – size 4-5
Upper paratracheal nodes

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3
Q

Evaluation for superior vena cava syndrome d/t mediastinal mass

A
  • dilated facial/upper extremity veins with collateralization
  • facial edema / upper extremity edema ?airway edema
  • respiratory symptoms: nasal congestion, cough, orthopnea
  • CNS: mental status, headache
  • Chest CT with contrast
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4
Q

Management of superior vena cava syndrome

A
  • Carefully review history of symptoms with supine position
  • Consider effect of airway edema/compression on intubation
  • Lower extremity IV
  • Elevate head of bed
  • Diuretics and steroids
  • Pre op Radiation Therapy
  • Maintain pre load
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5
Q

Mediastinoscopy indications and anesthetic considerations

A

Indications:
- Diagnose Intrathoracic malignancies & Determine Resectability
Anesthetic Considerations:
- GETA
- Large Bore IV (14 or 16 ga.)
- NIBP on Left Arm/Arterial line
- Pulse Ox on Right side (finger or ear)**

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6
Q

Carcinoid Tumor“Cancer in slow motion”

A
  • Neuroendocrine Tumor
  • Hormonal Mediators
  • Begins in the Gi System

Periop Goals:
- Prevent mediator release
- Avoid anxiety, hypercapnia, hypothermia, hypotension
- Histamine releasing drugs
- Succinylcholine

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7
Q

Mediastinoscopy Complications

A

1 Hemorrhage

#2 Pneumothorax
- Reflex bradycardia
- Decreased carotid blood flow and CBF (innominate)
- Airway obstruction (trachea)
- Chylothorax
- Phrenic and recurrent laryngeal nerve paresis
50% permanent
Bilateral paresis: airway obstruction

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8
Q

Anesthetic Management of Mediastinoscopy

A
  • Allows direct inspection and diagnosis
  • Supine
  • General anesthesia with topical 4% Lidocaine to trachea
  • Innominate Artery occlusion can occur with decrease blood flow to Right carotid and subclavian.
  • Monitor Pulse oximetry on Rt arm. (reposition mediastinoscope)
  • Monitor BP both arms
    Complications: Hemorrhage, pneumothorax, vagal reflex,
    Contraindicated: Vena Cava Syndrome, tracheal deviation, thoracic aneurysm
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9
Q

Bronchoscopy: general indications

A

Indications:
R/O TB and evaluate lung disease (sarcoidosis…)
Evaluate Abnormal CXR (Mass)
Foreign body
Preoperative Biopsy

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10
Q

Flexible Bronchoscopy indications

A

Evaluating upper lobe lesions
Securing airway in difficult intubations

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11
Q

Rigid Bronchoscopy indications

A

Assessment of vascular tumors of the lower airway
Bronchoscopy in small children
Removal of foreign body
Control of massive hemoptysis

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12
Q

Bronchscopy Anesthetic Considerations

A

GETA (Flexible or Rigid)
Large ETT/Good IV Access
Three Techniques
Apneic oxygenation with small catheter alongside the scope.
Conventional ventilation through a ventilating scope.
High-frequency ventilation through an injector-type scope.

MAC/TIVA (Flexible only):
Depends on Practitioner’s Technique
Give up airway

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13
Q

EBUS

A

Bronchoscopy with US
Indications:
Transbronchial needle aspiration
Staging of Non small cell lung cancer
Planning for surgical resection

Evaluation:
Mediastinal lesions
Intrapulmonary nodules
Endobronchial leasions

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14
Q

Contraindications to EBUS

A

Life threatening cardiac dysrhythmias
Recent MI
Poorly controlled heart failure
Severe hypoxemia
Uncooperative patient
Current antiplatelet/anticoagulation therapy
Coagulopathy/thrombocytopenia
Elevated renal indices

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15
Q

Anesthesia for EBUS

A

Sedation and LA
Nebulizing 1% or 2% lidocaine
1% or 2% lidocaine installed through bronchoscope
GA/TIVA
ETT – size 8 - 9
LMA/iGel – size 4-5
Upper paratracheal nodes

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16
Q

Mediastinoscopy indications & Anesthetic Considerations

A

Indications:
Diagnose Intrathoracic malignancies
Determine Resectability

Anesthetic Considerations:
GETA
Large Bore IV (14 or 16 ga.)
NIBP on Left Arm/Arterial line
Pulse Ox on Right side (finger or ear)

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17
Q

Anesthetic Management of Mediastinoscopy

A

Allows direct inspection and diagnosis
Supine
General anesthesia with topical 4% Lidocaine to trachea
Innominate Artery occlusion can occur with decrease blood flow to Right carotid and subclavian. Monitor Pulse on Rt arm. (reposition mediastinoscope)
Monitor BP both arms.
Complications..Hemorrhage, pneumothorax, vagal reflex,
Contraindicated with Vena Cava Syndrome, tracheal deviation, thoracic aneurysm

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18
Q

Mediastinoscopy Complications

A

1 Hemorrhage

#2 Pneumothorax
Reflex bradycardia
Decreased carotid blood flow and CBF (innominate)
Airway obstruction (trachea)
Chylothorax
Phrenic and recurrent laryngeal nerve paresis

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19
Q

Anterior Mediastinal Mass

A

Tracheal Bronchial obstruction: Static measurable symptoms and dynamic component unmasked by supine position and paralytics.
SVC Syndrome
Compression of Heart and PA

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20
Q

Pre Op Respiratory Evaluation of Patient with Mediastinal Mass

A

CXR
Chest CT (look for compression of airways)
Flow Volume Loops ( Truncation of expiratory, possibly inspiratory limb)
Echocardiography
History of DOE, orthopnea

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21
Q

Management of Respiratory Compression

A
  1. PREVENT IT!
    Position tilt or head up, spontaneous respirations
    Awake fiberoptic bronchoscopy
    Avoid NMB
  2. Overcome it:
    Rigid bronchoscopy or long ET.
    Change position to lateral
    Open chest (if median sternotomy was scheduled)
  3. Sidestep it:
    Fem-Fem bypass before induction of anesthesia
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22
Q

Evaluation for Superior Vena Cava Syndrome: Mediastinal Mass

A

Dilated facial/upper extremity veins with collateralization
Facial edema/ upper extremity edema/?airway edema
Respiratory symptoms (nasal congestion, cough, orthopnea)
CNS (mental status, headache)
Chest CT with contrast

23
Q

Management of Superior Vena Cava Syndrome

A

Carefully review history of symptoms with supine position
Consider effect of airway edema/compression on intubation
Lower extremity IV
Elevate head of bed
Diuretics and steroids
Pre op Radiation Therapy
Maintain pre load

24
Q

Evaluation of Heart Compression from Mediastinal Mass

A

History of Syncope with Valsalva
Echocardiography …may see extrinsic compression of cardiac chambers or PA

25
Management of Mediastinal Mass with Symptoms of Cardiac Compression
Monitor with Echo Position to minimize compression.:.lateral or prone Maintain venous return/PAP/CO Spontaneous ventilation if possible Have patient position self while awake Potential CPB stand by Consider local anesthesia for small procedures
26
Removal of Mediastinal Tumors
Multidisciplinary approach and pre op evaluation Pre op reduction of mass with drugs or Radiation Pre induction A-line Rigid Bronchoscope available Attending surgeon in OR Lower extremity IV/?femoral central line Slow induction with spontaneous ventilation Consider Succinylcholine Smooth, no coughing , emergence
27
Four "Ms"
Mass Effects: obstructive PNA, lung abcess, SVC syndrome, tracheobronchial disortion, RLN or phrenic nerve paresis, chest wall/mediastinal extension Metabolic Effects: lamber-eaton syndrome, hypercalcemia, hyponatremia, cushings Metastases: brain, bone, liver, adrenals Meds: bleomycin and cisplatin
28
Lung Resection: Pre Op
- History: Tobacco, cough, dyspnea , etc - Physical Exam - Labs/work up: Routine ABG’s CXR ECG Spirometry DLCO Determine reserve PFT’s
29
Lung Resection Contraindications - Pulmonary Reserve
Resection may be contraindicated if: FEV1 less than 50%predicted FVC less than 2 L (FVC 3x Vt needed for effective cough) RV/TLC greater than 50% predicted (severe COPD) MBC less than 50% predicted Low FEV1 or FVC show mechanical impairment FEV1 less than 800 ml. cannot breath without assistance Consider Split PFT’s to determine if one lung only is impaired. Mortality is proportional to FEV1
30
Thoracic Room Patient Set Up
A-line Large Bore IV PA/CVP if indicated by procedure and patient co-morbidity ET and DLT in various sizes : use largest possible. Bronchoscopy equipment Lower body Bair Hugger Padding, gel, head rolls for lateral decubitus position
31
Anesthetic Technique for Thoracotomy
Choice of agent related to patient co-morbidity. Technique that allows for 100% O2 when needed Controlled ventilation/neuromuscular block Consider General Anesthesia with epidural Limit fluids Plan for post op analgesia Plan for Post op ventilatory management
32
Thoracoscopy/Robotic Surgery
Lateral thoracic wall Video directed and minimally invasive tumor or mass resection, gas entry to pleural space Often prefer DLT because Positive pressure ventilation will interfere with visualization of thoracic contents Consider intercostal nerve blocks Robotic: Provides better visualization & Smaller incision (in theory) Better manipulation of surgical instruments
33
Minimally Invasive Procedures
Biopsies: Lung mass, pleura, and mediastinal mass Lobectomy Resection of bullae Treatment of pneumothorax or empyema Diagnosis and treatment of thoracic trauma
34
Complications of VAT/Robotic
Dysrhythmias: Atrial fibrillation & SVT Respiratory failure Bleeding Infection Air leak Chronic pain
35
Positioning in Lateral Decubitus
Head rest, pillow, gel or blanket to assure neutral position without pressure on eye or ear. Axillary roll to maintain perfusion of lower arm and prevent stretch of suprascapular nerve. Hips at break in table Bean Bag upper edge at shoulder. All pressure points padded Tape secure between iliac crest and femoral head
36
Lateral positioning pearls
Head neutral Axillary roll “Bean bag” padding Recheck BS
37
Complications of Lateral Position
Pressure injury to dependent eye/ear Suprascapular nerve stretch injury Atelectasis Aseptic necrosis of the femoral head (pressure necrosis) Peroneal/Ulnar nerve injury.
38
Indications for One Lung Ventilation: Absolute
Massive bleeding in one lung Sepsis and pus Broncho pleural fistula Broncho cutaneous fistula Giant unilateral bullae Lavage for cystic fibrosis Video Assisted thoracoscopy
39
Indications for One Lung Ventilation: Relative
Open lobectomy Pneumonectomy Thoracic aneurysm repair Esophageal surgery Surgical preference Mediastinal tumors mediastinoscopy
40
Assessment of Pulmonary Reserve
Airflow: FEV1 < 40% predicted Gas Exchange: DLCO < 40% predicted Cardiopulmonary reserve: VO2 max < 15 mL/kg/min (Normal ~ 35 – 40 ml/kg/min)
41
Methods of Lung Separation for One Lung Ventilation (OLV)
Bronchial blocker (pediatrics): DLT 8- 9 years = 26, DLT 10+ years – 28 - 32 Fogarty catheter Endobronchial intubation Univent Tube Double Lumen Left or Right Tubes: Size = Female 35 – 39 Male 39 – 41 Depth 27 – 29 Tracheal cuff 5 – 10 mL Bronchial cuff 1 – 2 mL
42
Left Lumen Tube: OLV
Tracheal cuff up Endobronchial cuff up Tracheal lumen clamped All ventilation through bronchial lumen Right lung collapsed
43
Univent Tube
Single lumen for ventilation Easier to position Useful for small patient, short bronchus, child, brief procedure Difficult to deflate lung (absorption) and remove secretions
44
Physiology of Lateral Position and OLV
Effect of gravity: Upper non-dependent lung zone 1 Lower non-dependent lung and upper dependent lung zone 2 Lower dependent lung zone 3 Nondependent Lung: Better compliance Optimal ventilation Dependent lung: Less compliant Perfusion is best (effect of gravity) Reduction of alveolar volume = atelectasis
45
Factors affecting HPV: Direct inhibitors
High PvO2 Potent inhaled anesthetics – dose dependent Vasodilators Calcium channel blockers Pulmonary artery hypertension Respiratory or Metabolic Alkalosis Hypocarbia Hypothermia
46
Factors affecting HPV: Indirect Inhibitors
Vasopressors Increased CO: B2 agonists & Inotropic agents Volume Overload Mitral stenosis Thromboembolism PEEP
47
Shunt and OLV
Physiological (postpulmonary) shunt: About 2-5% CO, Accounting for normal A-aD02, 10-15 mmHg Including drainages from Thebesian veins of the heart The pulmonary bronchial veins Mediastinal and pleural veins Transpulmonary shunt increased due to continued perfusion of the atelectatic lung and A-aD02 may increase
48
Factors Correlating with Increased Risk of Desaturation during OLV
High % of ventilation or perfusion to the operative lung on pre-op V/Q scan Poor Pao2 during two-lung ventilation, particularly in lateral position intra-op Right-sided thoracotomy Normal pre-op spirometry or restrictive lung disease Supine position during OLV
49
Management OLV
FiO2 100% Vt 6 – 8 mL/kg PEEP 5 cm H2O RR 12 – 15 breaths per minute Reconfirm placement after position changes If PIP > 40 cm H2O – rule out distal occlusion
50
Hypoxemia during OLV
SpO2 < 90 check the position of DLT Rule out physiologic causes of hypoxemia – if severe then resume two lung ventilation Apply 10 cm H2O CPAP to non-dependent lung PEEP 5 – 10 cm H2O to dependent lung Use alveolar recruitment techniques (sigh breaths) TIVA may minimize inhibition of HPV If hypoxemia continues – consider clamping of the PA supplying the nondependent lung May need to convert to open procedure – DO NOT tolerate prolonged hypoxemia
51
Treatment of Hypoxemia During OLV
TV of dependent lung = 10-12 mL/kg 100% O2 Periodically inflate nondependent lung Search for cause of hypoxemia CPAP 5-10 cm H2O to non-dependent PEEP 5-10 cm H2O to dependent lung Clamp the non-dependent PA
52
Complications of OLV
Tracheal/bronchial laceration Occlusion with bronchial inflation RUL occlusion Bronchial cuff pressure ischemia Secretions and atelectasis Hypoxemia
53
Post Op Care
- Pain management: Thoracic Epidural - with local and/or narcotics Paravertebral nerve block: Catheter inserted open before wound closure - Interpleural catheters - Intercostal blocks - Cryoanalgesia - 6 months - Change to single lumen tube at end of case
54
Thoracic Anesthesia
Remember basics Know the capabilities of the equipment Careful patient evaluation of respiratory Reserve and co-morbidity Assess for Symptoms of Mediastinal mass Communicate with surgeon before OR Post op Analgesia to maximize respiratory function

Concepts 2 (11 decks)

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