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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
Q

Management of Mediastinal Mass with Symptoms of Cardiac Compression

A

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
Q

Removal of Mediastinal Tumors

A

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
Q

Four “Ms”

A

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
Q

Lung Resection: Pre Op

A
  • History: Tobacco, cough, dyspnea , etc
  • Physical Exam
  • Labs/work up:
    Routine
    ABG’s
    CXR
    ECG
    Spirometry
    DLCO
    Determine reserve
    PFT’s
29
Q

Lung Resection Contraindications -Pulmonary Reserve

A

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
Q

Thoracic RoomPatient Set Up

A

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
Q

Anesthetic Technique for Thoracotomy

A

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
Q

Thoracoscopy/Robotic Surgery

A

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
Q

Minimally Invasive Procedures

A

Biopsies: Lung mass, pleura, and mediastinal mass
Lobectomy
Resection of bullae
Treatment of pneumothorax or empyema
Diagnosis and treatment of thoracic trauma

34
Q

Complications of VAT/Robotic

A

Dysrhythmias: Atrial fibrillation & SVT
Respiratory failure
Bleeding
Infection
Air leak
Chronic pain

35
Q

Positioning in Lateral Decubitus

A

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
Q

Lateral positioning pearls

A

Head neutral
Axillary roll
“Bean bag” padding
Recheck BS

37
Q

Complications of Lateral Position

A

Pressure injury to dependent eye/ear
Suprascapular nerve stretch injury
Atelectasis
Aseptic necrosis of the femoral head (pressure necrosis)
Peroneal/Ulnar nerve injury.

38
Q

Indications for One Lung Ventilation: Absolute

A

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
Q

Indications for One Lung Ventilation: Relative

A

Open lobectomy
Pneumonectomy
Thoracic aneurysm repair
Esophageal surgery
Surgical preference
Mediastinal tumors
mediastinoscopy

40
Q

Assessment of Pulmonary Reserve

A

Airflow: FEV1 < 40% predicted
Gas Exchange: DLCO < 40% predicted
Cardiopulmonary reserve: VO2 max < 15 mL/kg/min
(Normal ~ 35 – 40 ml/kg/min)

41
Q

Methods of Lung Separation for One Lung Ventilation (OLV)

A

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
Q

Left Lumen Tube: OLV

A

Tracheal cuff up
Endobronchial cuff up
Tracheal lumen clamped
All ventilation through bronchial lumen
Right lung collapsed

43
Q

Univent Tube

A

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
Q

Physiology of Lateral Position and OLV

A

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
Q

Factors affecting HPV: Direct inhibitors

A

High PvO2
Potent inhaled anesthetics – dose dependent
Vasodilators
Calcium channel blockers
Pulmonary artery hypertension
Respiratory or Metabolic Alkalosis
Hypocarbia
Hypothermia

46
Q

Factors affecting HPV: Indirect Inhibitors

A

Vasopressors
Increased CO: B2 agonists & Inotropic agents
Volume Overload
Mitral stenosis
Thromboembolism
PEEP

47
Q

Shunt and OLV

A

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
Q

Factors Correlating with Increased Risk of Desaturation during OLV

A

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
Q

Management OLV

A

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
Q

Hypoxemia during OLV

A

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
Q

Treatment of Hypoxemia During OLV

A

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
Q

Complications of OLV

A

Tracheal/bronchial laceration
Occlusion with bronchial inflation
RUL occlusion
Bronchial cuff pressure ischemia
Secretions and atelectasis
Hypoxemia

53
Q

Post Op Care

A
  • 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
Q

Thoracic Anesthesia

A

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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