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adv princip II exam 2 (6/13) > thoracic anesthesia part 2/3 > Flashcards

thoracic anesthesia part 2/3 Flashcards

0
Q
  1. what is the most common symptom of bronchopulmonary issues (i.e. bronchial irritation, ulcer, obstruction, infection etc.)?
  2. what are the rest
A
  1. cough

2. hemoptysis, chest pain, dyspnea, wheezing

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1
Q

for respiratory assessment, which is the most common complaint in regards to LUNG CARCINOMA (what brings them in to see us)?

A

hemoptysis

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2
Q

what are the extrapulmonary intrathoracic symptoms seen with cancer?

A
  1. pleura- EFFUSION
  2. chest wall -PAIN
  3. esphagus- DYSPHAGIA
  4. SVC- svc syndrome (aka thoracic outlet syndrome)
  5. brachial plexus- arm pain, horner’s syndrome (ptosis, miosis, anhydrosis, ipsilateral face involvement of cervical sympathetic plexus)
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3
Q

extrathoracic metastitic symptoms:

what organs are affected?

A

brain, kidneys, skeleton, liver, adrenals, GI tract, pancreas

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4
Q
  1. what are extrathoracic nonmetastatic symptoms?
  2. what is the name of the syndrome it creates?
  3. 3 examples of ‘this’ syndrome:
  4. what are other syndromes/ issues?
A
  1. endocrine or endocrine like substances are secreted d/t cancer
  2. paraneoplastic syndrome
  3. examples of paraneoplastic syndromes
    -cushing syndrome (excess corticoid or cortical hyperplasia)
    -ADH secretion (SIADH)
    -Eaton-Lambert (myasthenia like) syndrome
  4. OTHER: carcinoid syndrome,
    –hypercalcemia,
    –ectopic gonadotropin secretion,
    –hypoglycemia,
    –neuro muscular syndromes (mysathenia gravis)
    -
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5
Q

cancer:

what are non specific symptoms

A

weakness, weight loss, anorexia, lethargy, malaise, vague respiratory febrile symptoms (flu like)

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6
Q

what type patient might have Cancer?

A

avg age 60-70, heavy cigarette smoker, urban living, recent weight loss

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7
Q
  1. what is the nmenomic for effects of lung cancer?

2. what is the break down (a,b,c,d)?

A
  1. the “4 M’s “
  2. breakdown:
    a–mass effect: obstruction to lungs, abcess, svc syncrome, tracheobroncihal distortion, pancoast syndrome, laryngeal and phrenic nerve compression, chest wall or mediastinal extension
    b–medicine side effects: bleomycin causes o2 toxicity, adriamycin is cardiac toxic
    c–metabolic: Eaton-lambert, cushing syndromes; hyponatremia and hypercalcemia
    d–metastasis: to bone, liver, brain, adrenals
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8
Q

what does smoking cause: (6 things…BESIDES CANCER)

A
  1. changes in airflow and closing capacities
  2. decrease FVC
  3. decreased mucocilliary transport and increased secretions
  4. increased carboxyhb (=decreased o2 transport)
  5. increased myocardial work with decreased o2 supply (vasopressor/ stimulant)
  6. increased airway irritability
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9
Q
  1. what type of flow pressure loop will a copd (obstructive) patient have?
  2. what does this mean?
A
  1. they will have a half moon shaped wave with decreased inspiratory and expiratory flow times; they will have a higher total lung volume than normal but will have a higher retained lung volume
  2. they retain air on exhalation to keep smaller airways open and it takes them longer to exhale
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10
Q
  1. what type of pressure loop will a restrictive (obese, pulm fibrosis, etc.) patient have/
  2. why?
A
  1. restrictive pressure loop will have about half the total lung volume of norman (approx 3L) with quicker inspiratory and expiratory times
  2. they are restricted from getting much in and since compliance is low, exhalation shoots air right back out.
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11
Q

what are good pre-opretive respiratory manuvers?

A
  1. discontinue smoking 12 hours to 8 weeks before:
    a. 8 hours prior: decreases co-Hb
    b. 4-8 weeks prior: decreases risk of pulm complications
  2. B2 sympathomimetics (albuterol, terbutaline)
    - -corticosteroids (decreases edema and bronchoconstrictiong substances)
    - -cromalyn sodium, theophylline
    - -robinol (decreases broncho constriction by blocking histhamine)
    - -hydration (loosens secretions) can be done by humidifier
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12
Q
  1. what are the best cardiac function monitors for thoracic surgery?
  2. which one is now infrequently used?
A
  1. best monitors for thoracic surgery:
    - - #1 arterial line (for bp and abgs)–remember art to right and pulse ox to left;
    - -cvp
  2. swan (usually goes to right and if doing a left lung (laying on right) , the PAP will be falsely high)
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13
Q

where are blood flow and oxygenation greatest in the lungs?

A

closest to the moving diaphragm

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14
Q
  1. what region does positive ventilation (in an anesthetized/ paralyzed patient) ventilate?
  2. why is this?
  3. what does this result in?
A
  1. positive pressure ventilation (i.e. the diaphragm is no longer pulling air; we are pushing air) ventilates the upper most part of the lung or zone 1
  2. this will be the path of least resistance
  3. VQ mismatch d/t most of the oxygen going to areas that have the least perfusion
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15
Q

what 2 things can happen when an awake patent is lying lateral with an open chest (pleural cavity- but not lung; i.e., the lung is lung on the open chest is not attached to the chest cavity and is free floating but still holds air)?

A

1a. mediastinal shift: as the open lung deflates, the negative pressure on the good lung side pulls the heart over with it.
1b. this puts torsion on the heart and great vessels
2a. Paradoxical respiration (pendulum or pendeluft air): as the good lung inhales, it pulls air from the open lung and when the good lung exhales, it pushes air back into the open pleural cavity.
2b. this increases dead space because stale air is breathed back and forth into a non perfused lung sac (open lung side)

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16
Q

what are the biggest problems with a lateral decubitus, anesthetized, paralyzed patient with open chest?

A
  1. Hypoxemia is most common problem

2. greatest V/Q mismatch (d/t most oxygen going to non dependent (up) lung and most blood going to dependent lung)

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17
Q
  1. THOERETICALLY, what would be the perfusion ratios from each lung in the lateral position?
  2. ACTUALLY, the perfusion pressures are what? why?
A
  1. 60% of CO goes to dependent and 40% to non dependent.
    -normal venous admixture (physiological shunt) is 5% each lung
    -NORMALLY 55% of CO from dependent and 35% from non dependent lung participate in gas exchange;
  2. BUT… because HPV (hypoxic pulmonary ventilation) decreases blood flow to lung by 1/2…
    -THEREFORE: there is a shunt of 17.5% + 5% shunt=22.5% in the non dependent lung + 5% shunt in the dependent lung for a total shunt of 27.5% (as opposed to normal 10%)
    -this greatly reduces pao2 to 150 mmHg on 100% when it should be higher than .198
    ex; if fio2 in lungs increases to 90% =.9 x 760~ 684 mmHg pao2 (give or take); this cannot occure d/t the subtraction of oxygen d/t 27.5% shunt
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18
Q

Indications for one lung ventilation (DLT):
what are the ABSOLUTE indications (3reasons + examples)?
A.
B.
C.

A
  1. absolute:
    A. to avoid spillage or contaminationn of good lung from:
    -infected (purulent) fluids
    -hemorrhage
    B. to divert ventilation to just one lung:
    -bronchopleural fistula
    -surgical opening of a major conducting airway
    -giant unilateral cyst or bulla
    -tracheobronchial tree disruption
    -life threatening hypoxemia r/t unilateral lung disaese
    -VATS
    C. unilateral bronchopulmonary lavege
    -pulmonary alveolar proteinosis
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19
Q

Indications for one lung ventilation (DLT):
what are the RELATIVE indications for DLT (4 reasons with examples)?
A.
B.
C.
D.

A

A. surgical exposure:
-thoracic aortic aneurysm
-pneumonectomy
-thoracoscopy
-upper lobectomy
-mediastinal exposure
B. surgical exposure (medium-lower priority)
-middle and lower lobectomies and subsegmental resections
-esophageal resection
-procedures in thoracic spine
C. postcardiopulmonary bypass pulmonary edema OR
hemorrhage after removal of occluding unilateral chronic pulmonary emboli
D. severe hypoxemia related to unilateral lung disease

20
Q

how do you place a robert-shaw DLT?

lets say left DLT for example

A
  1. prep and check tube; place stylet
  2. lube tube
  3. insert with distal curvature facing anteriorly
  4. REMOVE STYLET once blue bronchial (“b=b”) cuff is thru cords
  5. rotate tube 90 degrees (in direction of left lung)
  6. cease advencement once resistance is encountered
21
Q

how do you inflate cuffs and check placement of a left DLT

6 steps

A
  1. inflate traheal cuff (high volume; low pressure-20 mL max)
  2. listen for bilat lungs -just like with standard ETT; (if not equal, tube is down too far -withdraw 2-3 cm and re-ascultate)
  3. clamp the right side (connecter) marked “tracheal” (on left DLT) and remove right cap and ventilate(you may hear some leak from left lung since left bronchial cuff is still deflated).
  4. slowly inflate bronchial cuff (using minimal cuff technique); 1-3 cc to inflate cuff
  5. remove right clamp and replace cap; check ventilation to both lungs (checking to make sure that bronchial cuff is not blocking anything).
  6. check each lung by clamping the opposite and ascultating:
    i. e. clamp left and listen on right; then clamp right and listem on left
22
Q
  1. what is the most important problem with placing a DLT?

2. what are the consequences?

A
  1. MALPOSITION;
  2. wrong lung collapse,
    - inadequate lung separation,
    - increased PIP, instability of the DLT,
    - tracheal or bronchial laceration,
    - obstruction of RUL bronchus by left sided DLT bronchial cuff
23
Q

how is a DLT always checked (or should always)?

A

with a fiberoptic bronchoscope

24
Q

what is are (rare) potential complications of DLT?

A
  1. bronchial rupture

2. tracheal rupture

25
Q

Management of one lung ventilation:

  1. vent settings:
    a. fio2
    b. tidal volume
    c. resp rate
    d. peep
A

a. fio2=100%
b. vT=5-8 cc/kg
c. RR to desired ETco2
d. peep=5 cmH20

26
Q

Management of one lung ventilation:

  1. what should you do 15-20 min post instituting OLV?
  2. what can be done to non dependent lung to help with hypoxia? how common of a practice?
  3. what can too much peep to dependent lung do?
A
  1. check ABG 15-20 min post instituting one lung ventilation
  2. CPAP to non dependent lung can oxygenate the shunted blood decreasing hypoxia (although not commonly done)
  3. peep on dependent lung at around 5 cmH20 can help keep alveoli open; too much peep increases the pressure too much so that blood cannot enter and is shunted to the non dependent lung.
27
Q
  1. when should lung deflation be done for:
    - a. open thoracotomy?
    - b. VATS?
  2. if pneumonectomy, what can be done to prevent excessive shunting?
A
  1. deflation of lung and OLV should be started for:
    - a. Open thoracotomy: when told by physician
    - b. VATS: as soon as placed (it may take 30 min for lung to deflate)
  2. clamp surgical pulmonary artery asap.
28
Q

what is considered hypoxia with OLV?

A

SpO2 less than 90%

29
Q
  1. what is a recruitment manuver?
  2. what might a surgeon call it?
  3. how is it done?
  4. what side effects may be seen?
A
  1. a peep manuver used to “pop open” previously unused alveoli (may be good to do prior to surgery to get as many alveoli as possible ready for the surgery)
  2. aka: “valsalva”
  3. peep of 20 x 20 seconds (then let the patient exhale); then peep of 30 for 30 seconds (let air out); then peep of 40 for 40 seconds
  4. patients with poor cardiac output may really drop their blood pressure d/t all the peep in the lung prevents blood from flowing thru (you may crap your pants).
30
Q

how is cpap applied to the up (deflated/ non dependent) lung?

A

a pressure regulator connected to a c-pap valve, a 1 liter anesthesia bag and some 02 tubing connected to oxygen supply

31
Q

what are contraindications for double lumen tube placement?

A
  1. too small of a patient
  2. sull stomach
  3. carina or proximal bronchial mainstem lesions
  4. difficult airway or anatomy
  5. too critically ill and cannot tolerate peep
32
Q
  1. what size DLT for men? Women?

2. approximately where should a DLT be placed to (at the lip)?

A
  1. size DLT for men=37-39 french. Women=35-37 french (can use 35 fr. for both without incident).
  2. average lip line for a DLT is approx 29 cm (+/- 2 cm)
33
Q

complications of double lumen tubes:

A
  • traumatic laryngitis

- tracheobronchial tree disruption (bronchial ruptuer)

34
Q
  1. what is HYPOXIC PULMONARY VASOCONSTRICTION (HPV)?
  2. is this a good thing?
  3. how does anesthesia affect this?
A
  1. when a lung is hypoventilated, the co2 will increase. This causes an opposite effect in the lungs than it does in the body (in the body, it causes vasodilation- to bring oxygen to the tissues). In the lungs, the vessels constrict (if bloods job is to get oxygen, why be sent to a place with no oxygen?).
  2. this is good because it doesnt allow for wasted energy sending blood where it is not needed
  3. anesthesia causes (some)pulmonary vessel dilation (even in hypoxic lungs, decreaseing HPV and therefore shunting blood to un-necessary area.
35
Q

what are the advantages of general anesthesia (inhaled agents) in a thoracotomy?

A

Inhaled anesthesia agents:

  1. decrease airway irritation
  2. allows for higher concentration of inspired oxygen without loss of anesthesia
  3. rapid elimination of inhaled agents reduces chance of post op resp depression
  4. maintain reasonable cardiac stability
  5. less decrease in PaO2 than with iv anesthesia
36
Q

what are the advantages of narcotics for anesthesia with a thoracotomy?

A

Narcotics:

  1. have no significant effect on hemodynamics
  2. keeps post opertively intubated patients comfortable
  3. (when used in combination with inhaled agents), high dose narcotic technique allows for high Fio2 and less inhaled gas.
  4. narcotics DO NOT INHIBIT HPV
37
Q
  1. What is a good drug to use in anesthesia of a thoracotomy?
  2. why is it a good drug for thoracotomy?
  3. what other reasons?
  4. what are disadvantages of using this drug?
A
  1. ketamine 1-2 mg/kg
  2. it is a sympathomimetic and therefore maintains BP and is a bronchodilator (reduces incidence of bronchospasm in asthmatics)
  3. rapid onset (good for full stomach)
    - does not impair arterial oxygenation during OLV
  4. ketamine increases secretions and can cause cardiovascular depression in hypovolemic or sympathetic nervous system exausted patients
38
Q
  1. what medication do all respiratory procedures get?

2. what other med should be given (prior to laryngoscopy)?

A
  1. robinol

2. lidocaine 1 mg/kg IV or via LTA

39
Q

how much fentanyl can be used during induction for a thoracic procedure?

A

3-10 mcg/kg (4-15 cc of fentanyl at 50 mcg/cc)

in other words 200-750 mcg of fentanyl

40
Q

how much fluid is given during these cases?

A

less than 1 liter (should be very cautious- some cases may run 6-8 L/kg/hr though)

41
Q

complications of a thoracotomy:

what can happen to the heart after PNEUMONECTOMY?

A

HEART can herniate if:

  • -suction is applied to the chest tube (NO SUCTION TO CHEST TUBE POST PNEUMONECTOMY)
  • -if turned onto affected side (GOOD LUNG DOWN FOR PNEUMONECTOMY)
42
Q

complications of a thoracotomy:

what are others (6 major complications)?

A
  1. respiratory insuffeciency (MOST COMMON COMPLICATION)
  2. hemorrhage
  3. bronchial disruption
  4. right CHF d/t increased PA / PVR pressure (which will cause a RA pressure which is higher than PCWP and a decreased CO)
  5. right to left intracardiac shunt through PFO (d/t RA pressure rising higher than LA pressure» which pushes open the foramen ovale).
  6. neural injury:
    - phrenic nerve injury= failure to wean
    - vagus nerve injury=GI atony
    - recurrent laryngeal nerve=adductor spasm of vocal cords if bilateral injury
    - ischemia to greater artery of adamkowitz from aortic crossclamping(at T10 of anterior spinal cord)=paraplegia
    - damage to spinal branches of intercostal arteries=paraplegia
43
Q

Thoracotomy of which lung gives better oxygenation?

A

left thoracotomy (which means ventilation of right lung) has better oxygenation (RIGHT LUNG IS LARGER)

44
Q

what can obstructive disease cause in during thoracic surgery?

A

auto peeping (breath stacking) d/t prolonged expiratory times common in COPD

45
Q

which position has the least hypoxemia:

a) lateral; b) semi lateral; c) supine?

A

lateral positioning has the least hypoxia

46
Q

what are some ways to limit atalectasis and hypoxemia during OLV?

A
  1. high VT (10-12 mL/kg) without peep
  2. ensure that expiratory flow reaches zero before next breath (otherwise breaths will stack) may have to adjust rate and I:E ratio.
  3. moderate VT (6-8 mL/kg) with peep
47
Q
  1. what happens when you allow for the alveoli to snap open and snap shut during ventilation?
  2. what prevents this?
A
  1. causes wall stress on alveoli and may cause damage

2. peep

adv princip II exam 2 (6/13) (5 decks)

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