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Thoracic Sugery Flashcards

1
Q

Smoking cessation 2 motns

A

bronchial secretions increase = risk of complications

however, with advanced lung cancer patients can’t wait 2 months for surgery

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2
Q

What PFTs are needed for thoracic surgery to predict postoperative risk?

A

PPO FEV1 - calculates current FEV1 multiplied by the fraction of functioning lung

and DLCO

Traditional FEV1 is not enough

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3
Q

DLCO

A

diffusion capacity

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4
Q

DLCO (diffusion capacity)

A

measures the lung’s ability to transport gas across the alveolar capillary membrane

pt holds breath of CO for 10 seconds, then exhales. Measure meant of exhaled CO is calculated with predicted values

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5
Q

What DLCO increases complicaion risk?

A

<60%

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6
Q

Normal DLCO

A

17-25 mL/min/mmHg

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7
Q

Predicted postoperative product is

A

FEV1 multipled by DLCO

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8
Q

VO2 max

A

max O2 consumption during exercise

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9
Q

VO2 low posoperative risk

A

> 20 mL/kg/min

can climb 5 flights of stairs

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10
Q

VO2 high postperative risk death

A

<10 mL/kg/min

cannot climb one flight of stairs

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11
Q

V/Q tests postoperative risk (how?)

A

Radioisotope IV dye shoes perfusion to all areas of lung - calculations can be made to determine pulmonary function once diseased areas are removed

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12
Q

Post operative complications ABGs and SPO2

A

SpO2 <90% is indicative of post-op complications

PaCO2 is indicative of poor ventilatory function but not post op complications

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13
Q

EKG high postoperative complication risk

A

RV hypertrophy - low QRS and poor R wave progression

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14
Q

Cancer risk factors

A

4 M’s (lung damage/poor lung funtion)
mass effects
metabolic effects
metastases
medications

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15
Q

What PPO FEV1 warrants further testing preoperatively?

A

PPO FEV1 < 40%

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16
Q

What should be checked if PPO FEV1 is < 40%?

A

DLCO
V/Q scan
VO2 max

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17
Q

High risk candidates FEV1

A

<2L or <40% of predicted

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18
Q

Oxygen desaturation high risk

A

> 4% during exercise

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19
Q

Pulmonary artery catheter monitoring will not be accurate if

A

surgery on the right lung and is collapsed

usually not used

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20
Q

Arterial line placement lateral decubitus

A

Dependent arm for stabilization

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21
Q

Arterial line placement during medistinoscopy and why

A

R arm - detects compression of innominate artery - able to identify a decrease in cerebral blood flow

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22
Q

SPO2 monitor placement for mediastinoscopy

A

R arm - detection of innominate artery compression

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23
Q

Normal lung blood flow distribution in lateral position

A

60% to dependent lung, 40% to nondependent lung

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24
Q

How does V/Q mismatch occur in lateral decubitus position?

A
  1. FRC is reduced during induction
  2. FRC is further reduced in dependent lung (where perfusion is best) = uneven reduction in FRC–>ventilation increases in nondependent lung

ventilation is not best in dependent lung

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25
Q

V/A mismatch in paralyzed, mechanically ventilated patient

A

Further reduced FRC (diaphragm no longer counteracting)

ventilation goes to nondependent lung even more, but perfusion still better in dependent lung = even more V/Q mismatch

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26
Q

Open chest and V/Q mismatch

A

Open chest reduces resistance in ventilation, so it goes even more to nondependent lung.

Mediastinum shifts downward from loss of neg intrapleural pressure in open lung = ventilation of dependent lung decreased even more

Creates the largest V/Q mismatch

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27
Q

How does OLV help V/Q mismatch

A

Hypoxic Pulmonary Vasoconstriction - lung is deflated and blood flow diverts to areas of higher PAO2 (better ventilated, nondependent lung)

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28
Q

What triggers HPV

A

alveolar hypoxia

NOT arterial hypoxemia

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29
Q

Where does HPV take place?

A

ONLY in proximal pulmonary arteries

(in circulation, hypoxemia causes vasodilation)

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30
Q

HPV decreases blood flow during OLV by

31
Q

In OLV, the blood flow distribution between lungs is

A

80:20 (instead of 60:40)

32
Q

What fraction of lung hypoxia causes HPV to yield right ventricular strain?

A

When 80% of lung is hypoxic, increased PVR causes RV strain and failure

33
Q

What anesthetic factors/events can redcuce HPV?

A
  1. Hypo/hypervolemia
  2. Too high Vt or PEEP
  3. inhalation agents >1.5 MAC
  4. acidosis or alkalosis
  5. hyOcapnia
  6. HypOthermia
  7. vasodilators and vasoconstrictors
34
Q

Absolute indications for OLV

A
  1. isolation from one lung to another (infection or massive hemmorage)
  2. Control of distribution of ventilation
  3. Unilateral bronchopulmonary lavage
35
Q

Relative indications for OLV

A

Will lung get in the way of surgery? Ideally OLV, but may not be tolerated

36
Q

Know this list

37
Q

When should you turn ETT 90 deg for OLV

A

immediately after advancing through cords. Then remove stylet and advance

38
Q

Once throught cords and after removing stylet, how far should you advance ETT for OLV?

39
Q

Tracheal cuff inflation

40
Q

bronchial cuff inflation

41
Q

Complication of DLT

A

bronchial rupture from over-inflating cuff

1-3mL max

42
Q

Complication of Right sided DLT and why

A

bronchial lumen can obstruct right upper lobe

less distance from carina to right upper lobe (2.5 cm compared to 4-5 cm on left)

consider using left sided DLT unless there is a contraindication

43
Q

Basic anesthetic considerations in OLV

A
  1. <1.5 MAC
  2. No N2O (increases PVR and traps air)
  3. avoid long acting NMB (panc)
  4. frequently monitor NMB fxn and always reverse
44
Q

Main goal during surgery for anesthesia

A

Maintain adequate oxygenation while maintaining visualization of lung for the surgeon

45
Q

Ventilator settings for OLV

A
  1. Vt limited to 6mL/kg
  2. PEEP only 5-10
  3. Reduce FiO2 - absorptive atelectasis
  4. avoid hypocapnia (reduces HPV)
  5. normal ETCO2 (28-32)
46
Q

Hypoxemia occurance during OLV: what should you do?

A
  1. increase FiO2
  2. check for malposition of tube (listen, bronchoscope)
  3. differentiate physiologic causes
  4. recruitment manevuer, CPAP, PEEP to dependent lung (let surgeon know)
  5. Possible early ligation of PA (if this is in the plan)
  6. Almitrine to NDL
  7. NO to dependent lung
47
Q

Definitive treatment for hypoxemia during OLV

A

Resume two long ventilation

48
Q

After lung resection, the operative lung is ______. You should

A

reinflated and checked for air leaks.

keep PIP < 30-40

49
Q

Following lung re-expansion _____

A

deflate bronchial cuff (avoid ischemia to bronchus)

50
Q

Most effective pain control for thoracic surgery

A

Thoracic epidural T6-T8

51
Q

Thoracic epidural analgesia and HPV

A

does NOT decrease HPV

can use less agent with working epidural

52
Q

Analgesia considerations (thoracic surgery)

A
  1. PCA
  2. adjuncts (ketamine)
  3. Thoracic epidural *
  4. Paravertebral nerve blocks at level of incision plus 1-2 levels above and below
  5. cryoanalgesia
  6. intrapleural catheter with LA before closure
53
Q

Acute lung injury MOA

A

reperfusion induces inflammatory mediators at alveolar-endothelial barrier causing leakage of fluid

54
Q

Fluid overload causes

A

stretching of cappilaries. Disturbs permeability = failure of microvessels

55
Q

Dysrhymias after thoracotomy

A
  1. afib
  2. SVT

associated with fluids > 2000 mL intraoperatively

56
Q

Basic categories complicatinos after thoracotomy

A
  1. ALI
  2. dysrhymias
  3. Low CO
  4. Increased PVR
  5. Respiratory complications
  6. Nerve and spinal cord injuries
  7. Thoracic duct injury
57
Q

Which side lobectomy is better tolerated and why

A

Left is better tolerated because R lung is bigger, has more blood flow and oxygenation

58
Q

Nerve injuries that can occur during thoracotomy

A
  1. Phrenic nerve
  2. L recurrent laryngeal nerve
  3. spinal cord
59
Q

Types of mediastinal masses

A

4 Ts:
1. thymoma
2. thyroid
3. teratoma
4. “terrible” lymphoma

can cause complete collapse

60
Q

Symtoms of mediastinal mass

A
  1. changes in CO
  2. Syncope, sweats, orthopnea, superior vena cava obstruction
  3. airflow obsturction
  4. cough and hoarseness
  5. atelectasis
  6. CNS changes
  7. inability to lie flat
61
Q

Surgical tx/diagnosis of mediastinal masses include:

A
  1. thoracotomy
  2. thoracoscopy
  3. mediastinoscopy
62
Q

Best plan for medistinal mass OR

A
  1. Locate mass on CT before induction
  2. awake fiberoptic
  3. spontaneous respiration

be sure to have fiberoptic bronchoscope available

63
Q

Complications of mediastinoscotpy

A
  1. hemorrhage
  2. pneumothorax
  3. innominate arter compression
64
Q

What can occur with compression of innominate arterty

A

decreased cerebral blood flow

65
Q

Methods of reducing risk of decreased cerebral blood flow d/t compression of innominate artery

A
  1. SPO2 and/or art line on R arm for monitoring
  2. NIBP on L arm to avoid interruption of monitoring on R arm
66
Q

Best IV placement for anticipating hemmorage during mediastinocscopy

A

Large bore in lower extremity

in upper, blood given will pass through area of vascular injury and enter mediastinum

67
Q

Absolute contraindciations for mediastinoscopy

A

previous mediastinoscopy d/t scarring

68
Q

relative contraindications for mediastinoscopy

A
  1. tracheal deviation
  2. thoracic aortic aneurysm
  3. superior vena cava obsturction
69
Q

Thorascopy management

A

art line should be placed except in extremely healthy patients

70
Q

What increases bullae and why?

A
  1. PPV increases
  2. N2O increases

air trapping occurs

71
Q

Bullae complications

A
  1. hypoxemia
  2. polycythemia
  3. cor pulmonale
  4. ruptured bullae can cause pneumothorax and cardiopulmonary collapse
72
Q

Cullae treatment: thoracotomy to resect bullous tissue. What are anesthetic considerations?

A
  1. DLT
  2. No N2O
  3. spontaneous ventilation is preferred (reduce risk of rupture)
  4. Small Vt and increased rate to keep PIP below 10-20 cm H2O
  5. jet ventilation
73
Q

Ventilator thoracotomy bullous resection strategies

want to keep PIP below ____

A
  1. Small Vt
  2. Increased RR

In order to keep PIP below 10 - 20

Clinical assessment (10 decks)

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