Thoracic Surgery Flashcards
A patient who underwent a thoracotomy six months ago reports shooting pain on
the chest wall occurring without any trigger. This is known as:
Post thoracotomy pain syndrome
IASP Post-thoracotomy pain syndrome:
“Pain that recurs or persists along a thoracotomy incision at least two months following the surgical procedure” in general it is burning or stabbing pain with dysesthesia thus shares many features of neuropathic pain.
Dysesthesia: unpleasant abnormal sensation spontaneous or evoked
A 69-year-old patient is dyspnoeic and complains of right shoulder tip pain while in the post-anaesthesia care unit after a laparoscopic-assisted anterior resection. A focused thoracic ultrasound is performed and an image of the right lung is shown below. This represents:
a) Pneumothorax
b) Pulmonary Oedema
c) Normal Lung
d) Consolidated Lung
REPEAT
c) Normal Lung
Normal lung = A lines (pleura) + batwing appearance + sliding
The following is a chest X-ray from a patient with dyspnoea after thoracic surgery.
The diagnosis is:
A. Dextracardia
B. Cardiac hernation
C. LLL collapse
D. Tension Pneumohorax
REPEAT
A patient has blunt chest trauma. A thoracotomy is indicated if the immediate blood drainage after closed thoracostomy is greater than:
a) 500mL
b) 750mL
c) 1L
d) 1.2L
e) 1.5L
REPEAT
1,500 mL immediately
OR
200 mL/hr in the first 2-4 hours
NP B lines (comet tails) in lung ultrasound are NOT observed in:
a) ARDS
b) Interstitial
c) Normal lung
d) Pneumothorax
D) pneumothorax
From BJA 2016 lung US article
The features of a pneumothorax are abolished sliding, absence of B lines, absence of the lung pulse, and presence of the lung point
You have been asked to provide general anaesthesia for a complex thoracic endovascular aortic aneurysm repair. After the placement of a lumbar drain the recommended safe time before the administration of intravenous heparin is
a) 1 hour
b) 4 hours
c) 6 hours
d) 12 hours
AT - 1 hour
1.2.3 Time of lumbar drain placement to systemic intravenous heparinization should be greater than 60 minutes
Perioperative Management of Adult Patients with External Ventricular and Lumbar Drains Guidelines from the Society for Neuroscience in Anesthesiology and Critical Care
ASRA: 1 hour
Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted.
Currently, insufficient data and experience are available to determine if the risk of neuraxial haematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimise sensory and motor block to facilitate detection of new/progressive neurodeficits.
NYSORA:
Administration of intravenous heparin intraoperatively should be delayed for at least 1 hour after epidural placement; a delay before administration of subcutaneous heparin is not required. In cases of full heparinization for CPB, additional precautions include delaying surgery for 24 hours in the event of a traumatic tap, tightly controlling the heparin effect and reversal, and removing catheters when normal coagulation is restored.
NP A 65-year-old presents with an acute dissection of their thoracic aorta. Their blood pressure is 150/90 mmHg. The best medication to reduce the blood pressure is:
a) Esmolol
b) SNP
c) GTN
d) Hydralazine
A) esmolol
They get anti impulse therapy which usually starts off with beta blockade before alpha blockade.
Up to date: Patients often present with severe hypertension and are initially stabilized with fast-acting, intravenous beta blockers (eg, esmolol or labetalol) or calcium channel blockers. Anti-impulse therapy lowers blood pressure
Kate For driving pressure guided ventilation, driving pressure is the:
a) Pplat-peep
b) Peak pressure-peep
c) Other formulas
Pplat-PEEP
driving pressure is defined as distending pressure above the applied Peep Required to generate Vt
- key variable for optimisation when performing mechanical ventilation in ARDS
- also Vt/CRS (Ratio of Tidal volume to static resp system compliance)
21.1 The lung ultrasound finding most consistent with atelectasis is three or more
A. B lines
B. A lines
C. Comet tails
D. Z lines
E. Lung Pulse
comet tails or B-lines
useful resource: https://academic.oup.com/bjaed/article/16/2/39/2897763
Comet Tail artefact:
- a short path reverberation artefact that weakens with each reverberation, resulting in a vertical echogenic artefact that rapidly fades as it continues in to the ultrasound image.
https://litfl.com/comet-tail-artefact/
Short path reverberation artefact
- The ultrasound appearance of this artefact is a thin vertical bright or echogenic line that passes from the point of origin, to the deepest part of the ultrasound image.
- When appearing deep to the pleural line these are known as B-lines.
- Elsewhere in the body the identical artefact is known as ring down artefact.
- Where these artefacts fade quickly they are called comet tail artefacts
https://litfl.com/short-path-reverberation-artefact/
Radiopedia “B-line distribution corresponds with sub-pleural thickened interlobular septa” - more consistent with homogenous atelectasis
20.1 In a Blalock–Taussig shunt, blood passes to the pulmonary artery via the
a. Aorta
b. Subclavian artery
c. IVC
d. SVC
e. Left atrium
B
21.2 You have been asked to provide general anaesthesia for a complex thoracic endovascular aortic aneurysm repair. After the placement of a lumbar drain the recommended safe time before the administration of intravenous heparin is
a) 1 hour
b) 4 hours
c) 6 hours
d) 12 hours
1 hour
ASRA: 1 hour
Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted.
Currently, insufficient data and experience are available to determine if the risk of neuraxial haematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimise sensory and motor block to facilitate detection of new/progressive neurodeficits.
NYSORA:
Administration of intravenous heparin intraoperatively should be delayed for at least 1 hour after epidural placement; a delay before administration of subcutaneous heparin is not required. In cases of full heparinization for CPB, additional precautions include delaying surgery for 24 hours in the event of a traumatic tap, tightly controlling the heparin effect and reversal, and removing catheters when normal coagulation is restored.
21.1 The part of the lung that is typically divided into superior, medial, anterior, lateral and posterior bronchial segments is the
A. Right Upper lobe
B. Right Lower lobe
C. Left Upper lobe
D. Right Middle lobe
E. Lingula
RLL
1.Superior (apical bronchus 6)
-> most common site for foreign body or secretions to collect if patient laying flat in bed
20.1 You want to position a internal jugular CVL with a CXR at the caval-atrial junction. Where is this?
a) 2 vertebral bodies superior to carina
b) 1 vertebral body superior to carina
c) At the carina
d) 1 vertebral body inferior to carina
e) 2 vertebral bodies inferior to carina
e) 2 vertebral bodies inferior to carina
23.1 The following is a chest X-ray from a patient complaining of dyspnoea after thoracic surgery. The diagnosis is
(not the image from the exam)
A. Dextracardia
B. Cardiac hernation
C. LLL collapse
D. Tension Pneumohorax
B. Cardiac hernation
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.109.896829
22.2 A thoracic regional technique that will NOT provide analgesia for sternal fractures is a
a. PECS I
b. PECS II
c. Parasternal intercostal nerve block?
d. Transfascial muscle block (can’t remember wording)
e. transverse thoracic plane block
b. PECS I
(PECS II Covers SA and will extend to the sternum)
20.1 What is the abnormality in this CXR?
a. Pneumonectomy
b. Pleural effusion
c. Pneumonia
d. Unilateral pulmonary oedema
c. Pneumonia
Complete white-out of left lung with air bronchogram sign consistent with total consolidation. Patchy areas of ground glass opacities in right lung. There is silhouetting of the left heart border and left hemi-diaphragm. There is no rib crowding to suggest atelectasis.
Complete white-out of the hemithorax with air bronchograms and trachea in a central position is consistent with consolidation secondary to pneumonia. The patient is on linezolid, micafungin, and piperacillin-tazobactam pending culture and susceptibility studies.
Differential diagnosis of hemithorax white-out with a midline trachea include:
- consolidation
- pulmonary edema/ARDS
- pleural mass
- chest wall mass
20.2 This lung ultrasound shows
a) Normal lungs
b) Pulmonary odema
c) Pneumothorax
d) Pleural effusion
e) Pneumonia
b) Pulmonary oedema
B-lines
> Vertical echogenic short path reverberation artefacts originating at the pleural line and extending to the deepest part of the ultrasound image.
They interrupt any horizontal A-lines.
Occasional B-lines are considered normal.
More than 3 B-lines in any single view is considered pathological.
Where there are numerous B-lines in close proximity they become confluent.
B-lines move with lung movement.
They are caused by ultrasound energy reverberating in a fluid filled focus that is surrounded by air. These foci may be interstitial or alveolar.
Cardiogenic and noncardiogenic oedema may have very similar appearances.
Interstitial thickening due to fibrosis or lymphangitis can also create the sonographic appearance of diffuse B-lines.
20.2 A patient has a peripherally inserted central catheter (PICC) inserted. The follow-up chest X-ray shows the tip positioned in the (Chest X-Ray shown)
a) Azygos vein
b) Coronary sinus
c) SVC
d) R atrium
e) L atrium
a) Azygos vein
Correct positioning in image
21.1 The function of the bottle labelled ‘D’ in the diagram below is to protect against the consequences of
(diagram of chest drain bottles)
a. Suction failure
b. Excess positive pressure
c. Drain kinking
d. Excess negative pressure
bottle A = fluid trap or collection bottle, can be independently emptied and allows accurate record of drainage amount
- first tube connecting drain to drainage bottles must be wide to decreased resistance
- volume capacity of this tube should exceed ½ of patient’s maximum inspiratory volume (otherwise H2O may enter chest)
bottle B = underwater seal drain, maintained at a predetermined level whilst still allowing for drainage of pleural fluid (if bubbling continuously -> bronchopleural fistula)
- volume of H2O in bottle B should exceed ½ patient’s maximum inspiratory volume to prevent indrawing of air during inspiration
bottle C = manometer or pressure-regulating bottle allows suction to be attached and should bubble continuously
- The maximum negative pressure (in cm H2O) generated by suction equals to the distance (in cm) the vent tube is below the water line (this can be adjusted)
-The negative pressure generated by the vent tube is independent of the amount of pleural drainage that is collected in the trap bottle
- If suction is turned off then tubing must be unplugged -> so air can escape into atmosphere
23.1 A 69-year-old man is dyspnoeic and complains of right shoulder tip pain whilst in the postanaesthesia care unit after a laparoscopic-assisted anterior resection. A focused thoracic ultrasound is performed and an image of the right lung is shown below. This represents
a) Pneumothorax
b) Pulmonary Oedema
c) Normal Lung
d) Consolidated Lung
Normal Lung
- A 45 Year old man has poor oxygenation in the post anaesthesia care unit after a low anterior resection. His chest xray is below. The most likely diagnosis is
a. LLL collapse
b. Pneumothorax
c. L pleural effusion
d. R bronchopneumonia
The lungs are hyperinflated with relatively flat diaphragms - a sign of pulmonary emphysema. There is a dense triangular opacity overlying the cardiac shadow with increased lucency of the left upper zone relative to the right upper zone. This is the “sail sign” of left lower lobe collapse with subsequent left upper lobe hyper-expansion.
A patient has undergone a laparotomy with a central line inserted intra-operatively. In the PACU, the patient is dyspnoeic and a lung ultrasound is performed. The ultrasound, shown below, is consistent with
A. Pneumonia
B. Effusion
C. Normal lung
D. Pneumothorax
E. Pleural odema
C. Normal lung
- shows sandy shore sign of normal lung sliding
Alternative: Absent sliding & PTx: Stratosphere sign
22.2 You are asked to review a 65-year-old man in the emergency department who has presented with hypoxia and confusion. The chest x-ray shows a left-sided
a. Pneumothorax
b. pneumonia
c. one sided pulmonary oedema
d. pleural effusion
e. haemothorax
b. pneumonia
Air bronchogram
The part of the lung that is typically divided into medial and lateral segments is the
a. Left upper lobe
b. Lingula
c. Right upper lobe
d. Right middle lobe
e. Right lower lobe
d. Right middle lobe
21.1 The following is an image from a focussed cardiac ultrasound in a patient with dyspnoea presenting for thoracic surgery. The diagnosis is
a) Pericardial effusion
b) Tamponade
c) Pleural effusion
d) Loculated lung abscess
c) Pleural effusion
Source: BJA Ultrasound in critical care
Thoracic US revealing a large pleural effusion (E) that has displaced the lung. The diaphragm (D) and liver (L) are visualized. The depth from the skin to the fluid has been measured. Insertion of the needle at this site is not advised; given the proximity to the liver, a more superior approach should be marked.
20.2 This lung ultrasound shows
a) Normal lungs
b) Pulmonary odema
c) Pneumothorax
d) Pleural effusion
e) Pneumonia
a) Normal lungs
Probe selection
Linear probe (8–12 MHz)
These high-frequency probes give good resolution of superficial structures. As the anterior pleura is relatively superficial, excellent images of the pleura and lung sliding can be obtained. The poor penetration of high-frequency US and the narrow sector width mean deeper structures are poorly imaged.
Curvilinear probe (3–5 MHz)
This is the best all-round probe for LU. Lung sliding can be easily visualized as can IS. Effusions, consolidated lung, and the diaphragm are also well imaged because of the good penetration and large sector width. The large footprint of the probe means some angulation is needed to avoid the ribs when scanning postero-laterally.
Phased array (3–4.5 MHz)
These probes have a useful footprint for getting in between the ribs. They can be used to demonstrate all the signs of LU but the clarity of the images is not as good.
General points
The clearest images are obtained by having the image as shallow as possible with the focus point at the level of interest. The frequency can be adjusted to enhance the image, depending on the depth. Increasing the frequency on a curvilinear probe will improve the appearance of lung sliding whilst worsening the appearance of a consolidated lung base.
20.2 This lung ultrasound shows
a) Normal lungs
b) Pulmonary odema
c) Pneumothorax
d) Pleural effusion
e) Pneumonia
e) Pneumonia
Signs of Pneumonia on lung ultrasound:
> Early Pneumonia
- B-lines and areas of sub pleural consolidation
- Fluid filled alveoli surrounded by air-filled lungs cause a short path reverberation and B-lines can be seen
- localised patches of numerous B-lines indicate sub-pleural consolidation
> Hepatization: solid appearing consolidated lung
- inflammatoy and purulent fluid filled alveoli makes the lung appear solid, with homogenous relatively fine echotexture similar to liver
- Atelectasis can also cause solid non-aerated lung and it can be difficult to distinguish the two conditions
> Shred sign: irregular consolidation/ air interface
- consolidated areas adjacent to aerated areas where the consolidated areas will be linear and well defined
> Air bronchograms and dynamic air bronchograms
- Air within consolidated area may remain in small aerated patches of lung or more commonly air remains within small bronchi, small air bubbles all lined up within a bronchus are known as sonographic air bronchograms
- when air bubbles are seen to bubble in and out with each breath the term “dynamic air bronchogram” is used
> Colour doppler interrogation: flow remains
- pulmonary arterial and venous vasculature are well demonstrated in areas of consolidation
Associated pleural effusion or empyema
- small hyperechoic parapneumonic effusion are frequently demonstrated
- echogenic debris within the effusion suggest empyema
22.2 This lung ultrasound image is consistent with
a. pulmonary oedema
b. pneumonia
c. pneumothorax
d. pleural effusion
e. Normal lung
c. pneumothorax
In the three-bottle chest drainage system set up shown, the maximum suction pressure (cmH2O) generated inside the underwater seal bottle would be minus
Depth of tube in water in bottle 3
