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Thoracic Surgery Flashcards

1
Q

What is the most appropriate form of treatment
recommended for patients with early-stage lung
cancer?

A

Surgery.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 281.

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2
Q

Thoracic surgery commonly involves fiber optic
bronchoscopy. What is the smallest endotracheal
tube (ETT) in which a standard fiber optic
bronchoscope will pass?

A

8.0
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 278.

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3
Q

What perioperative test is an adequate assessment
of pulmonary function in patients presenting for
thoracic surgery who have very little or absent
functional impairment?

A

Spirometry
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 282

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4
Q

Patients revealing what spirometric values warrant

further testing prior to pulmonary resection?

A

Patients with the following spirometric values warrant further
testing prior to surgery: FEV1 (forced expired volume in 1
second) 45mmHg.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 282.

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5
Q

The majority of patients undergoing pneumonectomy

or lobectomy are placed in what surgical position?

A

Lateral decubitus position. This position allows a posterolateral
or lateral thoracotomy, permitting the best exposure of the
pulmonary hilum.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 282.

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6
Q

What hemodynamic changes can result when the
pericardium or hilar structures are retracted
vigorously?

A

Cardiac arrhythmias and hypotension can occur.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 282.

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7
Q

The surgeon asks the anesthetist to reinflate the
lung while he clamps the bronchus that leads to the
lobe being resected. What is the purpose of this?

A

To ensure that the remaining lobes inflate adequately.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 282.

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8
Q

If a chest tube is placed following a pneumonectomy,

why is a balanced drainage system imperative?

A

A mediastinal shift towards the operative side will occur if a
balanced drainage system is not used, resulting in severe
hemodynamic changes.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 282-283

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9
Q

List 3 relative contraindications to lung resection.

A
  1. Right ventricular dysfunction 2. Pulmonary hypertension 3.
    Preoperative hypercapnia
    Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
    Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
    Wolters Kluwer Health, 2014: 285.
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10
Q

What are the most common preoperative diagnoses
seen in patients presenting for lobectomy or
pneumoectomy?

A

The most common preoperative diagnosis is carcinoma of the
lung, however patients may also present with infection (namely
bronchiectasis and mycobacterial disease), developmental
abnormalities, and trauma.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 283

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11
Q

A patient presenting for lung resection has
myasthenic syndrome (Eaton-Lambert syndrome).
How would you expect the patient to respond to
depolarizing muscle relaxants? Nondepolarizing
muscle relaxants?

A

The patient would exhibit resistance to depolarizing muscle
relaxants and an increased sensitivity to nondepolarizing
muscle relaxants.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 285.

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12
Q

What are the benefits to the intraoperative use of
regional analgesia during a lobectomy or
pneumonectomy?

A

The amount of systemic analgesics and anesthetic is reduced,
thus facilitating a quick emergence.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 286-287.

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13
Q

Why is it important not to overhydrate a patient

during a lobectomy or pneumoectomy?

A

Following surgery, the pulmonary vascular resistance increases
relative to the portion of removed lung tissue. Overhydration
places these patients at risk for pulmonary edema and right
ventricular failure.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 287.

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14
Q
  1. What are the most common sized double-lumen
    tubes (DLT) used in men? 2. What are the most
    common sized DTLs used in wormen?
A
  1. 39-41 Fr 2. 35-37 Fr
    Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
    Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
    Wolters Kluwer Health, 2014: 287.
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15
Q

What is a wedge resection? For what reasons would

a wedge resection be indicated?

A

A wedge resection is the excision of a mass in a way that does
not involve total removal of an entire pulmonary segment.
Wedge resections may be perfomed in those with peripheral
non-small-cell tumors, patients with extremely limited pulmonary
reserve who could not tolerate a lobectomy, for the resection of
multiple or single metastatic lesions arising from varying primary
neoplasms, therapeutic and diagnostic purposes in lesions that
cannot be diagnosed by less invasive techniques.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 290.

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16
Q

What are the two most common indications for chestwall

resection.

A
  1. Primary chest-wall tumors 2. Lung cancers that have
    invaded the thoracic cage
    Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
    Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
    Wolters Kluwer Health, 2014: 293
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17
Q

A patient presenting for chest-wall resection has
received chemotherapy with Adriamycin
preoperatively. What are the concerns associated
with this chemotherapeutic agent?

A

At high doses, Adriamycin is associated with cardiotoxicity.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 293.

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18
Q

What is empyema? How is it primarily treated?

A

Empyema is a collection of pus and fluid within the pleural
cavity. Drainage of the infected fluid is the primary treatment.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier Saunders; 2012: 477.

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19
Q

Empyema most commonly occurs secondary to

what disorder?

A

Pneumonia
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 300.

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20
Q

List the three phases of empyema.

A
  1. Exudative phase 2. Fibrinopurulent phase 3. Organized
    phase.
    Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
    Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
    Wolters Kluwer Health, 2014: 300.
21
Q
  1. Exudative phase 2. Fibrinopurulent phase 3. Organized
    phase.
    Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
    Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
    Wolters Kluwer Health, 2014: 300.
A

Thoracentesis
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 300.

22
Q

What signs and symptoms are associated with the

exudative phase of empyema?

A

Dyspnea, fever, and pleural effusion
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 300.

23
Q

What is the treatment for patients with extensive,

established empyema?

A

Open thoracotomy. Blood and flud losses can be sizeable due
to extensive intrapleural inflammation.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 301.

24
Q

What other underlying conditions are often

associated with patients with empyema.

A

Sepsis, malnutrition, bronchopleural fistula
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 302

25
What are common preoperative pulmonary findings | in patients presenting for drainage of empyema?
Mediastinal shift to the ipsilateral side, ipsilateral lung collapse, impaired hypoxic pulmonary vasoconstriction due to infection Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 302.
26
Proper tube position of double-lumen tubes is always important. What is of particular concern in patients with empyema and proper tube placement?
If the double lumen tube is not in proper position, the nonaffected lung can become contaminated by the affected side. Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases. 6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 303.
27
What are the two primary indications for tracheal | resection?
1. Benign strictures (frequently from prior intubations or tracheostomy) 2. Primary tracheal neoplasms, most often adenoid cystic carcinoma and squamous cell carcinoma Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 304.
28
Where would the incision be made for patients presenting for tracheal resection with lesions of the mid to upper trachea?
The neck Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 304.
29
Where would the incision be made for patients presenting for tracheal resection with lesions of the carina and lower trachea?
The right chest Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 304.
30
How should a patient be placed after tracheal | resection?
The patient should be placed head-up with th neck flexed. Flexion of the neck reduces tension placed on the tracheal suture line. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 308.
31
Describe the typical patient population presenting for | excision of apical blebs
These patients typically are young, otherwise healthy individuals, with normal lung function. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 334
32
What conditions are frequently seen in patients with | bullous emphysema?
Pulmonary hypertension, right ventricular dysfunction, endstage lung disease. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 334.
33
Are the majority of blebs or bullae excised through | open procedures or thoracoscopically?
Thoracoscopically. The goal of the procedure (regardless of technique used) is to remove the nonfunctioning bleb or bullae. This allows the compressed, preserved lung tissue to reinflate, once again contributing to gas exchange. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 333-334.
34
What is a major concern for patients undergoing | excision of bilateral, large bullae?
Tension pneumothorax/pulmonary tamponade due to the expansion of bullae from positive pressure ventilation. It is best to isolate the affected lung before positive pressure ventilation is initiated. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 335.
35
What measures can be taken to minimize the risk of | bulla rupture during positive pressure ventilation?
Use pressure-controlled ventilation
36
Describe the typical patient presenting for lungvolume | reduction surgery.
These patients have severe emphysema, require steroids, use supplemental oxygen and bronchodilators. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 336
37
How does lung-volume reduction surgery improve | pulmonary function?
By reducing lung volume through the removal of diseased tissue, elastic recoil improves and airway resistance is decreased. The chest cavity itself is reduced, therefore diaphragmatic and chest-wall function is improved. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 336.
38
What two surgical approaches can be used for lungvolume | reduction surgery?
Median sternotomy, endoscopically Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 337
39
Whether lung-volume reduction surgery is performed open or endoscopically, the patient should be extubated in the OR. Why is this?
To avoid unnecessary ventilatory pressures being placed on the lungs.
40
Following lung-volume reduction surgery, why are | chest tubes left to water seal and not suction?
To prevent the build up of negative pressure on the lung that could disrupt staple lines. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 337.
41
Why would a patient undergo a bronchopulmonary | lavage?
Bronchopulmonary lavage is performed in patients with pulmonary alveolar proteinosis. This condition is characterized by abnormal surfactant production that results in saturation of the lungs with proteinaceous fluid. The cause of this disorder is not well known. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 340.
42
Describe the process of a bronchopulmonary lavage.
Bronchopulmary lavage necessitates general anesthesia with the use of a double-lumen tube. The lung is irrigated with 500- 1000 cc's of normal or half normal saline. This lavage washes out and dilutes the excess surfactant, mucus, or pus, and it also obtains specimens for histochemical and cytological examination. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 340.
43
Pulmonary alveolar proteinosis is the the most common diagnosis seen in patients presenting for bronchopulmonary lavage. What are other possible preoperative diagnoses seen?
Cystic fibrosis, refractory asthma, inhalation of radioactive dust, silicosis, alveolar microlithiasis, lipoid pneumonitis, bronchiectasis Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 340.
44
Typically, unilateral lavage is performed, with the more diseased lung irrigated first. If both lungs are equally diseased, what lung is irrigated first?
The left lung is irrigated first. The right lung is larger and can be used for ventilation to provide more adequate gas exchange. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 341.
45
What signs and symptoms are seen in a person with | pulmonary alveolar proteinosis?
Fatigue, dyspnea, cough, cyanosis, clubbing, diffuse rales, decreased pulmonary compliance Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 341.
46
What would an ABG reveal in a person with | pulmonary alveolar proteinosis?
Repiratory alkalosis and hypoxemia Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 341.
47
List the most common indications for a lung | transplant.
Pulmonary fibrosis, emphysema, pulmonary hypertension, cystic fibrosis. People with pulmonary hypertension typically have normal lung mechanics but extremely abnormal cardiac function. Patients with cystic fibrosis, pulmonary fibrosis, and emphysema have profoundly abnormal mechanical pulmonary function. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 344
48
Is cardio-pulmonary bybass (CBP) required for lung | transplantation?
No, however a CPB circuit and perfusionist should be available at all times. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 344.
49
Upon reperfusion of the donor lung, should the anesthesia provider expect to see hypertension or hypotension?
Hypotension that usually spontaneously resolves Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia, PA: Wolters Kluwer Health, 2014: 344

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