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Applied Clinical Veterinary Nursing > Thoracic Surgery and Anaesthesia > Flashcards

Thoracic Surgery and Anaesthesia Flashcards

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1
Q

what does ipsilateral mean?

A

the same side

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2
Q

what is modified transudate?

A

fluid formed by leakage from normal/non-inflamed vessels

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3
Q

what is orthopnea?

A

when an animal adopts a particular positional orientation in order to breathe - often sternal with forelimbs, head and neck extended

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4
Q

what is parenchyma?

A

tissue of an organ (not including connective tissue)

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5
Q

what is pleural space?

A

the ‘potential’ space between visceral and parietal pleura which is filled with fluid/air with effusions/pneumothorax

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6
Q

what does radiolucent mean?

A

transparent to x-rays (doesn’t show up)

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7
Q

what does radiopaque mean?

A

opaque to x-rays (e.g. bone)

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8
Q

what is a TFAST?

A

thoracic focused assessment with sonography for trauma

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9
Q

what is a thoracostomy tube?

A

chest drain

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10
Q

what is transudate (pure)?

A

passive fluid accumulation e.g. with hypoproteinaemia

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11
Q

what type of thoracic pathology can cats be prone to?

A

mediastinal masses (thymoma/lymphoma)

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12
Q

what type of thoracic pathology can yorkies be prone to?

A

tracheal collapse

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13
Q

what type of thoracic pathology can pugs be prone to?

A

lung lobe torsions

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14
Q

what type of thoracic pathology can afghan hounds be prone to?

A

chylothorax

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15
Q

what type of thoracic pathology can ESSs be prone to?

A

foreign bodies

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16
Q

what clinical signs can indicate an animal might have a lower thoracic condition which might be surgical?

A

tachypnoea

abnormal breathing

pale MM, cyanosis

exercise intolerance, collapse

+/- cough
+/- injuries
+/- systemically ill

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17
Q

what types of abnormal breathing might we see in a patient with a thoracic condition?

A

orthopnoea
hyperpnoea
dyspnoea
abdominal breathing

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18
Q

what are the main aspects of preliminary management for patients with thoracic conditions?

A

minimise deterioration

monitor closely

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19
Q

how can we minimise deterioration in a patient with a thoracic condition?

A

oxygen supplementation

assessment and management of any thoracic wounds, protect from ongoing damage

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20
Q

what are the available methods of oxygen supplementation?

A

flow by
nasal cannula
face mask
oxygen collar
oxygen cage
intubation

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21
Q

how should we monitor patients presenting with possible thoracic conditions?

A

assess patient temperament, consider sedation if required

identify upwards/downward trends in condition

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22
Q

what diagnostics are beneficial to run ASAP if a patient presents with possible thoracic issue?

A

lab work - bloods, thoracocentesis for C+T

imaging - TFAST

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23
Q

why should we have care with radiography in a dyspnoeic patient?

A

restraint for radiography in conscious animals can be very stressful and make condition worse, esp cats

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24
Q

what is the advantage of TFAST?

A

quick way for triaging nurse to determine how urgently a case requires vet attention

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25
Q

what is required to determine if a pleural effusion is present/what it is?

A

imaging
thoracocentesis and lab analysis

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26
Q

what is important to quickly determine with a pneumothorax?

A

whether the chest is closed or open

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27
Q

what is important to consider in cases where thoracic trauma may have occurred?

A

skin may or may not be broken

broken ribs might puncture a lung

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28
Q

what thoracic pathology can be delayed in cats after RTA?

A

diaphragmatic hernia

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29
Q

name some of the common surgical thoracic conditions

A

pneumothorax
chest/lung trauma
pulmonary blebs or bullae
diaphragmatic rupture
pleural effusion
pyothorax
pericardial effusion
pulmonary neoplasia

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30
Q

which of the common surgical thoracic conditions does not have a thoracic approach during surgery?

A

diaphragmatic rupture - abdominal approach

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31
Q

what types of fluid might be seen in pleural effusion?

A

septic and non-septic exudates
transudates and modified transudates
blood
chyle
neoplastic effusions

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32
Q

what are the clinical signs of pneumothorax?

A

dyspnoea
lethargy
cough
exercise intolerance

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33
Q

what are the possible aetiologies for an open (‘external’) pnemothorax?

A

chest trauma e.g. dog attach

iatrogenic e.g. post lung-lobectomy, diaphragmatic rupture, complications of thoracocentesis/thoracostomy

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34
Q

how can we diagnose a pneumothorax?

A

imaging - determine if unilateral/bilateral

thoracocentesis

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35
Q

why might a bilateral pneumothorax still require bilateral chest drains?

A

if the mediastinum is still intact

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36
Q

how can we conservatively manage pneumothorax?

A

chest drain - only if air leak might spontaneously seal

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37
Q

when would a pneumothorax require surgical treatment?

A

if large air leak or if ongoing and not sealing itself

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38
Q

what are the treatment options for pneumothorax?

A

chest drain
thoracotomy

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39
Q

what are the possible aetiologies for chest and lung trauma?

A

accident - RTA, fall, hit by train/car, impaling or run-on injury

attack - animal, human

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40
Q

what are the clinical signs of chest/lung trauma?

A

shock - big component

dyspnoea

soft tissue damage - open, bruising/crushing wounds

ortho damage - rib fractures/flail chest

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41
Q

what is the most important part of treatment for chest/lung trauma cases?

A

stabilisation before any GA/surgery

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42
Q

what are the common complications seen with chest and lung trauma cases?

A

infection - depends on cause/degree of contamination and presence of devitalised tissues

healing - delayed/breakdown

effusion - depends on amount of trauma/tissue injury

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43
Q

what is the prognosis for chest/lung trauma cases?

A

very dependent on severity of injuries

cost can also be a limiting factor

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44
Q

what is the signalment for pulmonary blebs and bullae?

A

large breed, deep chested dogs

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45
Q

what is the aetiology of pulmonary blebs and bullae?

A

unknown cause
often no concurrent lung disease

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46
Q

what are the clinical signs of pulmonary blebs and bullae?

A

often none if haven’t ruptured

some non-specific signs - lethargy, anorexia, exercise intolerance

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47
Q

what are the respiratory signs of pulmonary blebs and bullae?

A

sudden onset dyspnoea with no history of trauma

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48
Q

what are the progressive signs of pulmonary blebs and bullae?

A

tachypnoea/orthopnoea/coughing

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49
Q

what are the peracute signs of pulmonary blebs and bullae?

A

spontaneous closed tension pneumothorax due to rupture of blebs/bullae

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50
Q

how can we diagnose pulmonary blebs and bullae?

A

radiographs and CT

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51
Q

what can radiographs assess about pulmonary blebs and bullae?

A

can diagnose pneumothorax but not helpful for showing which lobes affected

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52
Q

what can CT show about pulmonary blebs and bullae?

A

used to assess which lung lobes affected - ideally done before surgery attempted

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53
Q

what are the treatment options for pulmonary blebs and bullae?

A

conservative - intermittent thoracocentesis/indwelling chest tube

surgery - open sternotomy/thoracoscopy

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54
Q

what is involved in surgery for pulmonary blebs and bullae?

A

removal of the affected lung lobes - feasibility depends on number affected

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55
Q

what is the aetiology for diaphragmatic rupture?

A

blunt force trauma- RTA/fall/blow to abdomen

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56
Q

how does a diaphragmatic rupture form?

A

increased abdominal pressure with closed glottis - diaphragmatic muscle is the weakest link and pops through into chest, allowing organs to move forward

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57
Q

how can we improve dyspnoea in patients with diaphragmatic rupture?

A

raise the thorax to allow abdominal contents to leave the chest

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58
Q

what are the clinical signs for chronic diaphragmatic rupture?

A

none or vague ill-health

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59
Q

what are the clinical signs of acute/peracute diaphragmatic rupture?

A

depends on severity -
degree of herniation/size of tear and which organs involved
tachypnoea, orthopnoea
concurrent ortho injuries

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60
Q

how is diaphragmatic rupture different from PPDH?

A

congenital diaphragmatic hernia is atraumatic and associated with animals under 2 years old

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61
Q

what is the treatment for diaphragmatic rupture?

A

stabilisation - oxygen, analgesia, IVFT

exploratory surgery of chest and abdomen

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62
Q

why do diaphragmatic rupture patients require a chest drain after surgery if the approach is abdominal?

A

the moment the abdomen is opened we create an iatrogenic pneumothorax through the rupture

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63
Q

what is the aetiology of pleural effusion?

A

many possible different reasons

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64
Q

what are the clinical signs of pleural effusion?

A

dyspnoea
lethargy
cough
exercise intolerance

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65
Q

how can we diagnose pleural effusion?

A

imaging
thoracocentesis
lab work

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66
Q

what lab analysis might we do on fluid from pleural effusion?

A

specific gravity to identify whether transudate/modified transudate/exudate

cytology

C&S

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67
Q

what are the non-surgical conditions related to pleural effusion?

A

CHF
pyothorax (cats)

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68
Q

when might we surgically treat pleural effusion?

A

where conservative management unlikely to be successful and/or has failed

usually pyothorax in dogs or diaphragmatic rupture

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69
Q

what is the aetiology of pyothorax?

A

bacterial infection

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70
Q

which types of pyothorax are likely to try and be managed medically?

A

idiopathic pyothorax in cats - often from bites, extension from pulmonary abscesses

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71
Q

which types of pyothorax are likely to be managed surgically?

A

those in dogs - usually FBs, oesophageal tears, pulmonary infections

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72
Q

what are the common bacteria causing pyothorax in dogs and cats?

A

e coli in dogs
pasteurella in cats

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73
Q

what are the clinical signs of pyothorax?

A

lethargy, inappetence, PUO

dyspnoea due to purulent effusion

can be mild or severe

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74
Q

how can we diagnose pyothorax?

A

labs - cytology and C&S of effusion

imaging - radiographs, U/S

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75
Q

what is involved in medical management of pyothorax?

A

systemic abs, chest drain +/- lavage

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76
Q

what is involved in surgical management of pyothorax?

A

sternotomy - explore, remove, debride, flush and post-op medical management

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77
Q

why is surgery often carried out early on in dogs with pyothorax?

A

because of likelihood of a FB

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78
Q

what is aetiology of pericardial effusion?

A

idiopathic or neoplastic - makes large difference to signalment and presentation

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79
Q

what are the clinical signs of pericardial effusion?

A

cardiac tamponade - severity depends on how quickly the effusion forms

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80
Q

why is degree of cardiac tamponade with pericardial effusion dependent on how quickly the effusion formed?

A

affects how well the pericardium will have been able to adapt and stretch
idiopathic (slow-forming) - less severe
acute/peracute - severe tamponade

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81
Q

how is pericardial effusion diagnosed?

A

labs - cytology to rule in/out neoplasia

imaging - radiography/echo/advanced imaging

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82
Q

which aetiology for pericardial effusion has the poorest prognosis?

A

neoplasia

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83
Q

what is the treatment for pericardial effusion?

A

repeated pericardiocentesis

surgery - pericardectomy

chest drain

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84
Q

does pericardectomy resolve issues surrounding pericardial effusion?

A

no - just prevents the cardiac tamponade and converts into pleural effusion

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85
Q

what are the complications of pericardial effusion treatment?

A

recurrence both after draining and surgery

long-standing effusion causes ahesions

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86
Q

what is the aetiology of pulmonary neoplasia?

A

malignant - benign

metastatic - primary

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87
Q

what are the clinical signs of pulmonary neoplasia?

A

vague - non-productive cough, haemoptysis, dyspnoea, non-specific weight loss and anorexia, exercise intolerance

lameness (hypertrophic pulmonary osteopathy - paraneoplastic syndrome)

often no signs (25%)

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88
Q

how can we diagnose pulmonary neoplasia?

A

lab - min database of biochem, haem, urinalysis
+/- cytology

imaging - advanced (CT), 3 view radiographs

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89
Q

what is the treatment for pulmonary neoplasia?

A

palliative

thoracotomy for lung lobectomy

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90
Q

what is the prognosis for pulmonary neoplasia?

A

guarded - depends on presence of mets, histopathology, clean vs dirty surgical margins

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91
Q

what are the pre-emptive nursing considerations for patients undergoing thoracotomy?

A

multi-modal analgesia
management of hypothermia
prep for IPPV once thorax opened

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92
Q

what is important to monitor in thoracotomy patients?

A

TPR
regular pain scoring so can discuss adjusting analgesia with vet
post-op wound healing and management

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93
Q

why might we put a body bandage on a thoracotomy patient?

A

for increased comfort

to reduce risk of infection

to reduce risk of patient interference

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94
Q

what is important to remember when nursing thoracotomy patients in hospital?

A

don’t forget patients need help with basics - EDUF, may need Ucath, feeding tubes

IVFT to take into account fluid losses

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95
Q

what are fenestrations (in regards to chest drains)?

A

holes in chest drains that enable fluid/air to be withdrawn - MUST be within the chest to avoid iatrogenic pneumothorax

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96
Q

what are flange?

A

side tabs that allow for simple suturing of narrow bore chest drains to skin

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97
Q

what is thoracocentesis?

A

procedure involving the puncture of the pleural space for diagnostic and/or therapeutic purposes

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98
Q

what should we make sure we are prioritising during thoracocentesis?

A

performing safely - remember patient requires oxygen

sterility - skin prep, gloves, sterile drape/glove packet

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99
Q

what equipment should be prepared for a diagnostic thoracocentesis?

A

oxygen!!

short-acting LA +/- anxiolytic

sterile prep equipment

needle/IV catheter/butterfly catheter

3-way tap and 20ml syringe

+/- extension set

kidney dish/jug

lab equipment

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100
Q

what do we need to consider in terms of sample handling for thoracocentesis?

A

tubes - EDTA, heparin, plain tubes for cytology/biochem/culture

culture sample must be collected straight from collection equipment and not touch kidney dish

make fresh smear for cytology

check USG before sending

+/- diffquik

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101
Q

what is a chest drain?

A

a tube placed into the pleural space to allow ongoing, continuous or intermittent therapeutic drainage

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102
Q

what factors might determine whether a chest drain is placed over intermittent thoracocentesis?

A

underlying disease (whether production continuous)

quantity of air/fluid being produced

patient temperament

treatment plan (if likely to have thoracotomy)

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103
Q

when is a chest drain usually placed?

A

when intermittent thoracocentesis not working

following thoracotomy

if long-term pleural drainage required

instillation of medications

104
Q

why might a chest drain be placed following thoracotomy?

A

remove air/fluid introduced during surgery

detect air/fluid being produced due to underlying condition

detect air/fluid being produced due to complications of surgery

104
Q

when might intermittent thoracocentesis not be appropriate?

A

large volumes of air/fluid being produced

fluid too thick to come through butterfly

proving too risky - causing lung trauma

105
Q

why might long-term pleural drainage be required?

A

pneumothorax due to underlying lung disease

pleural effusion e.g. pus/chyle

106
Q
A
107
Q

which chest drain types require GA?

A

large bore

108
Q

what are the general sizes for chest drains?

A

large bore and narrow bore

109
Q

what are the placement techniques for large and narrow bore chest drains?

A

large bore - trocar technique

narrow bore - seldinger technique

110
Q

what size chest drains are typically available?

A

6Fr to 20Fr

111
Q

what does the size of chest drain selected depend on?

A

reason for drainage
amount expected

112
Q

how is french scale for chest tubes different to ET tube sizing?

A

french scale is 3x the outside diameter in mm
3mm tube = 9Fr

113
Q

can chest drains be placed into closed chests?

A

yes (trocar?) but requires significant skill to do so

114
Q

how do we measure chest drain length?

A

pre-measure so tip sits cranioventrally but not too close to the thoracic inlet

115
Q

what is important to remember about fenestrations on chest drains?

A

when drain is placed, all fenestrations must be completely within the chest

116
Q

why should we check the integrity of all the connectors of the chest drain before it is placed?

A

to avoid iatrogenic pneumothorax

117
Q

how are trocar drains typically secured?

A

using roman sandal style sutures

118
Q

how are seldinger-type drains usually secured?

A

usually come with built-in anchor flanges to facilitate securing to the body wall with simple sutures

119
Q

how can we protect chest drains?

A

24-hour nursing
gate clamps
secure sutures
body bandages and buster collars

120
Q

when are trocar drains most commonly placed?

A

post-procedure, under GA

121
Q

are trocar drains fenestrated?

A

yes

122
Q

why do trocar drains require a subcut tunnel?

A

air leaks common

123
Q

how can we reduce risk of air leaks with a trocar drain?

A

ensure placed through subcut tunnel

124
Q

what are the advantages of trocar chest drains?

A

lots of different sizes available

versatile - good for air/fluid, not easily blocked

robust/rigid, unlikely to collapse

once learned, easy to place

easy monitoring of tube due to transparency

125
Q

what are the disadvantages of trocar chest drains?

A

typically need GA to place

possibly higher complication rate than narrow bore (published evidence minimal)

needs careful training for placement and anchoring (sutures)

less comfy than narrow bore

126
Q

what are the advantages of narrow bore (seldinger) chest drains?

A

no GA required

easy to place and secure

versatile

more comfy

127
Q

what are the disadvantages of narrow bore (seldinger) chest drains?

A

may not cope with pleural fluid/block (e.g. pyo)

smaller sizes difficult - may be overlong meaning too much inside chest (may kink) or outside chest (patient interference easier)

lack of rigidity means can end up in weird placement - can be difficult to position cranioventrally

may not be able to do the normal SQ tunnel in large patient as introducer catheters not very long

128
Q

when is a pleuraport used?

A

palliative care where long-term drainage required

129
Q

what is required to drain a pleuraport?

A

special Huber Point needles

130
Q

what equipment is required for placing a chest drain into a closed chest?

A

sterile prep equipment

anaesthetic kit and monitoring

assistant

chosen pre-measured chest drain

basic instrumentation, scalpel and blade

fenestrated drape

3-way tap

syringes

extension set

kidney dish/jug

suture material

131
Q

what are the drainage options for chest drains?

A

intermittent or continuous

132
Q

how often is intermittent drainage typically carried out?

A

4-8 hours and/or determined by resp rate/dyspnoea

133
Q

when is continuous drainage commonly used?

A

with large air-leak pneumothorax cases

134
Q

how can we reduce infection risk for patients with a chest drain?

A

aseptic technique at all times

good bandage hygiene

early identification for culture rather than just giving antibiotics

135
Q

what can be used as part of multi-modal analgesia for patients with a chest drain while hospitalised?

A

local e.g. lidocaine
systemic opioids
local down chest drain e.g. bupivacaine
CRIs
paracetamol inj (dogs only)

136
Q

what medications are patients with a chest drain typically send home with?

A

NSAID
oral paracetamol (not cats)

137
Q

what are the possible complications of chest drains?

A

failure to place
failure to drain
patient interference
iatrogenic issues
infections

138
Q

what issues with placement may arise during chest drain placement?

A

physically unable to place

incorrect placement (caudal not cranial/didn’t enter thorax/stuck in mediastinum)

139
Q

how can we check chest drain placement?

A

x-ray post-placement

140
Q

why might a chest drain fail to drain after placement?

A

inadvertent/accidental removal

tube disconnection/obstruction/kinking

tube slipped out a little (care not to break sterility of tube if adjusting)

141
Q

what iatrogenic issues can occur due to chest drain placement?

A

haemorrhage/haemothorax

heart/lung damage

inappropriate/premature removal –> recurrence

nerve damage (phrenic/Horners)

pneumothorax

pyothorax

seroma (often due to high volume effusion rather than truly iatrogenic)

subcut emphysema

142
Q

why might a vet decide to keep a chest drain in?

A

ongoing treatment via the drain

clinically significant production of air/fluid

143
Q

why might a vet decide to remove a chest drain?

A

complications where risk of tube remaining is greater than removal risks

resolution of issue (reduced volume)

ongoing need for drainage (switch to pleuraport)

144
Q

what should we consider in terms of preparation for thoractomy?

A

patient stability - risk assessment, ASA grading, bloods, IVFT

analgesia and abs - pre-emptive and perioperative plan

surgical plan - approach, kit, specialised instruments, potential complications and management of them

145
Q

what are the main 4 approach options for thoracic surgery?

A

left lateral intercostal thoracotomy
right lateral intercostal thoracotomy
vental sternal thoracotomy/sternotomy
thoracoscopy

146
Q

what is a thoracotomy defined by (numerically)?

A

numbered rib space

147
Q

what is the advantage of an intercostal thoracotomy?

A

less painful than sternotomy

148
Q

what must we consider when choosing a lateral approach to thoracotomy?

A

need to be sure that condition can be treated with unilateral surgery

need to be sure of the correct side to approach

need to be sure of the correct intercostal space to use

149
Q

what are the disadvantages of median sternotomy?

A

more painful than thoracotomy

not appropriate if issue is in dorsal thorax

150
Q

what procedures is a median sternotomy more appropriate for?

A

exploratory thoracotomy

bilateral conditions

151
Q

why is thoracoscopy not commonly used?

A

steep learning curve

specialised equipment required

reduced visualisation

limitations in which procedures can be safely completed using a scope

152
Q

how is the thorax accessed during a median sternotomy?

A

osteotomy with saw blade

153
Q

how wide should the clip be for a median sternotomy?

A

from thoracic inlet to mid abdomen, at least to width of axilla

154
Q

how wide should the clip be for thoracoscopy?

A

fully clipped as for sternotomy in case have to convert to open surgery

155
Q

how should the patient be positioned for a lateral thoracotomy?

A

front legs +/- back legs loosely tied out of the way
+/- sandbag under chest

156
Q

how should a patient be positioned for a median sternotomy?

A

dorsal recumbency, legs tied loosely out of the way

may need cradle and/or sandbags to stabilise if narrow chested

157
Q

how should patients be positioned for thoracoscopy?

A

can be done in lateral or dorsal depending on procedure

158
Q

how can thoracic surgical instruments be easily identified?

A

much longer handles than standard instruments (tissue forceps, scissors, needle holders)

159
Q

what are the purposes of tissue forceps during thoracic surgery?

A

atraumatic tissue handling
atraumatic fine dissection
clamping vessels prior to ligation

160
Q

what are sternotomy instruments used for?

A

to break through the bone

161
Q

which types of retractors may be used during thoracic surgery?

A

handheld e.g. malleable, langenbeck

ratcheted e.g. finochietto, gelpis

162
Q

which tissue forceps may be used during thoracic surgery?

A

debakeys - atraumatic

vascular/statinsky/soft palate clamps - for vessels prior to ligation

right-angled clamps - useful for dissection, come with/without ratchet

163
Q

what are the options for osteotomy during a sternotomy?

A

manual - chisel and hammer

electrical - oscillating saw

164
Q

which other miscellaneous items might be required during thoracic surgery?

A

lap swabs and suction

wire/thick suture

pre-selected chest drain and connectors

tourniquet

pledget sutures

vessel loops

165
Q

what is classed as basic electrosurgery?

A

monopolar and bipolar diathermy

166
Q

what is classed as advanced electrosurgery?

A

gen11
ligasure
harmonic

167
Q

what is the advantage of bipolar diathermy?

A

no earthing pad required to avoid burns

168
Q

what is a pneumonectomy?

A

removal of one half of the lungs

169
Q

how well do patients cope with pneumonectomy?

A

surprisingly well - remaining lung expands to fill the chest

170
Q

what is the disadvantage of lung lobectomy using sutures?

A

slow, technically challenging, higher risk of leakage

171
Q

what is the advantage of lung lobectomy using staplers?

A

quick, lower risk of leakage

172
Q

what are the disadvantages of lung lobectomy using staplers?

A

more expensive to keep in stock
steep learning curve

173
Q

what procedure should always be performed after a lung lobectomy?

A

leak testing

174
Q

how is leak testing carried out?

A

chest is filled with warm saline, suction on standby

IPPV and check for air bubbles

suction fluid back out once happy no bubbles are passing

175
Q

why does opening of the thorax give specific anaesthesia considerations?

A

it removes the negative pressure in the pleural space, meaning the lungs cannot expand on their own

176
Q

why can’t the lungs expand when the negative pressure in the pleural space is removed?

A

when the chest wall expands, there will be little/no air entry into the lungs because the pressure inside the lungs is the same as atmospheric pressure

177
Q

what does opening of the thorax during anaesthesia lead to?

A

inadequate ventilation and impaired gas exchange

requires IPPV

178
Q

what happens to the structure of the lungs when the thoracic cavity is opened?

A

atelectasis (small airway collapse)

179
Q

what happens to the lung capacities when the thoracic cavity is opened?

A

decreased:
total lung capacity
vital capacity
functional residual capacity

180
Q

what might occur during thoracic surgery to exacerbate hypoxaemia?

A

packing off lung lobes - direct pressure on lungs

manipulation of major blood vessels

leak testing exerts pressure

181
Q

which thoracic approach is more painful?

A

sternotomy

182
Q

why is thoracoscopy less painful than sternotomy?

A

less invasive, should be associated with less pain than a fully open procedure

183
Q

how should ventilation be managed in diaphragmatic hernia cases?

A

treat as thoracotomy and ventilate from start - chest wall compromised

184
Q

why is thoracotomy painful?

A

large skin incision

nerve trauma and muscle damage due to extensive retraction

inflammation at surgical site

all leads to hyperalgesia

185
Q

why is post-op hypoxaemia common after thoracotomy?

A

unwillingness to move the chest wall due to pain leads to reduced efficacy of ventilation

186
Q

what are the respiratory system-related reasons for opening the thorax?

A

lung lobe torsion, bulla, neoplasia, abscess etc

187
Q

what are our considerations for opening the thorax for respiratory system surgery?

A

pre-existing pneumothorax hypoventilation
hypoxaemia

188
Q

what are the cardiovascular system-related reasons for opening the thorax?

A

patent ductus arteriosus

persistent right aortic arch

pericardectomy

heart surgery

189
Q

what are our considerations for opening the thorax for cardiovascular system surgery?

A

cardiovascular changes
bleeding
hypotension
risk of arrhythmias

190
Q

what are our specific considerations for persistent right aortic arch?

A

often present with regurgitation

predisposes aspiration

young patients - risks associated

191
Q

what are our main anaesthetic consideration for patent ductus arteriosus?

A

altered movement of blood - abnormal circulation, hypotension

systemic blood pressure increase when vessel ligated –> profound bradycardia

192
Q

what are our anaesthetic considerations for oesophageal FB, thoracic duct ligation etc?

A

risk of aspiration

risk of regurgitation

septic complications - often contaminated surgery

post-op pain management vital

193
Q

which risks do we need to be aware of pre-GA for thoracic patients and how do we mitigate these?

A

bleeding - blood type, check blood availability

hypotension - fluids/drugs, make a plan with vet

hypoventilation - oxygen, IPPV

194
Q

which equipment is it vital to check before GA for thoracic surgery?

A

facilities for IPPV - check ventilator

check monitoring equipment

195
Q

what type of blood pressure measurement is ideal under GA for thoracic surgery?

A

direct continuous via an arterial line

196
Q

which parameter is important to monitor in neonates/septic patients undergoing thoracic surgery?

A

blood glucose

197
Q

what might be involved in pre-anaesthetic support/stabilisation?

A

chest drainage where applicable

pre-oxygenation if not causing more stress

analgesia

198
Q

what type of drugs should be avoided for pre-med in thoracic cases?

A

a2 agonists and ACP - most patients will be too unstable

199
Q

what is an appropriate pre-med plan for an unstable thoracic surgery patient?

A

methadone only

200
Q

what are the aims of our drug choices for thoracic surgery patients?

A

minimise CVS depression

201
Q

which drugs should we prepare in advance for thoracic surgery?

A

consider whether inotropes are likely indicated

prepare infusions of analgesics e.g. fentanyl

202
Q

what is etomidate?

A

an IV, ultra-short-acting, nonbarbituate hypnotic drug

203
Q

what is etomidate used for?

A

widely used in man as a induction agent and by continuous infusion

204
Q

is etomidate licensed for any animal species?

A

not in UK

205
Q

what are the major advantages of etomidate use in thoracic cases?

A

minimal cardiopulmonary depression - produces minimal change in HR, MAP or myocardial performance

206
Q

what is the main disadvantage of etomidate use?

A

quality of induction is poor - not smooth, vomiting

207
Q

what are the respiratory effects of etomidate?

A

similar to those of thiopentone and propofol

208
Q

what is the major benefit of fentanyl usage in thoracic cases?

A

it is a potent anaesthetic sparing drug - minimises dose-dependent CVS/respiratory depression due to inhalant drugs

209
Q

what is the onset and duration of action of fentanyl?

A

onset within 5 mins

duration 20-40 mins (dose-dependent)

210
Q

when is one lung ventilation used?

A

when pathology affects one lung but not the other e.g. infection or tumour

to improve surgical exposure e.g. in thoracoscopy

211
Q

what special equipment is used for one lung ventilation?

A

a double lumen tube or endobronchial blocker

212
Q

why is one lung ventilation rarely carried out?

A

placement is difficult and effects of incorrect placement can be catastrophic

213
Q

what is the advantage of performing one lung ventilation using a single lumen ET tube?

A

easier to perform than other methods

214
Q

what are the disadvantages of performing one lung ventilation using a single lumen ET tube?

A

may not achieve effective one lung only ventilation

risk of contamination between lungs

difficult in bigger dogs (>20-25kg) due to tube length

215
Q

what is the advantage of performing one lung ventilation using an endobronchial blocker?

A

results in effective one lung ventilation

216
Q

what are the disadvantages of performing one lung ventilation using an endobronchial blocker?

A

requires a bronchoscope to place and skill/training

expensive to buy

217
Q

what is the advantage of performing one lung ventilation using a double lumen ET tube?

A

can be done blind

218
Q

what are the disadvantages of performing one lung ventilation using a double lumen ET tube?

A

tubes are bulky and can be difficult to place

not achievable in dogs >20-25kg due to tube length

219
Q

what are the considerations for one lung ventilation using an endobronchial blocker?

A

only use stated inflation volumes for cuff of blocker to prevent bronchial wall damage

only inflate cuff when OLV is required

avoid moving patients when blocker is placed/inflated

220
Q

why should moving patients be avoided once an endobronchial blocker is placed?

A

increased risk of dislodgement if moved

221
Q

why should moving patients be avoided when an endobronchial blocker is inflated?

A

increased risk of bronchial wall damage if moved

222
Q

what care considerations are there for OLV with a double lumen ET tube?

A

care needs to be taken when moving patient - can become easily dislodged

deflate cuff before moving

223
Q

what is the ideal tidal volume range on a ventilator?

A

10-15ml/kg
(8-10 in cats?)

224
Q

what is the ideal peak inspiratory pressure range on a ventilator?

A

8-12cm H2O

225
Q

what is the ideal RR range on a ventilator?

A

10-30mpm

226
Q

what is the ideal I:E ratio on a ventilator?

A

1:2 max

227
Q

how can we assess appropriateness of tidal volume on a ventilator?

A

visualisation - observation of the thorax

adapt with monitoring

228
Q

how can we assess appropriateness of peak inspiratory pressure on a ventilator?

A

adapt to open/closed thorax

increased if recruitment

229
Q

how can we assess appropriateness of RR on a ventilator?

A

adapt to animal

increase if tidal volume is decreased

230
Q

how can we assess appropriateness of I:E ratio on a ventilator?

A

adapt according to RR

231
Q

why does care need to be taken with volumes used on a ventilator?

A

to avoid barotrauma or volutrauma

limit pressure/volume applied to the chest

232
Q

how does re-expansion pulmonary oedema occur?

A

due to rapid overexpansion of lungs at end of surgery

233
Q

how can we avoid re-expansion pulmonary oedema?

A

be careful at end of surgery not to over expand lungs - especially if compressed for extended period e.g. thoracic tumour

234
Q

why are differences between ETCO2 and PaCO2 not consistent in dogs with an open thorax?

A

due to altered ventilation and perfusion (VQ) relationships

235
Q

how can we check the efficiency of ventilation/perfusion under GA?

A

measure PaCO2

236
Q

what is the minimum oxygen monitoring requirement during thoracic surgery?

A

SpO2 should be the minimum - PaO2 if possible

237
Q

how can we detect hypoxaemia during thoracic surgery?

A

requires placement of an arterial catheter

238
Q

during which thoracic surgery is it mandatory to place an arterial catheter?

A

thoracoscopy - detection of hypoxaemia

239
Q

how can we manage hypoxaemia during thoracic surgery?

A

check 100% FiO2

check patency of ET tube

ensure CVS function is optimised

switch to manual ventilation temporarily - perform alveolar recruitment manoeuvre

introduce PEEP

reduce concentration of volatile agent, intro CRI

re-expand collapsed lung

240
Q

how can patency of the ET tube affect hypoxaemia?

A

endobronchial blocker may be dislodged

secretions blocking lumen of tube

241
Q

how can we ensure CVS function is optimised during thoracic surgery?

A

appropriate depth of anaesthesia

circulating blood volume is adequate

confirm that surgeon is not decreasing VR (hand/arm/leaning on chest)

242
Q

why can switching to manual ventilation help with hypoxaemia?

A

to give a few larger breaths - can decrease atelectasis

can perform alveolar recruitment manoeuvre

243
Q

what other supportive therapies should be considered for thoracic surgery?

A

fluid therapy

management of hypothermia - large wound, minimise losses, warm fluids

244
Q

what are the options for analgesic management during thoracic surgery?

A

combination of local and systemic analgesics

full mu agonists

epidural morphine

intercostal nerve block (lateral thoracotomy)

LA down the chest drain (bupivacaine)

NSAIDs for management of blood pressure

245
Q

why should use of NSAIDs be carefully considered in thoracic patients?

A

due to reduced CVS function - ensure BP maintained, avoid in patients at risk of/with hypotension

consider on recovery if stable

246
Q

how can we aid pulmonary expansion when weaning patients from a ventilator?

A

consider an alveolar recruitment manoeuvre

247
Q

what are patients more at risk of developing after >12 hours on a ventilator?

A

pulmonary oedema if tried to wean off too quickly

248
Q

when should we time end of IPPV when weaning a patient off a ventilator?

A

time end of IPPV with closure of the chest and drainage of the chest - won’t be able to breathe spontaneously otherwise

249
Q

when is an alveolar recruitment manoeuvre particularly useful?

A

if lavage atelectasis has occurred

250
Q

what are the most important steps involved in weaning a patient off a ventilator?

A

turn off the ventilator and support respiration until breathes spontaneously

decrease IPPV gradually - will allow PaCO2 to rise

decrease anaesthetic/analgesic drugs

reverse NMBA before stopping IPPV

251
Q

how can we ensure the patient is weaning back onto room air efficiently?

A

use a pulse ox to measure

supplement oxygen if not saturating adequately

check chest drain for blood/fluid/air if not saturating

252
Q

why should we avoid long term high concentration oxygen supplementation?

A

can cause oxygen toxicity >6 hours

253
Q

which blood parameter should we consider monitoring after thoracic surgery?

A

monitor PCV, check PCV of fluid in the chest drain to see if actively bleeding

consider transfusion if necessary (>20% blood loss)

254
Q

what are the overall key factors for thoracic surgery?

A

IPPV
good pain management
basic life support (fluids/temp)
robust anaesthesia protocol

255
Q
A

Applied Clinical Veterinary Nursing (31 decks)

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