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Advanced Anesthesia II > Thoracic Surgery I > Flashcards

Thoracic Surgery I Flashcards

1
Q

How do we determine if a patient is fit for thoracic surgery?

A

Usually, CV, thoracic, and anesthesia are involved in this decision. It needs to be determined how much lung can be removed without rendering the person a pulmonary cripple. There is certain testing that can be done to determine this.

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2
Q

Characteristics of small cell carcinoma

A

Represents about 25% of diagnosed lung CAs
Poor prognosis
Usually metastatic on presentation
Survival is 3 months after diagnosis d/t extensive metastasis
Often neuroendocrine in nature

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3
Q

Patients with small cell lung CA may present with one of these neuro-endocrine diagnoses

A

1) Eaton Lambert Syndrome
- Autoimmune reaction against pre-synaptic voltage gated Ca++ channels
- Results in weakness of the extremities
- Weakness of the respiratory muscles may occur late in the disease process
- Patients will have prolonged responses to NMBs

2) SIADH
- Excessive release of ADH
- Results in dilutional hyponatremia

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4
Q

Characteristics of Non-Small Cell Lung CA

A

Represents about 75% of diagnosed lung CAs
Often linked to cigarette smoking
Surgery is considered in all these patients
Prognosis is variable. Better than small cell, but still very aggressive. Less than 50% will survive 5 years.

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5
Q

Acronym of TNM for tumor staging

A

T (Tumor)
- Describes the tumor. The size and extent of the primary tumor.

N (Nodes)
- Degree of spread to regional lymph nodes

M (Metastasis)
- Presence of distant metastasis beyond the lymph nodes

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6
Q

Why is diagnosis of non-small cell lung CA often delayed?

A

Because the symptoms of the tumor (like coughing) are very similar to symptoms that smokers experience already. So they often don’t seek medical treatment until something like hemoptysis happens.

Often, patients experience 7 months of symptoms before they present to the ED. Usually they complain of a cold that they can’t get rid of.

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7
Q

Demographics of typical lung CA patients

A

Usually in the 6th or 7th decade of life
Usually a male with history or heavy smoking, recent weight loss (d/t the cancer), and lives in an urban area.
Chemical industrial workers have a higher incidence of lung CA (asbestosis, chromates, nickel, and uranium).

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8
Q

Non-smokers make up less than __% of lung cancers

A

less than 10%

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9
Q

Specific and non-specific symptoms of lung CA

A

Specific:

  • Cough (recently worsened)
  • Dyspnea
  • Chest pain
  • Unilateral wheezing (d/t tumor site and obstruction)

Non-specific:

  • Weight loss
  • Anemia
  • Lethargy
  • Malaise
  • Vague cold-like symptoms
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10
Q

Possible tumor sites and their symptoms

A

Bronchopulmonary

  • Involvement of the lung
  • Cough, dyspnea

Extrapulmonary Intrathoracic

  • Tumor that extends beyond the confines of the lung
  • Pleural effusion, chest wall pain, dysphagia

Extrathoracic Metastatic

  • Tumor spread outside of the thorax
  • May invade brain, skeletal, kidney, and cause symtoms related to those sites

Extrathoracic Nonmetastatic

  • Paraneoplastic syndrome
  • Causes endocrine or endocrine-like syndromes (Cushing’s disease, hypercalcemia, etc)
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11
Q

Labs/testing done to evaluate the patient’s lungs prior to surgery

A

Physical exam
- Inspection, palpation, auscultation, percussion
Lab Tests
- Routine labs, sputum gram stain, C&S, cytology, LFTs, BUN/Cr
CXR
- If you can see a tumor on CXR, then it has been there for a long time
PFTs
- Help determine how functional the remaining lung tissue will be after resection
Pre-op Bronchoscope

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12
Q

What is the most useful common test before thoracic surgery?

A

CXR

Helps look at respectability, existence of pleural effusions, cardiac disease, risk for venocaval obstruction with mediastinal masses, etc.

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13
Q

PFTs help answer this question

A

How operational or functional will the remaining lung tissue be after resection?

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14
Q

PFTs should be considered in these 3 phases

A

Phase 1
- Whole lung test (ABGs and spirometry)

Phase 2
- Single lung testing (Individual lung split function test)

Phase 3
- Mimic post-op conditions (temporary unilateral balloon occlusion of the right or left main stem bronchus or right or left pulmonary artery

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15
Q

CXR findings and their anesthesia implications

A

Tracheal deviation and obstruction
- Difficulty with intubation or ventilation

Mediastinal mass

  • Difficulty with ventilation
  • SVC syndrome
  • Compression of PA

Pleural effusions
- Decreased VC and FRC

Cardiac enlargement
- High susceptibility to depressant effects on the heart

Bullous cyst
- Risk of rupture. Avoid PEEP!

Parenchymal reticulation consolidation
- Prone to atelectasis and edema

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16
Q

What is the major factor associated with post-op pulmonary problems?

A

Pre-existing pulmonary problems!

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17
Q

Who needs PFTs?

A
  • Patients with evidence of COPD
  • Patients with restrictive lung disease (chest wall or spinal deformities)
  • Morbidly obese (affects 30% of this surgical population –> restrictive lung disease)
  • Patients with history of wheezing or DOE
  • Smokers with history of persistent cough
  • Candidates for upper abdominal surgery
  • Candidates for thoracic surgery**
  • Patients of 70 years of age!*
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18
Q

Why bother performing PFTs?

A
  • They identify patients with abnormal lung function
  • They answer questions about resectability
  • They improve the outcome of patients at risk
  • They reduce the risk of post-op rest and ventilatory compromise
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19
Q

Phase I PFTs

A

Whole Lung Testing!

Two components to this phase:

1) Detect abnormalities of gas exchange
2) Detect abnormalities the mechanical aspects of ventilation (lungs and chest wall)

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20
Q

What values can be measured with spirometry?

A

TV, VC, IRV, ERV, and IC

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21
Q

What is the normal value of VC?

A

Remember that values vary with HEIGHT and AGE
Normally, VC is about 60mL/kg
Normal is considered >/= 80% of the predicted value of VC for that person’s age and height

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22
Q

When is vital capacity (VC) decreased?

A
  • Moving from sitting to supine
  • Restrictive lung disease (everything decreases with this)
  • Loss of distensible lung tissue
  • Whenever the patient is unable to obtain maximum inhalation or exhalation (Post-op pain, abd distention, or muscle weakness)
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23
Q

A patient is a high risk for PPCs if VC is less than __%

A

50%.

VC should be >50% and over 2L total

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24
Q

What is FVC?

A

Forced vital capacity.
Reflects resistance to flow in the airway
Rapid, forced exhalation after maximal inspiration.
Exhalation is measured in time, and must not be interrupted by cough, closure of the glottis, or mechanical obstruction.

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25
Q

What reduces FVC?

A

The same things that reduce VC, because they are essentially the same thing.

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26
Q

What is FEV1?

A

Forced expiratory volume in 1 second.

The volume expelled in the first second of a FVC measurement (forceful, rapid exhalation after maximal inhalation)

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27
Q

Tell me about the FEV1/FRC ratio?

A

Three spirograms are generated, and the best FVC and FEV1 values are used to create the ratio. FEV1 alone isn’t all that useful, you get the most information from looking at it as a ratio with FVC.

Normal FEV1/FVC ratio is 75-80%

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28
Q

What value is MVV closely related to?

A

FEV1
This is because they both require a high rate of air flow and little airway resistance. Changes in airway resistance will decrease both.
In general, MVV = FEV1 x 35

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29
Q

These factors affect MVV

A
  • Patient effort (requires a lot of work in 1 minute)
  • The elastic properties of the lung
  • Chest wall abnormalities (need good mechanics to generate that much airflow in a short amount of time)
  • Strength of respiratory muscles
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30
Q

What is closing volume?

A

The lung volume at which airways begin to close or stop contributing to expired gas.

On exhalation, the lung volume continues to get smaller and smaller. The volume will decrease to a point that some airway begin to close. These airways will no longer contribute to the gas expelled in expiration.

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31
Q

For healthy individuals, normal closing volume in the sitting position is _____

A

15-20% of the VC

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32
Q

Is closing volume lower or higher in smokers?

A

Higher! This means, their airways will begin to close sooner than those will healthy lungs.
This is due to the loss of elastic recoil and/or small airway pathology. The small airways become floppy and close easily.

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33
Q

Patients with increased operative risk for pneumonectomy

A

If:

  • ABG shows hypercapnia on room air
  • FEV1/FVC ratio is <50%
  • FEV1 is less than 2L
  • RV/TLC ratio is more than 50%
34
Q

Patients presenting for pneumonectomy are more likely to tolerate it if:

A
  • FEV1/FVC ratio is >50%
  • FEV1 > 2L
  • MVV > 50% predicted
  • RV/TLC ratio < 50%
  • DLCO is less than predicted (<40%)
    (DLCO is diffusion capacity for carbon monoxide)

If these factors are not met, then we need to move on to phase II PFTs (split lung function testing)

35
Q

What is Phase II of PFTs?

A

Split lung testing!

Looks at the function of each lung separately (compared to phase I testing, which looks at lung function as a whole)
To do this, ventilation and perfusion of each lung is measured using radio isotope.

Combines right and left fractional lung perfusion with conventional spirometry. Based on this, predicted FEV1 should be greater than 850mL.

If a FEV1 of 850mL is NOT met, then dyspnea and CO2 retention will result.

For example:
- If perfusion to the lung to be removed has been calculated to be 40%, and the pre-op FEV1 is 1.4L
This means that 60% of lung perfusion is going to the non-operative lung.
1.4L x 0.6 = 0.84L –> the Predicted FEV1 is 0.84L, so the patient should move on to phase II testing.

36
Q

What is Phase III Testing?

A
  • Simulates post-op conditions the patient will experience
  • Done via temporary balloon occlusion of the major pulmonary artery to the operative lung.
  • The procedure is done with and without exercise
  • Compliance of the remaining pulmonary vascular bed is tested
37
Q

These values during Phase III testing indicate an inability to tolerate removal of this amount of lung

A

PAP > 40mmHg
PaCO2 > 60mmHg
PaO2 < 45mmHg

38
Q

Why is a thorough CV workup important in thoracic surgery?

A

Because cardiac complications are the SECOND most common cause of peri-op morbidity and mortality.

Many people presenting for thoracic surgery are probably smokers. This can contribute to CAD and ischemia.

39
Q

The cardiovascular system has this response to COPD and CAD (often inter-related)

A
  • Increased PVR
  • Pulmonary HTN
  • RV hypertrophy and dilation
  • LV dysfunction d/t CAD, HTN, and possible prior MI
  • EKG may be needed to determine severity of associated CV disease
  • Measurements obtainable by PAC may be required (PAP, PCWP, CO, SVR, etc)
40
Q

What is our overall goal of our pre-op testing for thoracic surgery?

A

To decrease post-op pulmonary complications (PPCs) like atelectasis and pneumonia

41
Q

What are some reasons for post-op pulmonary complications?

A

1) Patient likely has high pre-op pulmonary dysfunction (degree of dysfunction correlates to risk of PPCs)
2) Resulting surgical impairment of the lung
- The operative (non-dependent) lung had tissue resected or traumatized
- The dependent (non-operative lung) experienced compression that may result in edema and atelectasis
- Incisional pain inhibiting deep breathing. Adequate pain management is essential!

42
Q

Pre-op methods to reduce PPCs

A
  • Encourage smoking cessation
  • Dilate the airways (B2 agonists, PDE inhibitors, inhaled anticholinergics and steroids)
  • Loosen and remove secretions (hydrate!)
  • Increase patient motivation and to encourage proper post-op care
  • Possible digoxin therapy
43
Q

Benefits of smoking cessation over time

A

12-24 hours –> decreased CO and nicotine levels
48-72 hours –> COHb levels normalize and ciliary function improves
1-2 weeks –> Decreased sputum production
4-6 weeks –> PFTs improve
6-8 weeks –> Immune function improves and metabolism normalizes
8-12 weeks –> Decreased overall post-op morbidity and mortality*

44
Q

Ways to dilate the airways and treat bronchospasm

A

Sympathomimetics (increase cAMP production, resulting in bronchodilation)

PDE Inhibitors (decrease breakdown of cAMP)

Steroids (decrease mucosal edema)

Cromolyn (mast-cell stabilization, but must be on board at least 7 days prior to surgery)

45
Q

Ways to loosen and remove secretions

A

Hydration
Treating existing infection
Postural drainage
Chest PT
Forced expiration technique
GE reflux prophylaxis
Humidify and warm inspired gases
Suctioning (prevents increased airway resistance and alveolar collapse)
Mucolytics (mucomyst 2-5mL 5%-20% solution Q6-8 hours)
Therapeutic bronchoscopy to remove mucus plugs

46
Q

These factors can reduce mucociliary flow

A

ETT inflation, high FiO2, and cold inspired gases,

47
Q

Education and patient motivation that should be given to the patient preoperatively

A 
Importance of deep breathing
Weight loss (restrictive lung pattern and OSA)
Use of home O2
Realistic post-op expectations
Post-op respiratory care
Chest PT
Importance of ambulation
48
Q

Prevention of arrhythmia in thoracic surgery

A

A-fib and a-flutter are common d/t atrial stretch. Occurs d/t increased right sided heart pressures.
More common in patients > 60 years old and those presenting for L pneumonectomy.

How to prevent arrhythmia:

  • Digoxin
  • BBs
  • Diltiazem
  • Amiodarone
49
Q

These are factors that place the patient at risk for PPCs

A
  • Dyspnea
  • Cough and sputum production (lots of shit in there just begging to get infected)
  • Recent URI****
  • Hemoptysis
  • Wheezing and/or use of bronchodilators and steroids
  • History of smoking
  • Age, general PMH and other significant comorbidities
  • Breathing pattern
  • Body habits
  • Site of the proposed surgery
  • Emergency surgery
50
Q

Characteristics of emphysema

A 
PINK PUFFER
PaO2 > 60, PaCO2 normal
Thin, anxious, pursed lips (puffer)
Dyspnea and use of accessory muscles
Scant secretions
VERY diminished breath sounds
Respiratory infections can result in R sided heart compromise
CXR shows hyperinflation with a low diaphragm
51
Q

Characteristics of chronic bronchitis

A

BLUE BLOATER (bronchitis = BB!)
PaO2 < 60, PaCO2 > 45 (all these secretions lead to ineffective mechanics and shit, so labs are more off)
Often overweight and cyanotic with a dusky appearance (blue and bloated)
Cough with copious amount of secretions (the secretions are irritating to the airways)
Diminished breath sounds
Can result in R sided heart failure / or pulmonale
CXR shows bronchovascular markings

52
Q

Anesthesia considerations for obstructive disease

A
  • We want controlled ventilation at a slower RR (6-10)
  • Longer expiratory time to minimize VQ mismatch
  • The worse a patient/s FEV1, the more CO2 the patient will retain if the patient is permitted to SV during GETA
  • Regional techniques with spread above T6 is not recommended because accessory muscles will be wiped out, and many (especially emphysema –> pink puffer) depend on accessories for ventilation
53
Q

Mediators of airway hyper-responsiveness in asthma

A

A lot of dumb shit we probably don’t have to know.

Eosinophils, mast cells, neutrophils, macrophages, basophils, and T lymphocytes.

Other dumb shit that probably causes it includes cytokines, interleukins 3,4,&5, metabolites of arachidonic acid (leukotrienes and prostaglandins), kinins, histamine, adenosine, and platelet activating factor

54
Q

These are various classes of bronchoactive drugs used

A 
Beta agonists
Corticosteroids
Methylxanthines
Anticholinergics
Cromolyn
55
Q

Anesthesia considerations for asthma

A
  • Consider regional techniques

- GA technique should be individualized to depress airway reflexes, and to blunt hyperactivity/bronchoconstriction

56
Q

Characteristics of restrictive lung disease

A
  • Decreased lung compliance and impaired lung/chest wall expansion
  • Increased work of breathing
  • Decreased spirometry values
  • VC < 70mL/kg
  • Normal expiratory flow rate
  • FEV1/FVC ratio normal
  • Shallow and rapid breathing pattern
  • Increased PaCO2 (unable to compensate for low TVs)
57
Q

S/S of PE in general

A

Acute dyspnea and tachypnea, pleuritic chest pain (pain that occurs with breathing), coughing, accentuation of pulmonic 2nd heart sound, rales, tachycardia, fever, and hemoptysis

ABG shows decreased PaO2 and PaCO2

58
Q

S/S of PE during general anesthesia

A

Arterial hypoxia, hypotension, tachycardia, and bronchospasm

59
Q

Diagnosis of PE

A

Diagnosed by VQ scan and/or pulmonary ateriography

60
Q

Management and treatment of PE

A

Management:
- Monitor cardiac filling pressures, avoid drugs that increase PVR, give PPV

Definitive treatment:
- PA embolectomy, IVC filter placement, anticoagulants, pain control

61
Q

What is pneumonia and what are the symptoms?

A

Inflammatory process usually caused by gram negative bacilli and staph aureus

S/S include fever, chills, productive cough, and tachypnea.

Usually treated with antibiotics.

62
Q

Anesthetic considerations for the pt with pneumonia

A

Elective surgery is not recommended
Consider regional technique (want to avoid introducing anything else into the lungs that can cause infection, and PPV which could spread infection)
Inform the pt that they may need to be intubated and ventilated after the procedure.

63
Q

What causes TB and how is it spread?

A

Caused by mycobacterium tuberculosis and is transmitted via droplets

64
Q

Anesthesia considerations for the patient with TB

A 
Special masks (N95 or PAPR)
Follow institutional policies for cleaning the equipment, changing circuit, CO2 absorbent, etc. 
Remember things from previous semesters like doing the procedure when fewer personnel are present, do the case later in the day, close the OR down afterwards for the air to be recirculated, etc.

The breathing circuit should be COMPLETEY changed!

65
Q

S/S of for pulmonale

A

Dyspnea, syncope, mean PAP > 20, prominent “a” wave on CVP (atrial contraction)
Overt right heart failure may be present

66
Q

Treatment/anesthesia considerations for for pulmonale

A

We want to decrease the workload of the RV

  • Digoxin
  • Diuretics
  • Supplemental O2
  • Vasodilators
  • Antibiotics
  • Anticoagulants
67
Q

Considerations for URI

A

Usually viral in nature
Recommendation is to AVOID elective procedures that require intubation
–> Higher risk for airway hyperactivity, bronchospasm, and laryngospasm during URI***
Airway irritability may persist for weeks after URI

Routine case cancellation is controversial, especially in the pediatric ENT population

68
Q

What is sarcoidosis?

A

Sarcoidosis is a systemic granulomatous disorder. This is a multi system disease that involving abnormal collections of inflammatory cells (granulomas). These granulomas are mostly found in the lungs or lymph tissue, but can be found anywhere.

69
Q

S/S of sarcoidosis

A

Depends on where the sarcoid is located.
Cor pulmonale, heart block, dysrhythmias, and restrictive cardiomyopathy may develop.
Hypocalcemia occurs rarely
BP may increase d/t increased ACE activity

70
Q

How is sarcoidosis usually treated?

A

Steroids

Does the patient need a stress dose?

71
Q

Anesthesia considerations for sarcoidosis

A

Look at co-existing disease book

72
Q

Hallmark symptoms of hemothorax

A

Hypotension
Hypoxemia
Tachycardia
Increased CVP

73
Q

Anesthesia considerations for hemothorax?

A

Look in coexisting book

74
Q

Hallmark symptoms of tension pneumothorax

A

Hypotension
Hypoxemia
Tachycardia
Increased CVP

Symptoms for hemothorax and pneumothorax are the same

Other symptoms include unilateral decrease in breath sounds, increase in vent pressures, progressive tracheal deviation, wheezing, and CV changes.

75
Q

What is an empyema and what is a classic cause?

A

Accumulation of pus in the pleural space with or without abscess formation.

Classic Cause: Aspiration when drunk

Other causes: Substance abuse, prior pneumonia, lung CA, steroid-induce immunosuppression, DM, COPD, and infection at another site

76
Q

Anesthetic considerations for empyema

A

Lung isolate in an absolute requirement because PPV may result in contamination of the healthy lung.

Look in book for other considerations

77
Q

An increase in headspace will have this effect on PaCO2

A

PaCO2 will increase

78
Q

Physiologic effects of acidosis

A

CNS

  • Anxiety
  • Confusion
  • CO2 narcosis
  • Cerebral vasodilation and increased ICP

CV

  • HTN
  • Tachycardia
  • Increased catecholamine activity
  • Increased PVR
  • HYPERKALEMIA
79
Q

Physiologic effects of alkalosis

A

CNS

  • Lightheadedness
  • Confusion
  • Coma
  • NM irritability
  • Paresthesias
  • Tetany, Sz (related to decreased Ca++)
  • Cerebral vasoconstriction

CV

  • HYPOKALEMIA
  • Ventricular dysrhythmias
  • Hypotension
  • Decreased CO
  • Impaired O2 delivery to tissues (shift to the left)
80
Q

What is base excess/base deficit

A

A calculated value that illustrates the deviation from normal bicarbonate levels, using the normal bicarb level of 24

81
Q

How to dose your bicarb based on base deficit levels

A

mEq of bicarb = base deficit x weight in kg x 0.3

This is the dose for full correction. Try 1/2 of the dose at first and recheck your ABG in 5 minutes.

Advanced Anesthesia II (6 decks)

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