Thoracic Surgery (Shannon) Flashcards by Andrew Skuta

2 Important predictors of Post-op Complications:

Predicted postop FEV1 <40% of predicted

Predicted postop DLCO <40% of predicted

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Thoracic surgery patients often have a co-existing presence of ………

ischemic cardiac disease

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Useful meds for Thoracic Surgery patients with ischemic cardiac disease:

Cardioselective Beta-Blockers

(non-selective risk inhibiting bronchodilation)

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Dyspnea in the supine position may be related to:

COPD
Compression of the airways –> mediastinal mass
diaphragm displacement d/t Obesity (FAT)

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Lambert-Eaton syndrome = may be sensitive to………

Nondepolarizing muscle relaxants.

Patients will need LESS NDMBs!!!

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________ tumors make up 20% of lung cancers

Neuroendocrine tumors

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Occurs in 10-25% of patients with lung cancer related to parathyroid-like hormone, increased calcitriol, or overactivity of osteoclasts

Hypercalcemia

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Cancer drugs (toxicities)
Bleomycin =
Doxorubicin=
Cisplatin =

Bleomycin = pulmonary toxicity
Doxorubicin = cardiac toxicity
Cisplatin = renal toxicity

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What test can be a good initial assessment for pulmonary HTN?

ECHO
look it up before case

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PaCO2 _____ mmHg is an indicator of poor ventilatory function

> 45 mmHg

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This lab finding will Increase risk for postop pulmonary complications by as much as 2.5 times

Hypoalbuminemia

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Most common lab finding in lung CA / Thoracic patients?
< ____g/dL

Hypoalbuminemia
< 3.6 g/dL

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A ____% increase in FEV1 post bronchodilator treatment is considered significant

12%

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Airflow assessment =

postop predictor of FEV1

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PPO FEV1 <____% have a higher degree of likelihood to require postop ventilation

30%

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Parenchymal function measure by:

DLCO

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The extent of pulmonary surgery correlates _______with intraop partial pressure of arterial oxygen (PaO2)

inversely

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How will PaO2 compare with pneumonectomy, lobectomy, and segmectomy?

PaO2 will be HIGHEST with pneumonectomy!!!

Intraoperative PaO2 pneumonectomy > lobectomy > segmectomy

(removes highest amount of diseased tissue which increases PaO2)

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Removal of diseased lung tissue may not decrease pulmonary function it may…….

Improve it!!!

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DLCO ____% of predicted value: associated with increased complications following pulmonary surgery

< 40%

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Patient monitoring: obtain a baseline ABG within____ _____of initiating one lung ventilation

15 minutes

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Is CVP reliable indicator of fluid in an open chest or lateral positioned patient?

NO!

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90% of PA catheters float into the ____ _____ –> values will be falsely low

Right lung

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Most common position during Thoracotomy:

Lateral Decubitus Position

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Axillary roll should be placed just _____ to the axilla

caudal

Zone 1 =

PA > Pa > Pv

Zone 2 =

Pa > PA > Pv

Zone 3 =

Pa > Pv > PA

Perfusion is greatest in the _____ ______.

Dependent lung

Lateral Position: Anesthetized, Chest Closed, Spontaneous Ventilation: ____ decreases almost immediately upon initiation of anesthesia. Reduced proportion in zone ___. Ventilation is preferentially distributed to the _____ _______. Gravity causes blood flow to preferentially go to dependent lung. Results in a......

FRC 3 nondependent lung V/Q mismatch

Lateral Position: Anesthetized, Chest Closed Paralyzed, Mechanically Ventilated: Under mechanical ventilation, the _______ no longer contributes to ventilation of the lower lung ____ ______ intensifies. Addition of______ helps to restore some ____ and improve V/Q ratio

diaphragm V/Q mismatch PEEP FRC

What position and situation would spontaneous ventilation be utterly useless?

Lateral Position: Anesthetized, Open Chest

Lateral Position: Anesthetized, Open Chest: An immediate decrease in resistance to gas flow in the _______ ______.

nondependent lung

Lateral Position: Anesthetized, Open Chest, One-Lung Ventilation: Ventilation to the _______ lung is ceased ----> ventilation is directed to the______ lung. PaO2 is _____ during one lung ventilation in the lateral position than it is in the supine position

nondependent dependent higher

Lateral Position: Anesthetized, Open Chest, One-Lung Ventilation: The remaining perfusion to the nondependent lung creates a shunt, but _____ reduces the shunt by ____ by diverting much of that blood towards the dependent lung _______the airway to the nondependent lung reverses some of the changes that caused V/Q mismatch

HPV 50% Clamping

Absolute Indications for One Lung Ventilation: long list

Isolation to avoid contamination: infection Isolation to avoid spillage: massive hemorrhage Control of the distribution of ventilation: Bronchopleural fistula Surgical opening at a major conducting airway Giant unilateral cyst or bulla Tracheobronchial tree disruption Life-threatening hypoxemia related to unilateral lung disease Need for unilateral bronchopulmonary lavage: pulmonary alveolar proteinosis

Relative Indications for One Lung Ventilation: High priority only (only ones she focuses on)

Thoracic aortic aneurysm Pneumonectomy Thoracoscopy Upper lobectomy Mediastinal exposure

Gold standard of lung separation for ventilation

Double lumen endobronchial tubes

Most commonly used DLT?

Left DLT!

Does the bronchial lumen need to be placed within the bronchus of the operative lung?

Can a DLT be used on small children?

Internal diameters typically range from____ to ____. 37F has an external diameter equivalent to that of a standard _____ internal diameter ETT.

3.4 mm-6.6 mm 11mm

Double Lumen Endotracheal Tubes: Sizing ___for women up to 160 cm ___ for women over 160 cm ____ for men less than 175 cm _____ for men over 175 cm

35F for women up to 160 cm 37F for women over 160 cm 37/39F for men less than 175 cm 39/41 for men over 175 cm

Slight movements of a _______________ can lead to malpositioning

right sided DLT

Double Lumen Endotracheal Tubes: Sizing Most commonly seen: females ____, males ____

females 37F males 39F

Most common complication of DLTs

Malpositioning

Rupture of a thoracic aneurysm with a ___________.

left sided DLT

Insertion of Double Lumen Endotracheal Tubes: Rotate the ETT ____ degrees toward the bronchus that is to be intubated- advance ETT Approximate depth of ____ cm in females and ____ cm depth in males --> stop if resistance is met

90 degrees 27 cm in females 29 cm in males

The tracheal cuff requires ____ mL of air The bronchial cuff requires ____ mL of air

5-10 1-2

Bronchial cuff should be _______during the time that OLV is no longer needed to decrease risk of mucosal damage

Deflated

Advantages of Bronchial Blockers:

-Less complicated insertion- better for patients with a difficult airway or tracheostomy -Better for patients who are already intubated -Can be used in a pediatric population

What is HPV? Why is it unique?

Compensatory mechanism to minimize shunt by increasing vascular resistance in hypoxic areas of the lungs (A unique reflex since hypoxia usually causes vasodilation; arterial hypoxia has the opposite effect on pulmonary arteries)

HPV during OLV decreases the cardiac output to the nonventilated lung by approximately ___% HPV can increase PVR by ___-___% in a state of chronic hypoxia

50% 50-300%

Will HPV work if more than 80% of the lung is hypoxic?

Nope

What will vasodilators do during HPV?

Inhibit it

Factors that Reduce Effectiveness of Hypoxia Pulmonary Vasoconstriction (long list)

Alkalosis Excessive tidal volume or PEEP Hemodilution Hypervolemia (L atrial pressure >25 mmHg) Hypocapnia Hypothermia Prostacyclin Vasodilators, phosphodiesterase inhibitors, calcium channel blockers Volatile anesthetics >1.5 MAC

Most common type of anesthetic used for OLV?

Volatile anesthetics

Gold Standard anesthetic for an Open Thoracotomy?

Epidural anesthesia: found to reduce complications without inhibiting HPV Epidural catheter at the level of T6-T8

Why is hypoxemia more frequent in right sided lung surgery?

Due to anatomically larger/proportionally more perfusion to the right lung

OLV is best tolerated in the _____ position vs. _____.

lateral vs. supine

Causes of Hypoxemia During One Lung Ventilation: most common?

Tube malposition MOST COMMON: should be the first intervention Bronchospasm Decreased cardiac output Hypoventilation Low FiO2 Pneumothorax of dependent lung

1st intervention to manage Hypoxemia During OLV?

CPAP to the nondependent, nonventilated lung

Interventions to Manage Hypoxemia During OLV: Alternative to CPAP: --> What if interventions fail? -->

place a small catheter to deliver low-flow oxygen insufflation to the nondependent lung If interventions fail, communicate with your surgeon to return to two-lung ventilation

Mediastinal Mass Biopsy should be done under _____ anesthesia whenever possible

local

Mediastinal Mass Biopsy: Gold standard if intubation is required?

Awake intubation with a flexible bronchoscope is the gold standard -Maintain spontaneous ventilation if possible

IV placement for Mediastinal Mass Biopsy:

Place IV in a lower extremity ---> sites above the SVC could delay drug’s effects due to slow distribution

Mediastinoscopy: biggest point?

Potential for LOTS of complications d/t location of important anatomical structures. (left common carotid artery, the left subclavian artery, the innominate artery, the vagus nerve, left recurrent laryngeal nerve, the thoracic duct, the SVC, and the aortic arch)

Mediastinoscopy: Complications (long list)

Hemorrhage Pneumothorax Dysrhythmias Bronchospasm Left recurrent laryngeal nerve palsy Laceration of the trachea or esophagus Chylothorax from laceration of thoracic duct Air embolism

Mediastinoscopy: Anesthesia Management Watch for ________ with manipulation of the aorta/trachea during dissection ---> have______ or ______available

bradycardia glycopyrrolate or atropine

Preferred surgical approach for lobectomy in stage I non-small cell lung cancer ?

VATS

Preferred anesthetic method for Bullectomy:

Spontaneous ventilation under GA is preferred until the chest is open to decrease the risk of bulla rupture

Most common postoperative complications after Thoracotomy:

respiratory failure, cardiac dysrhythmias or failure, acute lung injury (ALI)

High risk patients that may require ICU postop: (after thoracotomy)

pulmonary fibrosis age greater than 80 PPO FEV1 or DLCO less than 40% ASA 4 surgical time longer than 80 minutes

Thoracotomy: Chest tube drainage >____ mL/hour necessitates surgical reexploration

200

Reduction in ____ ____ is greater following a pneumonectomy vs lobectomy

cardiac EF

Nerve Injuries following Thoracotomy

Damage to the phrenic nerve as it passes through the mediastinum Damage to left recurrent laryngeal nerve May happen during dissection of aortopulmonary lymph nodes and mediastinal procedures Spinal cord injury can occur if an intercostal artery supplying a major radicular artery is damaged