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Principles III > Thoracic sx (final) Open procedures ppt. Newby > Flashcards

Thoracic sx (final) Open procedures ppt. Newby Flashcards

this is part 2 of the thoracic PPt

1
Q

What are some Open Thorax Procedures

A
  • Lung bx/ pleurodesis
  • Leung resection (W< li=””> <>
  • Lung cyst and Bullae
  • Intrapulmonary hemorrage
  • Bronchopleural Fistula and Empyema
  • Esophageal sx
  • Tracheal resection
  • Lung transplant
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2
Q

Lung Isolation: indications:

what are indications for lung isolation?

A
  • Control of foreign material
  • Airway control
  • Surgical exposure
  • Special procedures
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3
Q

Lung Isolation: indications:

What type of foreign material would you want to control?

A
  • lung abcess
  • Brochiectasis
  • Hemoptysis
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4
Q

Lung Isolation: indications:

what specific d/o would need airway control

A

bronchopleural-cutaneous (B-p) fistula

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5
Q

Lung Isolation: indications:

what type of sx’s would need lung isolation for surgical exposure

A
  • Lung resection
  • Esophageal sx
  • Vascular Aortic Sx
  • VATS
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6
Q

Lung Isolation: indications:

what special sx’s will need lung isiolation?

A
  • Lung lavage
  • Differential ventilation
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7
Q

Open Thoracic sx: Preop Eval

what should you have done lab and reveiew wise?

A
  • ABG
  • PFT
  • CXR
  • V/Q scan
  • CT/MRI
  • Angiography
  • Coexisting pathology
  • prescreen for underlying pulm infections
  • Observe for tracheal stenosis (positional dyspnea, Airway collapse, hypoxemia, anatomic narrowing)
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8
Q

Open Thoracic sx: Preop Eval-Hematological

transfuse pt with pre-op Hct < __%

A

25%

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9
Q

Open Thoracic sx: Preop Eval-Hematological

Transfuse pt’s with pre-op Hct <25% with how many units?

A

2-4

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10
Q

Open Thoracic sx: Preop Eval-Musculoskeletal

Lung Ca pts may have myasthenic sysndrome with increased sensitivity to ______ muscle relaxants?

A

NDMR

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11
Q

Open Thoracic sx: Monitoring

what type of monitors?

A
  • Standard ASA monitors
  • A-line L vs R
  • Lateral decubitus position place A-line in dependent arm
  • PA cath
  • Central Line
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12
Q

Open Thoracic sx: Monitoring

PA cath/ Central line

where is it placed?

What may affect reading?

A
  • Place in NON-dependent side of neck
  • pressure readings may be affected by open chest, lateral position, and surgical manipulation
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13
Q

Open Thoracic sx: Anesthetic Tech

what type of anesthesia?

A

GETA +/- thoracic epidural

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14
Q

Open Thoracic sx: Anesthetic Tech

sx may start open thorax with _______ via SL-ETT

A

bronchoscopy

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15
Q

Open Thoracic sx: Anesthetic Tech

epidural ANALGESIA _______ VAA requirements, but epidural ANESTHESIA may create _____ ______ and _____

A
  • reduce
  • sympathetic blockade
  • hypotension
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16
Q

Open Thoracic sx: complications

what complications can occur from open sx

A
  • Pneumothorax
  • manipulation of lung, heart, and major vessels may interfere with ventilatory exchange and CV stability (both intraop and postop)
  • Lateral decubitus position changes distribution of blood flow and pattern of ventilation and wxposes lower lung to danger of contanination by secretions, blood, or fluids
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17
Q

Open Thoracic sx:

what are the risk involved

A
  • # 1 Dysrhythmias
  • DVT/PE/AMI
  • brochopleural fistula
  • Chylothorax
  • Subcutaneous Emphysema
  • Phrenic nerve injury*****
  • Recurrent Laryngeal nerve injury
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18
Q

Open Thoracic sx: Decortication/Pleurodesis

how is is performed? (approach surgical)

A

VATS

thorocotomy

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19
Q

Open Thoracic sx: Decortication/Pleurodesis

what type of ventilation may be needed?

A

single lung or hypoventilation

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20
Q

Open Thoracic sx: Decortication/Pleurodesis

what does the word mean

Pleurodesis?

Decortication?

A
  • Pleurodesis= inflammation= adherence
  • Decortication = peeling of inflammatory/ scar tissue
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21
Q

Open Thoracic sx: Lung resection

is often preceeded by what 2 procedures?

A
  • brochoscopy
  • mediastinoscopy
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22
Q

Open Thoracic sx: Lung resection

incision placement?

A

lateral or posterior lateral thoracotomy

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23
Q

Open Thoracic sx: Lung resection

position?

A

lateral decubitus

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24
Q

Open Thoracic sx: Lung resection

how is lung isolation produced?

A

double lumen ETT

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25
Q

Open Thoracic sx: Lung resection

average time?

A

2-3 hrs

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26
Q

Open Thoracic sx: Lung resection

EBL

A

= < 500 mls

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27
Q

Open Thoracic sx: Lung resection

postop care?

A

ICU

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28
Q

Open Thoracic sx: Lung resection

Fluid management?

A
  • as little as possible
  • preferable < 1000ml
  • b/c Right heart CO, Vascular beds and edema
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29
Q

Open Thoracic sx: Lung Cyst and Bullae

what are they?

A
  • Air filled, thin walled, brochogenic or alveolar destructive, post infective, infantile, or emphysematous cysts
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30
Q

Open Thoracic sx: Lung Cyst and Bullae

most pt’s have what co-existing D/O?

A

COPD with CO2 retention

31
Q

Open Thoracic sx: Lung Cyst and Bullae

what is their Ventilation mix-match from?

A

Increased ventilatory volume with decreased respiratory diffusion area

32
Q

Open Thoracic sx: Lung Cyst and Bullae

risk?

A

Positive pressure may rupture- causing tension pneumo

33
Q

Open Thoracic sx: Lung Cyst and Bullae

goals of sx

A

respirations usually improved after lung volume reduction

34
Q

Open Thoracic sx: Lung Cyst and Bullae

Induction- positive preesure of what?

A

< 10cmH2O

(DLT may be needed)

35
Q

Open Thoracic sx: Lung Cyst and Bullae

what gas do you not want to use in these pt’s

36
Q

Open Thoracic sx: Lung Cyst and Bullae

goal of extubation

A

Smooth

without coughing

37
Q

Open Thoracic sx:

what is a massive hemoptysis r/t trauma, pulmonary artery ruture, errosion into vessel by tracheostomy, abcess, or tumor called?

A

IntraPulmonary hemorrhage

38
Q

Open Thoracic sx: IntraPulmonary hemorrhage

treatment?

A
  • immediate intubation
  • 100% O2
  • Suction airway (ideally rigid bronchoscopy)
  • Lung isolation if unilateral involvement
  • May need thoracotomy and surgical repair
39
Q

Open Thoracic sx: Hemorrhagic Pulmonary Infarct

why are these infarcts hemorrhagic?

A
  • B/c though the pulmonary artery carrying most of the blood and oxygen is cut off, the brochial arteries from the systemic circulation (supplying about 1% of the blood to the lungs) is not cut off.
40
Q

Open Thoracic sx: Brochopleural Fistula

what is it

A
  • Abnormal communication b/t bronchial tree and pleural cavity
41
Q

Open Thoracic sx: Brochopleural Fistula

what type of intubation may be done (if there is only a small air leak and NO empyema)

42
Q

Open Thoracic sx: Brochopleural Fistula

what are the risk with this D/O

A

Contamination

Tension pneumo

43
Q

Open Thoracic sx: Brochopleural Fistula

what is the main goal with this d/o

A

to have minimal gas leak through fistual

44
Q

Open Thoracic sx: Brochopleural Fistula and Empyema

what is this?

A
  • Abnormal communication b/t brochial tree and pleural cavity with pus
45
Q

Open Thoracic sx: Brochopleural Fistula and Empyema

what causes this?

A
  • Pulmonary resection
  • bronchus or bulla rupture
  • penetrating chest wound
  • lung cyst or empyema cavity
46
Q

Open Thoracic sx: Brochopleural Fistula and Empyema

what are risk with d/o

A
  • Positive pressure ventilation may contaminate healthy lung
  • Tension Pneumo
47
Q

Open Thoracic sx: Brochopleural Fistula and Empyema

what are the goals with the d/o

A
  • Awake drainage under seal
  • isolation of affected lung DLT (lumen to unaffected side)
48
Q

Open Thoracic sx: Esophageal sx

What are indications for sx?

A
  • resection of neoplasms
  • Anti-reflux procedures
  • Repair tramatic or congenital lesions
49
Q

Open Thoracic sx: Esophageal sx

things to consider about the pt ( like what we are going to worry about)

A
  • Chronic malnutrition r/t Ca illnes and swallowing difficulty
  • Hypovolemia r/t difficulty swallowing
  • ETOHism r/t esophageal lesions
  • Aspiration risk
50
Q

Open Thoracic sx: Esophageal sx

what is the monitoring for the sx?

A
  • A-line
  • CVP and CVL
  • Foley
51
Q

Open Thoracic sx: Esophageal sx

anesthesia choice

A
  • DLT
  • epidural ANALGESIA intra/post-op
  • GETA
52
Q

Open Thoracic sx: Esophageal sx

sx approach for upper esophageal lesions?

A
  • transverse cervical incision for proximal anastomosis
  • Right side for thoracic incision
  • Midline abdominal for resection and closure
53
Q

Open Thoracic sx: Esophageal sx

sx approach for middle lesions

A

ride sided thorocotomy (ivor lewis approach)

54
Q

Open Thoracic Sx: Esophageal Sx

sx approach for lower esophageal lesions

A

extended left thorocoabdominal incision

55
Q

Open Thoracic Sx: Esophageal Sx

why are these pt’s usually kept intubated post-op?

A

for aspiration precautions

56
Q

Open Thoracic Sx: Tracheal Resection/Reconstruction

what are indications for sx?

A
  • Congenital lesions (agenesis, stenosis)
  • Neoplasms
  • Injury
  • Infections
57
Q

Open Thoracic Sx: Tracheal Resection/Reconstruction

Monitoring?

A
  • Left arm A-line
  • Standard ASA monitors
58
Q

Open Thoracic Sx: Tracheal Resection/Reconstruction

what tube do you intubate with?

A

Small bore anode tube through stenosis

ETT through glottis to above stenosis

HFJV

59
Q

Open Thoracic Sx: Tracheal Resection/Reconstruction

intraop management?

A
  • steroids for tracheal edema
  • 100% FiO2
  • head down position (prevent drainage into lungs)
60
Q

Open Thoracic Sx: Tracheal Resection/Reconstruction

what are your goals in the sx

A
  • extubation asap (minimize tracheal trauma)
  • neck flexedminimize suture tension
61
Q

Open Thoracic Sx: VATS

lits like Laparoscopic but with no what?

A

Insufflation

62
Q

Open Thoracic Sx: VATS

what are the benefits

A

less pain

less post op ventilation

faster recovery

63
Q

Open Thoracic Sx: VATS

what sx are performed through a VAT

A
  • Lung bx/wedge
  • Pleurodesis/decortication
  • lobectomy, bi-lobectomy
  • pneumonectomy
  • Extraplural-sympathetic denervation
64
Q

Open Thoracic Sx: VATS

complications compared to open

A
  • hemorrhage and access
  • Surgical times
65
Q

Open Thoracic Sx: VATS

anesthetic consideretions

A
  • similar to open
  • monitoring
  • strict fluid mgmt
  • positioning
66
Q

Open Thoracic Sx: Lung Transplant

Indications

A
  • End stage respiratory failure
  • Cystic fibrosis
67
Q

Open Thoracic Sx: Lung transplants

what we must consider?

A
  • usually emergent (full stomach)
  • Antibiotics/immunosupressents
  • Peripheral AV or Venovenous bypass oxygenator
  • Full cardiopulmonary bypass (???)
68
Q

Open Thoracic Sx: Lung transplants

monitoring

A
  • A-line
  • PA cath
    *
69
Q

Open Thoracic Sx: Lung transplants

operative approach

A

posterolateral or bilateral subcostal thoracotomy

70
Q

Open Thoracic Sx: Lung transplants

GETA

  • how much O2?
  • Narcs?
  • Benzo?
  • Muscle relaxants?
A
  • 100% fio2
  • High Narcs
  • benza with low dose VAA-amnesia
  • Muscle relaxants
71
Q

Open Thoracic Sx: Lung transplants

lung isolation

A
  • best with contralateral ETT
  • if Bilat transplant Left sided ETT
72
Q

Open Thoracic Sx: Lung transplants

post op, what 4 things must we do?

what is the gold standard?

A
  • leave intubated
  • Ventilated
  • and sedated
  • serial ABGs
  • (Gold standard give to Dr. Keller and let him fix our fuck ups)
73
Q

great job

Principles III (24 decks)

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