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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
Open Thoracic sx: Lung resection average time?
2-3 hrs
26
Open Thoracic sx: Lung resection EBL
= \< 500 mls
27
Open Thoracic sx: Lung resection postop care?
ICU
28
Open Thoracic sx: Lung resection Fluid management?
* as little as possible * preferable \< 1000ml * b/c Right heart CO, Vascular beds and edema
29
Open Thoracic sx: Lung Cyst and Bullae what are they?
* Air filled, thin walled, brochogenic or alveolar destructive, post infective, infantile, or emphysematous cysts
30
Open Thoracic sx: Lung Cyst and Bullae most pt's have what co-existing D/O?
COPD with CO2 retention
31
Open Thoracic sx: Lung Cyst and Bullae what is their Ventilation mix-match from?
Increased ventilatory volume with decreased respiratory diffusion area
32
Open Thoracic sx: Lung Cyst and Bullae risk?
Positive pressure may rupture- causing tension pneumo
33
Open Thoracic sx: Lung Cyst and Bullae goals of sx
respirations usually improved after lung volume reduction
34
Open Thoracic sx: Lung Cyst and Bullae Induction- positive preesure of what?
\< 10cmH2O | (DLT may be needed)
35
Open Thoracic sx: Lung Cyst and Bullae what gas do you not want to use in these pt's
N2O
36
Open Thoracic sx: Lung Cyst and Bullae goal of extubation
Smooth without coughing
37
Open Thoracic sx: what is a massive hemoptysis r/t trauma, pulmonary artery ruture, errosion into vessel by tracheostomy, abcess, or tumor called?
IntraPulmonary hemorrhage
38
Open Thoracic sx: IntraPulmonary hemorrhage treatment?
* immediate intubation * 100% O2 * Suction airway (ideally rigid bronchoscopy) * Lung isolation if unilateral involvement * May need thoracotomy and surgical repair
39
Open Thoracic sx: Hemorrhagic Pulmonary Infarct why are these infarcts hemorrhagic?
* 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
Open Thoracic sx: Brochopleural Fistula what is it
* Abnormal communication b/t bronchial tree and pleural cavity
41
Open Thoracic sx: Brochopleural Fistula what type of intubation may be done (if there is only a small air leak and NO empyema)
RSI
42
Open Thoracic sx: Brochopleural Fistula what are the risk with this D/O
Contamination Tension pneumo
43
Open Thoracic sx: Brochopleural Fistula what is the main goal with this d/o
to have minimal gas leak through fistual
44
Open Thoracic sx: Brochopleural Fistula and Empyema what is this?
* Abnormal communication b/t brochial tree and pleural cavity with pus
45
Open Thoracic sx: Brochopleural Fistula and Empyema what causes this?
* Pulmonary resection * bronchus or bulla rupture * penetrating chest wound * lung cyst or empyema cavity
46
Open Thoracic sx: Brochopleural Fistula and Empyema what are risk with d/o
* Positive pressure ventilation may contaminate healthy lung * Tension Pneumo
47
Open Thoracic sx: Brochopleural Fistula and Empyema what are the goals with the d/o
* Awake drainage under seal * isolation of affected lung DLT (lumen to unaffected side)
48
Open Thoracic sx: Esophageal sx What are indications for sx?
* resection of neoplasms * Anti-reflux procedures * Repair tramatic or congenital lesions
49
Open Thoracic sx: Esophageal sx things to consider about the pt ( like what we are going to worry about)
* Chronic malnutrition r/t Ca illnes and swallowing difficulty * Hypovolemia r/t difficulty swallowing * ETOHism r/t esophageal lesions * Aspiration risk
50
Open Thoracic sx: Esophageal sx what is the monitoring for the sx?
* A-line * CVP and CVL * Foley
51
Open Thoracic sx: Esophageal sx anesthesia choice
* DLT * epidural ANALGESIA intra/post-op * GETA
52
Open Thoracic sx: Esophageal sx sx approach for upper esophageal lesions?
* transverse cervical incision for proximal anastomosis * Right side for thoracic incision * Midline abdominal for resection and closure
53
Open Thoracic sx: Esophageal sx sx approach for middle lesions
ride sided thorocotomy (ivor lewis approach)
54
Open Thoracic Sx: Esophageal Sx sx approach for lower esophageal lesions
extended left thorocoabdominal incision
55
Open Thoracic Sx: Esophageal Sx why are these pt's usually kept intubated post-op?
for aspiration precautions
56
Open Thoracic Sx: Tracheal Resection/Reconstruction what are indications for sx?
* Congenital lesions (agenesis, stenosis) * Neoplasms * Injury * Infections
57
Open Thoracic Sx: Tracheal Resection/Reconstruction Monitoring?
* Left arm A-line * Standard ASA monitors
58
Open Thoracic Sx: Tracheal Resection/Reconstruction what tube do you intubate with?
Small bore anode tube through stenosis ETT through glottis to above stenosis HFJV
59
Open Thoracic Sx: Tracheal Resection/Reconstruction intraop management?
* steroids for tracheal edema * 100% FiO2 * head down position (prevent drainage into lungs)
60
Open Thoracic Sx: Tracheal Resection/Reconstruction what are your goals in the sx
* extubation asap (minimize tracheal trauma) * neck flexedminimize suture tension
61
Open Thoracic Sx: VATS lits like Laparoscopic but with no what?
Insufflation
62
Open Thoracic Sx: VATS what are the benefits
less pain less post op ventilation faster recovery
63
Open Thoracic Sx: VATS what sx are performed through a VAT
* Lung bx/wedge * Pleurodesis/decortication * lobectomy, bi-lobectomy * pneumonectomy * Extraplural-sympathetic denervation
64
Open Thoracic Sx: VATS complications compared to open
* hemorrhage and access * Surgical times
65
Open Thoracic Sx: VATS anesthetic consideretions
* similar to open * monitoring * strict fluid mgmt * positioning
66
Open Thoracic Sx: Lung Transplant Indications
* End stage respiratory failure * Cystic fibrosis
67
Open Thoracic Sx: Lung transplants what we must consider?
* usually emergent (full stomach) * Antibiotics/immunosupressents * Peripheral AV or Venovenous bypass oxygenator * Full cardiopulmonary bypass (???)
68
Open Thoracic Sx: Lung transplants monitoring
* A-line * PA cath *
69
Open Thoracic Sx: Lung transplants operative approach
posterolateral or bilateral subcostal thoracotomy
70
Open Thoracic Sx: Lung transplants GETA * how much O2? * Narcs? * Benzo? * Muscle relaxants?
* 100% fio2 * High Narcs * benza with low dose VAA-amnesia * Muscle relaxants
71
Open Thoracic Sx: Lung transplants lung isolation
* best with contralateral ETT * if Bilat transplant Left sided ETT
72
Open Thoracic Sx: Lung transplants post op, what 4 things must we do? what is the gold standard?
* leave intubated * Ventilated * and sedated * serial ABGs * (Gold standard give to Dr. Keller and let him fix our fuck ups)
73
great job
JACKASS

Principles III (24 decks)

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