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S5 - Principles III - Test 2 > VATS article- surgical procedure section > Flashcards

VATS article- surgical procedure section Flashcards

1
Q

Advantages for VATS procedure compared to open thoracotomy (4)

A
  • decreased blood loss
  • decreased rate of infection
  • decreased post-op pain
  • quicker recovery
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2
Q

What are the 2 primary reasons for V/Q mismatch (think v broad)

A
  1. greater ventilation and less perfusion in non-dependent lung
  2. Greater perfusion and less ventilation in dependent lung
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3
Q

Perfusion favors the dependent or non-dependent lung generally

A

dependent d/t gravity

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4
Q

What factors contribute to decreased ventilation of the dependent lung (3)

A
  • suboptimal positioning
  • compression of the lungs by mediastinum and abdominal contents
  • decreased lung volume associated with GA
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5
Q

Is there a greater or lesser need for OLV with VATS compared to open thoracotomy

A

greater

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6
Q

Principle physiologic change associated with OLV

A

redistribution of lung perfusion between ventilated and non-ventilated lung

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7
Q

Once the lungs are isolated and OLV has initiated all blood flow to the nondependent lung becomes?

A

shunt flow

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8
Q

Allows the redirection of blood flow to alveoli with higher oxygen tension, thereby reducing V/Q mismatch

A

Hypoxic pulmonary vasoconstriction

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9
Q

HPV has been shown to have the greatest benefit when what % of the lung is hypoxic

A

30-70%

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10
Q

Factors known to inhibit HPV (6)

A
  • systemic vasodilators (nitroglycerin, dobutamine, calcium channel blockers, beta-agonists)
  • inhalation anesthetics
  • v high or v low pulm artery pressures
  • hypocapnia
  • high or v low mixed venous pO2
  • pulm infection
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11
Q

Factors that decrease blood flow to ventilated lung and direct blood flow to non-ventilated lung (counteracts HPV)

A
  • high mean airway pressures (PEEP, hyperventilation, PIP)
  • low FiO2
  • vasoconstrictor medications
  • intrinsic PEEP from short expiratory times
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12
Q

Labs for VATS procedure

A
  • CBC
  • metabolic panel
  • glucose
  • renal fxn
  • liver fxn
  • coags
  • blood type and cross match
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13
Q

4 high-risk CV conditions that require additional screening and pre-op treatment

A
  • unstable coronary syndromes
  • decompensated heart failure
  • significant cardiac arrhythmias
  • severe valvular disease
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14
Q

What is the most common pre-op test used to evaluate thoracic disease

A

CXR

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15
Q

PaCO2 associated with increased perioperative risk (for laparoscopic?)

A

> 45mmHg

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16
Q

FEV1 associated with increased perioperative risk

A

< 2L

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17
Q

FEV1/FVC associated with increased perioperative risk

A

< 50% of predicted

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18
Q

maximum breathing capacity associated with increased perioperative risk

A

< 50% of predicted

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19
Q

residual volume/TLC associated with increased perioperative risk

A

> 50%

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20
Q

carbon dioxide diffusion in the lungs associated with increased perioperative risk

A

<60% of predicted

21
Q

5 interventions to optimize pulm fxn pre-op

A
  1. stop smoking
  2. bronchodilator therapy
  3. decrease the viscosity of secretions
  4. secretion mobilazation
  5. adjunct care (pharmacologic and psychologic)
22
Q

Preoperative interventions for patients with lung cancer should be implemented with consideration of the 4 Ms, what are they?

A
  1. mass effects
  2. metabolic effects
  3. metastases
  4. medications
23
Q

Contraindications for VATS (12)

A
  • inability to tolerate OLV
  • inability to tolerate lateral decubitus position
  • hemodynamic instability
  • tumor >6cm
  • chest wall involvement
  • mediastinal involvement
  • coagulopathy
  • T3 tumor
  • N2 disease
  • hilar structure involvement
  • preop chemo or radiation
  • expansive intrapleural adhesions
24
Q

what size tumor is contraindicated for VATS

A

> 6cm

25
Q

If pt had pre-op radiation or chemo can they have a VATS procedure

A

nope

26
Q

2 most common VATS complication

A
  • prolonged air leak

- bleeding

27
Q

prolonged air leak is more likely to occur after what specific procedure

A

lung resections

28
Q

the greater the amount of lung tissue resected the greater the likelihood of

A

prolonged air leak

29
Q

small air leaks are often resolved when

A

reexpansion of the noninflated lung over the course of a few days

30
Q

When is an air leak considered prolonged

A

lasting more than 7 days

31
Q

treatment for prolonged air leak

A

chest tube

32
Q

If bleeding cannot be controlled during VATS what is done?

A

conversion to open thoracotomy

33
Q

The formula for determining insertion depth of DLT

A

patient height in cm/10 + 12cm

34
Q

ideal position for the bronchial cuff of DLT

A

3-5mm beyond carina

35
Q

suggested TV

A

5-6ml/kg with PAP < 35

36
Q

suggested PEEP

A

5cm H20 except with COPD patients

37
Q

suggested RR

A

12-16/min

38
Q

vent mode for patients at risk for lung injuries like pneumonectomy or bullae

A

pressure control

39
Q

In the event of desaturation what steps should be followed to improve PaO2

A
  1. 100% FiO2
  2. bag ventilation
  3. check tube position
  4. CPAP
  5. PEEP
  6. intermittent 2 lung ventilation
  7. ask the surgeon to clamp pulm artery to the nondependent lung
40
Q

The site at greatest risk for injury r.t positioning

A

brachial plexus

41
Q

What can be used to keep weight off the dependent arm

A

chest roll between axilla

42
Q

How should the nondependent arm NOT be positioned

A
  • suspended from arm board or ether screen
  • not abducted
  • not flexed > 90 degrees
  • not extended posteriorly
43
Q

How can excessive fluid administration have a negative impact on patients during VATS (2)

A
  • increases shunting

- pulmonary edema of dependent lung

44
Q

What intra-op pain management option does not affect shunt or oxygenation while also providing excellent analgesia

A

thoracic epidural with GA

45
Q

What is post-op pain management crucial

A
  • facilitates improved resp effort

- decreased potential post-op complications

46
Q

What is the concern with relying solely on IV opioids for post-op pain management

A

respiratory depression

47
Q

What is the current standard analgesic therapy for post-op VATS pain

A

thoracic epidural at the T6-T8 interspace

48
Q

Ipsilateral shoulder pain is common following thoracotomy as a result of what

A

separating the anterior serratus and latissimus dorsi muscles

S5 - Principles III - Test 2 (5 decks)

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