Thoracic sx (final) typical anesthetic for open thorax Case as follows.... Newby

Question 1

Preinduction:

what do you do pre-induction! this is your pt you are the sole provider don;t fuck this up!! you have already reveiwed everything and your in the room with the pt on the table!! ready set go!!

Answer 1

• place lumbar epidural catheter
• Administer test dose of 3 ml lidocaine 1.5% w/ epi 1:200K
• if no HYPOtension
• then confirm funtioning epidural cath

Question 2

Induction:

Answer 2

• Standard induction
• Intubate with SLT >8mm
  
  • this will be replaced with DLT after Brochoscopy

Question 3

ok great now thats done and the pt has a DLT in place what position do you want to place pt in?

Answer 3

lateral and flexed on table

Question 4

ok now what do you do after the pt is positioned (since noone else in the fucking room is smart enough to give a fuck)

Answer 4

• secure tubes and lines
• take complete fucking control of ALL turning procedures
• proper Padding and assessment of PP
• Head, neck and eyes in neutral position ( i don’t know how you make the eyes neutral but thats what his ppt. says)
• Padding for axilla and lower extremities
• REASSESS BREATH SOUNDS, VS, monitors, A-line, PA lines, and IVs

Question 5

what is the maintenance of anesthesia

Answer 5

• O2 and Iso (1.0-1.5%)
  
  • less if using epidural)
• Avoid N2O, especially during OLV
• FiO2 100%
• Lidocaine 10 ml via lumbar epidural Q 45 min (or your choice)

Question 6

Intraop lung isolation (ehy?)

Answer 6

• to prevent contralateral contamination
• allow selective ventilation

Question 7

Intraop

Blood and fluid requirements

Answer 7

• restrict IV fluids
  
  • 1-1.5L NS/LR total
• +/- 1 unit autologous blood
• use vasopressers if hypotensive
  
  • ephedrine 5-10mg
  • Phenylephrine 50-100 mcg bolus

Question 8

Emergence:

Answer 8

• prior to closing chest- inflate lungs to 30-40cmH2O to reinflate atelectactic areas and check for leaks
• surgeon inserts chest tube
• pt extubated in OR, or exchange DLT for SLT if pt is to remain intubated
• Chest tubes to water seal and 20cmH2O suction
  
  • **except for pneumonectomy -water seal only**
• pt transfered in HOB elevated to ICU on monitors and Non-rebreathing Mask

Question 9

Post op complications you should look for?

Answer 9

• Airway trauma (from intubation)
• tracheobronchial rupture
• positioning injuries (pressure damage to ears, eye, nose, deltoid, iliac crest)
• Structural injuries (r/t thorocotomy- neurological, thoracic duct, spinal cord, brochopleural fistula
• Sugical complications (Cardiac herniation, tension Pneumo, Bleeding)
• Cardiopulmonary complications (pne, SVT, PE)

Question 10

yep you just did the whole case!!! great job

Answer 10

Noodle arms would be proud