Quiz 9 Anesthesia for Thoracic Procedures Flashcards
1
Q
What is high risk of pulmonary function criteria:
A
- FVC < 50%
- FEV < 2L
- FEV1/FVC < 50 %
- RV/TLC > 50 %
- Diffusing capacity < 50 % predicted
- PaCO2 > 45 mmHg
2
Q
What are the restrictive INTRINSIC parameters of FVC, FEV1, FEV1/FVC, and RV/TLC:
A
- FVC - Decreased
- FEV1 - Normal
- FEV1/FVC - Normal
- RV/TLC - Noraml
3
Q
What are the restrictive EXTRINSIC parameters of FVC, FEV1, FEV1/FVC, and RV/TLC:
A
- FVC - Decrease
- FEV1 - Normal
- FEV1/FVC - Normal
- RV/TLC - Increased
4
Q
What are the OBSTRUCTIVE asthma parameters of FVC, FEV1, FEV1/FVC, and RV/TLC:
A
- FVC - Normal
- FEV1 - Decrease
- FEV1/FVC - Decrease
- RV/TLC - Increased
5
Q
What are the OBSTRUCTIVE bronchitis parameters of FVC, FEV1, FEV1/FVC, and RV/TLC:
A
- FVC - Normal
- FEV1 - Decrease
- FEV1/FVC - Decrease
- RV/TLC - Increased
6
Q
What are the OBSTRUCTIVE emphysema parameters of FVC, FEV1, FEV1/FVC, and RV/TLC:
A
- FVC - Normal
- FEV1 - Decrease
- FEV1/FVC - Decrease
- RV/TLC - Increased
7
Q
What are the clinical S/S of Pulmonary Hypertension, Right Ventricular Hypertrophy, and Cor Pulmonary
A
- Prominent neck veins
- Prominent neck A and V waves on EKG
- Prominent left parasternal heave and rocking motion synchronous with heartbeat may be noted
- Auscultate: pulmonary component of 2nd heart sounds increases
- High pitched, early systolic ejection click
- Systolic ejection murmur
- R sided atrial S4 gallop indicating increased RVEDP
- Mid diastolic R sided S3 gallop, usually clear evidence of impaired RV function Differentiated: gallops increased in intensity with inspiration
- Early diastolic pulmonary regurg murmur and functional impair secondary to dilation of PA root
- Right heart failure with chronic dependent edema, large tender liver, ascites, dilated distended neck veins
8
Q
What does a CXR show in Pulmonary hypertension?
A
- Main pulmonary vessels dilated
- Characteristic of COPD with hyperinflated lungs, low flat diaphragm
- Evidence of RVH; clockwise cardiac rotation, loss of air space behind the sternum on a lateral view
9
Q
What are the contributors of Left dysfunction contributors;
A
- Hypoxia, hypercarbia, acidosis
- CAD/valvular disease
- Systemic hypertension
- Ventricular interdependence
- Alterations in intrathoracic pressure
10
Q
What are the preparation of patient for surgery with pulmonary hypertension:
A
Patient education
- Stop smoking
- breathing exercises/mucolytics & experctorants
- Bronchodilation
- Weight reduction
11
Q
What kinds of meds are used for bronchodilation for a pateint with pulmonary hypertension?
A
- Aminophylline
- Cromolyn sodium
- Parasympatholytics
- Sympathomimetics
12
Q
What are the intraoperative goals for pulmonary hypertension?
A
- minimize anesthesia time
- Control secretions
- Prevent aspiration
- Bronchodilation
- Intermittent hyperinflation
13
Q
What are the post op goals for pulmonary hypertension?
A
- Continue preoperative measures
- Mobilize secretions
- Early ambulation
- Cough and deep breathing
- Analgesia
14
Q
What is a sympathomimetic?
A
-Beta agonists that increase formation of cyclic-AMP = bronchodilation
15
Q
What are some names of sympathomimetics?
A
- Metaproterenol
- Albuterol
- Terbutaline
16
Q
What do Parasympatholytics do?
A
-decrease intracellular levels of cyclic-GMP, which modulate bronchoconstriction
17
Q
What are some names of parasympatholytics?
A
- Atropine
- Ipratropium Bromide
18
Q
What do Phosphodiesterase inhibitors do?
A
-inhibit enzymatic breakdown of Cyclic-AMP, which increases cellular levels
19
Q
Give the name of a phosphodiesterase inhibitor.
A
-Aminophylline
20
Q
What is the therapeutic blood levels, Loading dose, and Continous infusion dose of aminophylline?
A
- Blood levels = 5-20 ucg/ml
- Loading dose = 5-7 mg/kg infused over 20 min
- Continous infusion 0.5-0.7 mg/kg/hour
21
Q
What does Steroid do in the lungs?
A
-reduce mucosal edema and suppress inflammation
22
Q
What steroid is the choice for pulmonary hypertension?
A
Beclomethasone
23
Q
What does cromolyn sodium do in the lungs:
A
Mast cell stabilizer preventing degranulation and release of histamine
24
Q
What is digitalis good for?
A
Useful with left sided failure (CHF) or supraventricular dysrhythmias with rapid ventricular response.
25
What are the clinical application of a patient in a position of supine and prone?
- Cardiac
- Mediastinal
- Major liver/vascular trauma
- Pericardial tamponade
- Lung biopsy
26
What are the clinical application of a patient just in prone postion?
-Anytime there is a desire to prevent flooding to tracheobronchial tree during procedures (TB, pulmonary abscess)
27
What are the clinical applications of a patient in lateral decubitus position?
- Standard thoracotomy position
| - Improves exposure in certain cardiothoracic, vascular, or gastroesophageal procedures
28
Lateral decubitus position, awake and spontaneously breathing: More or less zone 1? More or less zone 2 & 3?
Awake Lateral Decub - Less zone 1 and more zone 2, 3.
29
A spontaneously breathing pt is in lateral decub position. Is ventilation & perfusion better to the dependent or independent lung?
Dependent lung
30
What is the diaphragm like in the awake pt in lateral decub?
Diaphragm on dependent side is pushed higher and stretched tighter
31
In the anesthetized, spontaneously breathing pt, which lung is better perfused? Which one is better ventilated? Which lung is less compliant?
Better perfused - depend lung
Better ventilated - independent lung
Less compliant - dependent lung
32
In the anesthetized pt in the lateral decub position, do they have an increase or decrease in shunt and dead space ventilation vs the awake pt?
Increase in shunt and dead space
33
The anesthetized pt in lateral decub position is being mechanically ventilated - is there any difference between vent/perf in the anesthetized spontaneously breathing pt?
Dependent lung still better perfused but poorly ventilated
| - Independent lung now has greater ventilation but poorly perfused.
34
The anesthetized pt in lateral decub position is being mechanically ventilated - what is different about the diaphragm?
mechanical ventilation obviates the effect of dependent lung diaphragm contraction
35
The anesthetized pt in lateral decub position is being mechanically ventilated - how does the weight of abdominal contents play on breathing?
restricts the expansion of the dependent lung
36
The anesthetized pt in lateral decub position is being mechanically ventilated AND his chest is open - how is lung compliance AND airway pressures be affected?
Both lungs will have INCREASE compliance and decreased pressure
37
The anesthetized pt in lateral decub position is SPONTANEOUSLY BREATHING AND his chest is open - what will be different about their mediastinum and respirations?
Mediastinal Shift
| Paradoxic Respiration
38
The anesthetized pt in lateral decub position is being mechanically ventilated AND his chest is open - how will their Cardiac Index and MAP be affected?
Increased CI
| No change in MAP
39
The anesthetized pt in lateral decub position is being mechanically ventilated AND his chest is open - how will their Zone 1 and dead space be affected?
both will be decreased
40
The anesthetized pt in lateral decub position is being mechanically ventilated AND his chest is open - how will CO2 elimination from independent lung be affected?
CO2 elimination will be greater from independent lung
41
What is an advantage to lateral decub position for chest surgery?
- Permits complete access to hemithorax
| - Great for accessing Hilar vessels
42
Disadvantages to lateral decub for chest surgery?
- Opposite hemithorax is inaccessible
- V/Q mismatch
- Contamination of dependent lung
- decrease FRC, airway closure & atelectasis to dependent lung
43
When separating ventilation to the lungs using a DLT, which tube is more commonly used, Left or Right?
Left tube almost always
44
If you had a pt in lateral decub but didn't want to contaminate the dependent lung with infected material from the independent lung, what could you do?
Intubate using a dual lumen ET tube (DLT)
45
What are 3 absolute reasons for lung separation?
- prevent contamination of disease to non-diseased lung
- Redistribution of ventilation
- pt requires unilateral bronchopulmonary lavage
46
what are some things that can put a pt scheduled for thoracotamy at increased risk for cardiopulmonary failure or death?
- Prexisting cardiopulmonary disease
- Obesity
- Advanced age
- Tumor: IADH (small cell), evaluation for myasthenic disease
- Pulm HTN
47
What are 2 things to avoid in GA to one lung?
- N2O
| - Hypoxemia
48
Monitoring during one lung anesthesia will require what two monitors?
- CVP for infusing vasoactives
| - Arterial line
49
What anesthetic drug may be a good choice for infusion during one lung anesthesia?
Ketamine infusion
50
During one lung ventilation, why could repositioning be a concern?
position changes could dislodge your dual lumen ET tube.
51
Hypoxia during one lung ventilation - what steps should you take during hypoxia?
1. Increase FiO2 to 100%
2. Hand bag the pt to check for compliance change
3. Give more volume to pt
4. confirm tube placement with fiber optic scope
5. CPAP to INDEPENDENT lung
6. PEEP to DEPENDENT lung
7. reinflate the independent lung
8. If all else fails, have surgeon cross clamp the pulmonary artery to independent lung
52
What is the purpose of cross clamping the pulmonary artery of the independent lung?
All blood will go to the dependent lung and should decrease shunt
53
Aside from a difficult airway and not being able to place a DLT, what is another major contraindication to DLT placement?
Lesion along the tube's pathway
54
Other contraindications to DLT besides lesion in airway and difficult airway?
- Critically ill pt's who won't tolerate apnea
| - Full stomach
55
What is the benefits to using a thoracic epidural along with GA for thoracic procedures?
- Uses minimal narcs and lower MAC
| - Quicker emergence/recovery with good analgesia
56
Why would a rigid bronchoscopy be performed?
Removal FB, massive hemoptysis, dilate tracheobronchial strictures, laser bronchoscopy, stent placement, biopsy and staging of malignant processes, establishment of an emergent airway
57
What are some big worries associated with doing a rigid bronchoscope?
Sharing the airway with the surgeon
- Arrythmias
- HTN
- Hypoxemia
58
What medication might be given early during bronchoscopy to prevent salviation?
Robinul 0.2mg
59
What positions are used for bronchoscopy?
sitting or supine
60
What types of meds are used for comfort during a bronchoscopy?
sedation and topicals (spray as you go)
| **keep sedation light to avoid hypoventilation**
61
Postop hypoxemia will usually correct with supplemental oxygen (T/F)
True
62
What is the advantage of fiberoptic to rigid bronchoscope?
Fiberoptic allows for evaluation of the tracheobronchial tree deeper than the rigid
63
What instances would you use fiberoptic bronchoscopy?
Pulmonary disease diagnosis, staging carcinomas, lavage/aspiration of thick secretions in acute atelectasis, transbronchial biopsy and brushings
64
absolute contraindications to fiberoptic bronchoscopy include...
- Unstable CV system
- life threatening arrythmias
- severe hypoxemia
65
Coughing, hypertension, and tachycardia are usually related to ______ _______ during the bronchoscopic procedure.
Inadequate anesthesia
66
Why may you need to go to one lung ventilation during fiberoptic bronchoscopy?
If bleeding develops
| **EBL is typically negligible in most cases
67
when performing a fiberoptic bronchoscopy, the surgeon wants to proceed through the ET tube. What size tube would be optimal?
7.5-8
68
when performing a fiberoptic bronchoscopy, the surgeon wants to proceed next to the ET tube. What size tube would be best in this situation?
5-6
69
What are some indications for pneumonectomy?
```
Non-small cell CA
Drug resistant TB
Mycobacterium
Fungal infections
necrosis
Trauma (as a last resort)
```
70
If a pt has Eaton-Lambert syndrome - how might this affect your anesthesia?
Eaton Lambert is a muscle wasting syndrome - may affect your muscle relaxants
71
When performing a pneumonectomy, how much fluids should you be willing to give the pt intraoperatively?
Run them dry - try to keep fluids under 500cc but no more than 1500cc
72
During pneumonectomy, what does an ispilateral mediastinal shift represent?
hypotension
arrhythmias
cardiac herniation
pulmonary edema
73
During pneumonectomy, what does a contralateral mediastinal shift represent?
Dec lung fxn
| dec venous return
74
During pneumonectomy chest tubes are used to prevent __________?
mediastinal shift
75
During pneumonectomy, why would you unclamp a chest tube?
for drainage of fluids (briefly unclamp)
76
Why would someone have lung reduction or pneumoplasty?
- alternative to lung transplant for terminal emphysema
