Thoracic Specific Procedures Flashcards
Describe the Transhiatal approach to Esophagectomy?
-Through neck and abdomen, hands in the chest, mostly on the left. Surgeon will want OLV or minimum ventilation.
-Often laparoscopic
-Steep reverse T-berg
Describe the Transthoracic approach to Esophagectomy? (Ivor Lewis Approach)
Left thoracotomy (also needs laparotomy)
-Requires OLV
What are indications for Bronchoscopy?
-Laser therapy
-Diagnostic
-Endobronchial stenting
-Airway obstructions (foreign bodies)
-Hemoptysis, secretions removal
-Endotracheal tube positioning
How do you perform a Bronchoscopy?
-Can do it awake with cooperative patient & local anesthetic/tracheal block (Transtracheal/spray)
-Can do it under GA with inhaled anesthetics (peds)
-CO2 is not the limiting factor. O2 is. Remember: PaCO2 increases 6 mmHg the first minute of apnea and 3 mmHg each minute after.
How do you perform Rigid Bronchoscopy?
-Mask ventilate to establish anesthesia plane
-Narcotics
-Ventilate through side arm of scope
-O2 at 100%
-Paralyze if necessary
-Might have to do TIVA otherwise everyone in the room is breathing in volatile agents.
How do you perform Flexible Bronchoscopy?
-8.0-10.0 ETT
-Adaptor for side port ventilation
-High flow 100% O2
-Anesthesia as per length of procedure
-Cut off ETT to shorten if needed (scopes aren’t that long)
What is the positioning for a Thoracotomy?
-Lateral decubitus position
-Remember midline stabilization
-Axillary roll
-Pressure points padded
-Verify DLT placement after turning
-Review effects of anesthesia and position on V/Q
What monitoring is used during Thoracotomy?
-Standard monitors
-Arterial line (dependant arm, if possible)
-2 large bore IV’s
-DLT for OLV
What Regional anesthesia blocks can be used for a thoracotomy?
-Combined general/epidural anesthesia: epidural needs to be thoracic and is for post operative pain control
-Intercostal block (High absorptive area, be careful -risk of LAST)
Describe anesthetic management of a Thoracotomy?
-Limit fluids to volume deficits and maintenance only (Right sided heart pressures are increasing, can cause fluid overload)
-With the fluid overload the added vascular pressure post-op will worsen the lung tissue edema.
-Crystalloids preferred above colloid (colloid pulls more fluids into the lungs)
-Keep fluids < 3 liters if possible
What is Postpneumonectomy Pulmonary Edema?
-Occurs in only 2-4% of cases
-Cases are 50% fatal
-Incidence right > left (3 lobes vs 2 lobes)
-Clinical onset 2-3 days post-op
-Possibly exacerbated by fluid overload
-Not associated with increased PA pressures (no correlation)
-Not responsive to conventional therapies (oxygen, diuretics)
-Possibly related to lymphatic damage, capillary leaking from increased blood flow, and increased airway pressures during OLV
-Atrial Fibrillation: Occurs in up to 50% of patients due to RV strain and increased SNS activity
What post-op complications can occur with Thoracotomy?
-Bronchopleural fistula
-Pulmonary dysfunction
-CV Complications
-Nerve injuries (Phrenic, RLN)
-Persistent air leak (not a good seal on lung tissue or bronchial tree)
What is a Bronchopleural fistula?
-Persistent communication between airway and interpleural space
-Amount of leak is dependent on mean airway pressure
-Air leak, pneumothorax
-Requires surgical intervention: chest tube without suction and lung separation
What cardiovascular complications can occur with Thoracotomy?
-Dysrhythmias
-Heart failure
-RV dysfunction more common with pneumonectomy (increased RV afterload)
What are advantages of thoracoscopic procedures vs open?
VATS: Stapling of blebs; pleurodesis; tumor resections
-less painful than open thoracotomy
-less hypoxemia and atelectasis
-less trauma to tissue
-May be less effective in removing malignant pulmonary tumors thus more recurrence
-Must always be prepared to convert to open
-can be used for most thoracic resections
What is a Pleurodesis?
-Persistent fluid accumulation in the pleura.
-Procedure is to rough up tissue so it’ll adhere to chest wall. Decreases fluid accumulation that is persistent.
-Can use talc powder to irritate tissues.
What are the anesthetic implications for a Thoracoscopic procedure?
-Same monitoring and lines as open procedure (Art line to monitor pressures/ABGs)
-DLT for OLV (need to drop lung early to prevent damage from port insertion)
-Lateral decubitus position
What Tracheal Surgeries fall under the category of Thoracotomies?
Tracheal or bronchial stenting:
-Critical airway stenosis
-Maintain spontaneous respirations vs. paralysis
Tracheal reconstruction
What is Mediastinoscopy?
Mediastinoscopy is used to check for spread of pulmonary tumors and other mediastinal masses.
-Give easy access to right side of chest
-More difficult access to left side (may consider Chamberlain procedure - enters through chest wall above suprasternal notch)
-Gives access to the mediastinal lymph nodes and is used to establish diagnosis or to determine the resectability of intrathoracic masses.
Describe insertion of the Rigid Mediastinoscope
-Rigid instrument inserted above the sternal notch
-In proximity to several great vessels
-Important to have large bore IV access in case of significant blood loss
-Scope will go under the Right Innominate Artery (supplies blood to the brain)
-Patients are paralyzed - must be absolutely still
Where should you place the arterial line for a Mediastinoscopy?
Place art line on right side. Need to make sure you’re still flowing to blood. If you lose art line, they’ve lost/restricted blood flow to the right common carotid.
Nagelhout:
-The mediastinoscope can place pressure on the innominate (brachiocephalic) artery prior to its division into the right common carotid artery and right subclavian artery. This can cause decreased blood flow to the right common carotid artery and right vertebral artery, and decreased right subclavian blood flow to the right arm.
-The decrease in cerebral flow can cause an acute ischemic stroke, especially if the patient has a history of cerebrovascular disease. Monitoring perfusion to the right arm with a pulse oximeter or radial artery catheter can detect decreased flow to the right arm and signal concurrent loss of flow to the brain via innominate artery compression. Repositioning of the mediastinoscope is required to reestablish flow to the brain. A noninvasive blood pressure cuff placed on the left arm enables continued monitoring of systemic blood pressure during periods of innominate artery compression.
What are potential contraindications to a Mediastinoscopy?
1) Previous mediastinoscopy
-Can only be done once
-Scarring issues increase risk of bleeding
-If doing another one within a few weeks of first one, probably don’t have scar tissue yet so might be ok. Any longer than that, they will push through scar tissue and inadvertently into aorta.
2) Distorted anatomy
-Tracheal deviation
-Thoracic aortic aneurysm
-Superior vena cava obstruction (Engorged vessel, obstruction)
-Impaired cerebral circulation
-Signs/Symptoms of Eaton-Lambert Syndrome
What are the two major perioperative concerns that can occur with a Mediastinoscopy?
-Airway collapse on induction
-CV collapse on induction
What can cause the airway to collapse on induction during a Mediastinoscopy?
Airway collapse on induction can happen if the mass is located in such a way that relaxation will collapse the trachea.
-Check for ability to lie supine and if any cough or SOB is present.
-If superior vena cava syndrome is present, the patient may have significant airway edema.
-If suspected have PFT with flow volume loops done. Always have a CT or MRI.
Nagelhout:
-Tumors within the anterior mediastinum can cause compression of the trachea or bronchi, increasing resistance to airflow. Changes in airway dynamics with supine positioning, induction of anesthesia, and positive pressure ventilation can cause collapse of the airway with total obstruction to flow. General anesthesia can therefore be very dangerous in these patients. Total airway obstruction can occur at any phase of anesthesia and through the recovery phase. To anticipate this potential, anesthetic preparation should include the availability of a rigid bronchoscope and readiness to turn the patient lateral or prone in case of airway collapse. Cannulation for potential emergency femoral-femoral bypass should be considered if the tumor is large or if the patient becomes symptomatic.
