Professional Documents
Culture Documents
OBJECTIVES
The student will
Correlate physiological comorbidity issues with the anesthesia care plan List position considerations specific to these surgical procedures Describe the use of DLT and general considerations Identify factors to prevent exacerbation of pulmonary vasoconstriction
FVC<50% FEV1 <2L FEV1/FVC <50% RV/TLC >50% Diffusing capacity <50% predicted PaCO2 >45 mmHg
PFTS - RESTRICTIVE
PARAMETER FVC FEV1 FEV1/FVC RV/TLC INTRINSIC dec normal normal normal EXTRINSIC dec normal normal increased
PFTS-OBSTRUCTIVE
PARAMETER FVC FEV1 FEV1/FVC RV/TLC asthma normal dec dec inc bronchitis normal dec dec inc emphysem normal dec dec inc
LV DYSFUNCTION CONTRIBUTORS
Hypoxia, hypercarbia, acidosis CAD/valvular disease Systemic hypertension Ventricular interdependence Alterations in intrathoracic pressure
PATIENT EDUCATION
Stop smoking Breathing exercises/mucolytics&expectorants Bronchodilation Aminophylline Cromolyn sodium Parasympatholytics sympathomimetics Weight reduction
INTRAOP GOALS
Minimize anesthesia time Control secretions Prevent aspiration Bronchodilation Intermittent hyperinflation
POSTOP GOALS
Continue preoperative measures Mobilize secretions Early ambulation cough & deep breathing analgesia
Useful with left sided failure (CHF) or supraventricular dysrhythmias with rapid ventricular response
Clinical application Cardiac Mediastinal Major liver/vascular trauma Pericardial tamponade Lung biopsy
PRONE
Distribution of ventilation
Independent lung blood flow increases more rapidly than ventilation
LATERAL DECUBITUS
PATIENT AWAKE, BREATHING SPONTANEOUSLY
Less Zone 1, more zone 2&3 Blood flow to dependent lung >blood flow to independent lung Ventilation greater in dependent lung Diaphragm of dependent lung pushed higher & stretched tighter
LATERAL DECUBITUS
PATIENT ANESTHETIZED, SPONTANEOUSLY BREATHING, CHEST CLOSED
Depend lung better perfused FRC dec both lungs Depend lung becomes less compliant, upper lung becomes more compliant Increase in shunt and dead space ventilation
LATERAL DECUBITUS
PATIENT ANESTHETIZED, PARALYZED, MECHANICALLY VENTILATED, CHEST CLOSED
Depend lung better perfused Vent to nondepend lung even greater Mech vent obviates effect of depend lung diaphragm contraction Weight of abd contents physically restricts expansion of dependent lung
LATERAL DECUBITUS
PATIENT ANESTHETIZED, SPONTANEOUSLY BREATHING, CHEST OPEN
MEDIASTINAL SHIFT PARADOXIC RESPIRATION
LATERAL DECUBITUS
PATIENT ANESTHETIZED, VENTILATION CONTROLLED, CHEST OPEN
OPEN CHEST INCREASES COMPLIANCE OF BOTH LUNGS Airway pressure dec in both lungs CI increases; no change in MAP CO2 elim greater from nondepend lung Dec amt of Zone 1 and dead space ventilation
LATERAL DECUBITUS
ADVANTAGES
Permits most complete access to hemithorax Length of incision can be easily extended Pt can be tilted forward/backward easily Safest position for hilar dissection Permits control of hilar vessels
LATERAL DECUBITUS
Disadvantages
Opposite hemithorax is inaccessible V/Q mismatch Contamination of dependent lung Decrease FRC, airway closure & atelectasis in dependent lung Injury from positioning
ABSOLUTE
Prevention of cross contam diseased to nondiseased lung Redistrib vent Required unilateral bronchopulm lavage
Preexisting cardiopulmonary disease Obesity Advanced age TUMOR: eval for myasthenic syndrome, IADH(seen with small cell) Consider pericardial involve Consider pulmonary hypertension
Re-expand the deflated lung carefully at the conclusion of resection. Positive pressure is held at 35-40 cm H2O to allow surgeon to view suture lines and check to air leaks Extubate(DLT); reintubate with normal ETT, continue emergence as
CONTRAINDICATIONS TO DLT
Lesion along the tubes pathway Difficulty obtaining direct vision intubation Critically ill pts who dont tolerate apnea Full stomach/inc risk of aspiration Any combination of above
REGIONAL/GA
May use combined thoracic epidural with GA Level of thoracic epidural determined by surgery Make sure a band of anesthesia exists after test dose Utilizes min narcotics, lower gas concentrations Enables quicker emergence/recovery with benefits of good analgesia
RIGID BRONCHOSCOPY
Performed for:
Removal FB, massive hemoptysis, dilate tracheobronchial strictures, laser bronchoscopy, stent placement, biopsy and staging of malignant processes, establishment of an emergent airway
RIGID BRONCHOSCOPY
Worry about: Sharing the airway with the surgeon
Requires extremely high vigilance and excellent ongoing communication Ventilating sidearm to maintain oxygenation & ventilation
RIGID BRONCHOSCOPY
Need to know:
Level of the lesion What is the lesion suspect for h/o ischemic processes How do the lungs sound
RIGID BRONCHOSCOPY
Position: sitting or supine Glyco early antisialogogue Routine monitors Usually sedation + topical, spray as go Use short acting drugs Postop hypoxemia will usually correct with supplemental O2 Keep the sedation light to avoid hypoventilation! Remember laser precautions if the laser is the surgical method
FIBEROPTIC BRONCHOSCOPY
Allow evaluation of the tracheobronchial tree deeper than rigid Use for:
Pulmonary disease diagnosis, staging carcinomas, lavage/aspiration of thick secretions in acute atelectasis, transbronchial biopsy and brushings
FIBEROPTIC BRONCHOSCOPY
Risks are related to reasons for procedure. Goes up in patients with comorbidities of cardiac disease, severe hypoxemia and bleeding diathesis. Absolute contraindications may include unstable CV system, current life threatening cardiac arrhythmias, and severe hypoxemia.
FIBEROPTIC BRONCHOSCOPY
Problems during the procedure:
FIBEROPTIC BRONCHOSCOPY
EBL is usually negligible Need to know from surgeon:
Proceed thru ETT? (req 7.5-8.0) Proceed next to ETT? (req 5.0-6.0)
PNEUMONECTOMY
INDICATIONS:
Non-small cell lung CA Drug resistant TB, mycobacterium, fungal infections, necrosis Trauma (last resort)
PNEUMONECTOMY
Preop assessment may include:
How is their respiratory reserve? Check the PFTs Is there Pulmonary HTN? b/o RV dys, valv dis, any arrythmias? Any concommitant CV dis? Hoarseness? May indicate recurrent laryngeal nerve involvement Eaton-Lambert syndrome = muscle wasting; may influence relaxant choice
PNEUMONECTOMY
Preop
Hydration, antibiotics, bronchodilators, place thoracic epidural Monitors: art line, CVP, PA on contralat side DLT
500cc
PNEUMONECTOMY
Anticipate:
Unrecognized flood loss Postop pulmonary edema, atelectasis Dysrhythmias DVT & Pulm Emb occur 20% Persistent air leak Excessive mediastinal shift = life threatening
PNEUMONECTOMY
MEDIASTINAL SHIFTS:
IPSILATERAL
Hypotension, arrhythmias, cardiac herniation, pulmonary edema
CONTRALATERAL
Dec lung function, dec venous return
CHEST TUBES are kept clamped to prevent this: brief unclamp for drainage of flds.
PNEUMOPLASTY
FEV1 PREOP average 25-30% pred 3-6% inhospital mortality 25% morbidity
Procedure goal: 20-30% lungs resect, reshaping diaphragm and chest wall. This allows improve lung recoil (dec LV & inc exp flow)
PNEUMOPLASTY
PREOP
Maximize bronchodil therapy Minimize narcotics Place thoracic epidural Your goal is to extubate in the OR!
PNEUMOPLASTY
Monitors include art line, CVP Prepare for DLT Procedure may begin with FOB by surgeon, then proceed with resection Resection may be unilateral / bilateral best side first Run them dry Remember your PIP
PNEUMOPLASTY
The need for reintubation and ventilation is associated with extremely high morbidity.