Mod XI: THORACIC SURIGICAL PROCEDURES Flashcards Preview

8361 Exam 4 > Mod XI: THORACIC SURIGICAL PROCEDURES > Flashcards

Flashcards in Mod XI: THORACIC SURIGICAL PROCEDURES Deck (33)
Loading flashcards...
1
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Major cause of morbidity and mortality in this patient population

A

Pulmonary complications

None of the complications can be predicted by pulmonary function studies

Research findings are limted in their ability to predict specific findings

Atelectasis, pneumonia, and respiratory failure occur in 15-20% of patients

2
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Lung surgeries are performed on a wide variety of pts including. Morbidly obese, end-stage COPD, advanced age (No maximal age cutoff for pulmonary surgical candidates) - What makes this possible?

A

Advances in surgical techniques, including the use of Video Assited Thoracospic Surgery (VATS)

VATS helped decrease incidence of post-op complications

3
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Diagnostic procedures

A

Bronchoscopy, mediastinoscopy, open-lung biopsy

4
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Plethora of indications for thoracic surgery

A

Thoracic malignancies

Chest trauma

Esophageal disease

Mediastinal tumors

Many procedures performed thoracoscopically

5
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

A

EKG

To assess for Ischemia, RVH

Echocardiogram

Assess for RVH, pulmonary HTN, ischemia

Chest radiograph

Findings indicative of COPD: hyperinflation, increased AP diameter, diaphragmatic flattening

Assess for tumor infringement on vascular structures, CHF, or pneumothorax

Ventilation-Perfusion Assessment

Great tool for the prediction of postresection pulmonary function

Should be considered for any patient who is to undergo pneumonectomy

Removal of the diseased portion of the lung may not decrease overall lung function, but may actually improve it

6
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

EKG

A

To assess for Ischemia, RVH

7
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Echocardiogram

A

Assess for RVH, pulmonary HTN, ischemia

8
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Chest radiograph

A

Findings indicative of COPD: hyperinflation, increased AP diameter, diaphragmatic flattening

Assess for tumor infringement on vascular structures, CHF, or pneumothorax

9
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Ventilation-Perfusion Assessment

A

Great tool for the prediction of postresection pulmonary function

Should be considered for any patient who is to undergo pneumonectomy

Removal of the diseased portion of the lung may not decrease overall lung function, but may actually improve it

10
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Remember that extent of pulmonary surgery correlates inversely with the intraoperative PaO2 - Between Pneumonectomy, Lobectomy and Segmentectomy, the pt undergoing which thoracic surgery will have a higher PaO2? why?

A

PaO2 higher in pneumonectomy > lobectomy > segmentectomy

This is said to be related to the amount of perfusion into the diseased lung, as perfusion and thus shunting during OLV will be diminished with the higher amount of the lung that is diseased

The more diseased the lung, the less amount of lung tissue partaking in perfusion. The amount of shunting that will occur is dependent on the perfusion. If perfusion is low, shunting will also be low and one lung ventilation may not cause as much hypoxemia as compared to a lung with less disease and more perfusion.

If perfusion is low, shunting will be less. If perfusion is higher, shunting will be greater. Shunting = BAD, but perfusion is good.

11
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

All patients to undergo thoracic surgery should have basic Pulmonary function testing performed - No single pulm function measurement provides an averall risk assessment - So a multi-modal approach should be taken, and the approach should consider

A

Respiratory mechanics

Gas exchange

Cardiopulmonary reserve

12
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

What’s the single Most valid test for predicting post-thoracotomy respiratory complications?

A

Predicted Postoperative FEV1 % (ppoFEV1)

aka (respiratory mechanics)

When compared to FEV1, FVC, MVV, RV/TLC

13
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

The general cut-off value for predicting increased risk is a Predicted Postoperative FEV1 % values of:

A

Postoperative FEV1 % values < 40% => Increased risk for postresection complications,

Postoperative FEV1 % values <30% => high risk

14
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Measurement of gas exchange that Deals with actual gas exchange at the alveolar/capillary level

A

Lung Parenchymal Function

15
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Historically, an arterial blood gas was used to assess the gas exchange capacity of the lungs - Why is arterial blood gas no longer used to assess the gas exchange capacity of the lungs?

A

Research has found that cancer ressections have been successfully performed in pts who did not meet the arterial blood gas cutoff criteria

16
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Since the arterial blood gas is no longer used to assess the gas exchange capacity of the lungs, which is now considered the most useful test for of the gas exchange capacity of the lungs

A

The Diffusing Capacity of the Lung for Carbon Monoxide (DLCO)

DLCO correlates with total functioning surface area of the alveolar to capillary interface

Measures the efficiency of the gas transfer characteristics of the lungs

Values <40% = increased risk

17
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

The communication between the respiratory and the cardiovascular systems is also known as:

A

Cardiopulmonary Reserve

•May be considered the most important assessment of respiratory function

18
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Which is considered the “gold Standard” assessment for Cardiopulmonary function?

A

Cardiopulmonary exercise testing, with

Maximal Oxygen Consumption (VO2max) being the most useful predictor of post-thoracotomy outcome

19
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Which component of Cardiopulmonary exercise testing is the the most useful predictor of post-thoracotomy outcome

A

Maximal Oxygen Consumption (VO2max)

20
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Risk assessment - Which VO2max values are associated with increased mortality?

A

High risk = VO2max < 15 mL/kg/min

Low risk = VO2max > 20 mL/kg/min

21
Q

PREOPERATIVE EVALUATION FOR THORACIC PROCEDURES

Complete laboratory exercise testing is expensive - Alternatives to it include:

A

The distance COPD patient can walk during 6-minute test

That distance in meters divided by 30 correlates with the maximum oxygen consumption mL/kg/min VO2max

Patient unable to walk 450 meters= VO2max = 15mL/kg/min

Ability to climb five flights of stairs

Ability to climb five flights of stairs correlates with VO2max >20 mL/kg/min

Ability to climb 2 flights of stairs correlates with VO2max 12 mL/kg/min

22
Q

OTHER PREOPERATIVE CONSIDERATIONS

Routine screening of Ischemia for lung ressection not cost-effective - Noninvasive testing is warranted for patients with

A

Clinical predictors of myocardial risk

23
Q

OTHER PREOPERATIVE CONSIDERATIONS

Optimization for ischemia prior to surgery includes:

A

Coronary angioplasty

CABG before or during lung resection

Medical management

24
Q

OTHER PREOPERATIVE CONSIDERATIONS

Delay of lung resection for how long after myocardial infarction, bare metal stenting, drug-eluting stenting

A

4-6 weeks after myocardial infarction,

4-6 weeks after bare metal stenting,

12 months after drug-eluting stenting

25
Q

OTHER PREOPERATIVE CONSIDERATIONS

Renal dysfunction - Significant increases in serum creatinine associated with

A

Prolonged length of stay

Was previously correlated with a high mortality rate

Studies now show that they are a/w prolonged stay, but not necesseraly high mortality

Significant increases in serum creatinine associated with prolonged length of stay

26
Q

OTHER PREOPERATIVE CONSIDERATIONS

Pulmonary complications are decreased in patients who cease smoking for

A

more than 4 weeks before surgery

27
Q

OTHER PREOPERATIVE CONSIDERATIONS

Smoking: concentrations of which hemoglogin varriant is decrease if smoking stopped > 12 hours prior to surgery

A

Carboxyhemoglobin

28
Q

INTRAOPERATIVE MONITORING FOR THROACIC SURGERY

Goal if monitoring is:

A

To quickly recognize sudden and severe changes in ventilation and hemodynamics

29
Q

INTRAOPERATIVE MONITORING FOR THROACIC SURGERY

EKG

A

Five lead EKG with precordial lead in V5 position should be used

The V5 precodial position is the most sensitive site for ischemia identification

However, depending on the side of the surgery and the position of the pt, this lead may not be able to placed correctly in the correct position

30
Q

INTRAOPERATIVE MONITORING FOR THROACIC SURGERY

Arterial pressure monitoring

A

Recommended

Preferrably on the opposite side of the surgical site

Because of the lateral decubitus position, placing the a-line in the non dependent arm can result in falsely low BPs

The arterial line should be placed in the dependent side

The NIBP cuff should be place on the non-dpendent side

31
Q

INTRAOPERATIVE MONITORING FOR THROACIC SURGERY

CVP monitoring

A

May not be indicated in all pts

Should be considered in pts where a large blood loss is suscpected

32
Q

INTRAOPERATIVE MONITORING FOR THROACIC SURGERY

Pulmonary artery catheters

A

Typically not placed ( - > +)

If one is placed, use caution with interpretation of these numbers

Numbers may be incorrect with the pt in the lateral position

Also potential that the OLV will change the compliance of the pul vessels, which will make the wedge pressure an inaccurate assessment of LV pressure

33
Q

INTRAOPERATIVE MONITORING FOR THROACIC SURGERY

Fiberoptic bronchoscopy

A

Should be present at all times

Used to place DLT

Will be needed for any repositioning or to confirm placement if OLV cannot be maimtained