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Anaesthesiology
Choice of Anesthesia for Thoracic Surgery
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
15 sections · 197 slides
Overview
- Scope of this topic
- Roadmap
Choice of anaesthetic agent for one-lung ventilation
- Volatile agents, hypoxic pulmonary vasoconstriction and shunt
- Trials comparing volatile agents with intravenous anaesthesia
- Preconditioning, tight junctions and capillary leak
- The endothelial glycocalyx
- How volatile agents may protect the lung
Tubeless thoracic surgery
- Definition and original concern of tubeless thoracic surgery
- Pompeo's 2004 report
- Thoracoscopic view of the vagus nerve
- Early tubeless case series
- Outcomes with tubeless versus conventional thoracoscopy
- Why avoiding positive pressure and relaxants helps
- Regional techniques used for tubeless surgery
- Choosing the block, sedation and oxygen delivery
- Patient selection and intraoperative problems in tubeless surgery
Robotic thoracic surgery
- Robotic thoracoscopic surgery and its procedures
- Cost, outcomes and postoperative pain with robotic surgery
- Insufflation and tube displacement in robotic surgery
- Double-lumen endobronchial tube
- Patient orientation and bronchoscopic checking
- Robotic versus thoracoscopic lobectomy, and the growth of practice
Anaesthesia for bronchoscopy
- From rigid tubes to fibreoptic bronchoscopes
- Flexible bronchoscopy in progress
- Assessment, equipment and monitoring for bronchoscopy
- Indications for bronchoscopy
- Reading the indications list
- Instruments of choice for bronchoscopy
- Rigid versus flexible: when each wins
- Topical anaesthesia of the mouth and throat
- Anaesthetising the trachea and the nasal route
- Advantages and disadvantages of local anaesthesia
- General anaesthesia technique for bronchoscopy
- The rigid ventilating bronchoscope and apnoeic oxygenation
- Ventilation techniques during rigid bronchoscopy
- Limits of apnoeic oxygenation and leaks around the scope
- Intermittent ventilation and the Sanders injection system
- Sanders system pressures and barotrauma risk
- Advantages and disadvantages of the Sanders system
- Mechanical ventilator and high-frequency ventilation in rigid bronchoscopy
- The flexible fibreoptic bronchoscope: roles and preparation
- Hypoxaemia and supplemental oxygen during flexible bronchoscopy
- Lung function changes and suction through the scope
- Tube size and the end-expiratory pressure effect of the scope
- Jet ventilation and laser resection through the bronchoscope
- Complications of rigid and flexible bronchoscopy
- Intubating the trachea after bronchoscopy
Anterior mediastinal mass
- The problem posed by an anterior mediastinal mass
- Anterior mediastinal mass on chest computed tomography
- Airway compression: reported cases, rates and predictors
- Rescue planning, radiotherapy and children with a mediastinal mass
- Mechanism of airway obstruction under anaesthesia
- Preoperative evaluation pathway for an anterior mediastinal mass
- Following the mediastinal mass evaluation pathway
- Relieving obstruction and the value of spontaneous ventilation
- Airway collapse despite spontaneous ventilation
Mediastinoscopy
- Purpose of mediastinoscopy and tumour side
- How the mediastinoscope is inserted
- Anatomic relationships during mediastinoscopy
- Structures at risk, contraindications and preoperative evaluation
- Anaesthetic technique and autonomic reflexes in mediastinoscopy
- Morbidity and mortality of mediastinoscopy
- Haemorrhage during mediastinoscopy and its management
- Pneumothorax, nerve injury and innominate artery compression
- Recognising innominate artery compression
- Cerebral risk and monitoring during mediastinoscopy
- Other complications of mediastinoscopy
Thoracoscopy and video-assisted thoracoscopic surgery
- Medical thoracoscopy: uses, working space and cough suppression
- Anaesthesia choice and physiology during thoracoscopy
- Double-lumen tubes and video-assisted thoracoscopic surgery
- Video-assisted surgery: therapeutic uses and lung separation
- Achieving lung collapse and recognising insufflation collapse
- Insufflation and hypoxaemia during video-assisted surgery
- Postoperative concerns after video-assisted surgery
High-frequency ventilation
- Gas transport in conventional and high-frequency ventilation
- Types of high-frequency ventilation
- High-frequency positive-pressure ventilation and its delivery systems
- The four lumens of the jet tracheal tube
- Jet ventilation and high-frequency oscillation
- Advantages of high-frequency ventilation and jet versus CPAP
- Why CPAP is preferred, and ventilating a divided airway
Bronchopleural fistula, empyema, cysts and bullae
- Bronchopleural fistula: causes and problems
- Draining an empyema before fistula surgery
- Isolating the affected side in bronchopleural fistula
- Alternative intubation approaches for bronchopleural fistula
- Conservative and differential ventilation for a fistula
- Jet ventilation for a fistula, and lung cysts and bullae
- Selecting patients for bullectomy
- Positive pressure, nitrous oxide and bullae
- Airway management and ventilation settings for bullectomy
- Tension pneumothorax and chest tube risk in bullous disease
- Sequential one-lung ventilation for bilateral bullectomy
- After bullectomy
Tracheal resection and bronchopulmonary lavage
- Tracheal resection: indications, problems and preparation
- Tube techniques for tracheal resection
- High-frequency ventilation for tracheal surgery: use and drawbacks
- Complex resections, positioning and extubation
- Bronchopulmonary lavage: indications and preoperative assessment
- Tube seal and monitoring for lung lavage
- Denitrogenation and oxygenation swings during lavage
- Performing the lavage and judging its endpoint
- Fluid balance and completing the lavage
- Spillage and balloon occlusion during lavage
- Fistula and size limits in lung lavage
Myasthenia gravis
- Why the thoracic anaesthetist meets myasthenia gravis
- Incidence and clinical features of myasthenia gravis
- Patterns of involvement
- Clinical classification of myasthenia gravis
- Using the myasthenia gravis classification
- The neuromuscular junction defect and seronegative disease
- The neuromuscular junction
- Antibodies and diagnostic testing in myasthenia gravis
- The regional relaxant test and antibody testing
- Confirming the diagnosis of myasthenia gravis
- Anticholinesterase therapy and its evidence base
- Anticholinesterase drugs used to treat myasthenia gravis
- Anticholinesterase doses and the two crises
- Distinguishing the two crises
- Immunosuppression and plasma exchange
- Thymectomy: indications, timing and approach
- Preoperative optimisation in myasthenia gravis
- Disorders associated with myasthenia gravis
- Associated disorders and respiratory preparation
- Anticholinesterase and premedication on the day of surgery
- Monitoring and induction in myasthenia gravis
- Neuromuscular effects of inhaled agents in myasthenia gravis
- Sensitivity and dosing of non-depolarising relaxants
- Relaxant choice, reversal and variable sensitivity
- Antibody status and sugammadex in myasthenia gravis
- Succinylcholine in myasthenia gravis
- Rapid-sequence and relaxant-free techniques for thymectomy
- Delayed arousal and drug interactions in myasthenia gravis
- Recovery, extubation and restarting therapy
- Postoperative respiratory failure and its predictors
- Limits of prediction and a newer crisis score
- Predicting and reducing postoperative ventilatory failure
- Postoperative pain relief in myasthenia gravis
- Eaton-Lambert syndrome: features and treatment
- Distinguishing Eaton–Lambert syndrome from myasthenia gravis
- Anaesthetic implications of Eaton–Lambert syndrome
Postoperative pain control
- Pain control and patient-controlled analgesia after chest surgery
- Ketamine and gabapentin as analgesic adjuncts
- Intercostal nerve blocks: technique and limits
- Continuous intercostal and paravertebral catheters
- Epidural catheter set
- Neuraxial opioids versus parenteral analgesia
- Adjuncts and intrathecal morphine
- Neuraxial opioid side effects and preventive analgesia
- Wound infiltration and soaker catheters
- Interpleural analgesia and chronic pain after thoracotomy
- Preventing and treating chronic postthoracotomy pain
- Pain after video-assisted thoracoscopic surgery
- Choosing an epidural for video-assisted surgery
- Choosing analgesia for video-assisted thoracoscopic surgery
- Practice and recommendations for video-assisted surgery analgesia
Complications following thoracic surgery
- Atelectasis: importance and causes
- How postoperative atelectasis develops
- Completing the atelectasis sequence and reversing it
- Extubation and postoperative ventilation
- Preventing atelectasis and positioning for a mucus plug
- Cardiovascular complications and low cardiac output
- Re-expansion oedema and treating myocardial dysfunction
- Postoperative cardiac dysrhythmias and their causes
- Atrial fibrillation and multifocal atrial tachycardia
- Digitalis and newer drugs for rhythm control
- Esmolol, haemorrhage and pneumothorax after chest surgery
- Underwater seal chest drainage unit
- Managing the pleural drainage system safely
- Bronchial stump dehiscence and ventilating around a fistula
- Neurologic injuries and the brachial plexus
- Intrathoracic nerve injuries: recurrent laryngeal and phrenic
Summary
- Key points: anaesthetic agent choice
- Key points: techniques and diagnostic procedures
- Key points: special situations and myasthenia gravis
- Key points: pain and complications
- References
- References (continued)
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- References (continued)
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition