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Lesson 281: PreAnesthetic Assessment of
the Patient For Lung Resection |
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Course Authors:
John R. Brenner, DO, Resident, Department of
Anesthesiology, University of Texas Health Science Center, San
Antonio, Texas
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Registration Fee: $15.00
2.0 AMA PRA Category 1 CreditsTM
available until August 31, 2010
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Reviewed By:
John S. Richardson, MD, Assistant
Professor, Department of Anesthesiology, University of Texas
Health Science Center, San Antonio, Texas
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Michael Little, MD, Instructor, Department
of Anesthesiology, University of Texas Health Science Center, San
Antonio, Texas
Review Date: February, 2009
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REGISTRATION INFORMATION:
Participants who do not possess a copy of Anesthesiology News
can download and print the course material in an easy to read
convenient format. Participants must reflect on the information
presented, and then register to complete the exam and course evaluation
online before the availability date listed above. (CME credit is not valid past this
date).
Click on the link below to download and print the course material
and post-test exam.
Register for the exam to enter your responses to receive CME credit. There are ten questions in the examination and you must achieve
a score of 80% or better to earn CME credit. Following successful
completion, your certificate will be immediately available online.
In addition, a historical record of completed CME courses is
maintained online in an individualized profile. This includes
copies of course certificates which can be printed at any time.
The registration fee for this course is $15.00
Physicians are provided with two opportunities to successfully complete the
exam presented here.
Software Requirements: Adobe Acrobat Reader and any standard
Internet Browser.
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NEEDS STATEMENT
Lung cancer continues to be the leading cause of cancer
mortalities in men and women. Improvements in the surgical treatment
of this deadly disease have increased the number of patients
admitted for lung resection surgery, including both lobectomy and
complete pneumonectomy. Cardiothoracic anesthesiologists as well as
general anesthesiologists should be familiar with the often
complicated management of these cases.
CASE HISTORY
A 60-year-old obese man with a history
of significant tobacco abuse (more than 50 pack-years), chronic
obstructive pulmonary disease, pulmonary hypertension, systemic
hypertension, type 2 diabetes, and chronic renal insufficiency was
evaluated for dyspnea on exertion; a right lower-lobe lung mass was
discovered. The patient was admitted for a video-assisted
thoracoscopic surgical biopsy of the lung mass, and possible
thoracotomy and lobectomy. A preoperative evaluation was significant
for the following: The patient was 78 inches tall and weighed 133
kg. His vital signs were as follow: heart rate, 75 beats/min; blood
pressure, 120/72 mm Hg; temperature, 98.4°F; respiratory rate, 18
breaths/min; SpO2, 96% on 2 L through a nasal cannula. Physical
examination findings included a Mallampati class I airway with an
oral opening of 5 cm and a temporomandibular distance greater than 5
cm. Lung auscultation revealed decreased breath sounds especially at
the right base, retractions, and a prolonged expiratory phase.
Computed tomography (CT) of the chest revealed a spiculated nodule
15-mm wide in the right lower lobe. Pulmonary function test results
were forced expiratory volume in 1 sec (FEV1), 2.04 L (42% of
predicted); forced expiratory flow 25%-75%, 0.54 L per second (11%
of predicted); diffusion capacity of the lung for carbon monoxide (DLCO),
61% of predicted. Echocardiography revealed moderate right atrial
and ventricular dilation, preserved left ventricular end diastolic
function, and no significant valvular abnormalities. Catheterization
of the right side of the heart determined that pulmonary artery
pressure was 60/26 mm Hg. A thallium stress test found mild apical
ischemia and ejection fraction of 70%. Electrocardiography (ECG)
revealed sinus bradycardia (54 beats/min). Laboratory test results
were blood urea nitrogen, 52 mg/dL; creatinine, 2.4 mg/dL;
urinalysis, 3+ protein; all other results were within normal limits.
LEARNING OBJECTIVES
At the end of this activity, the participant should be able to:
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Identify findings of concern from
preoperative chest x-rays and electrocardiograms.
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Outline the stepwise process of a
preoperative evaluation to determine a patient’s ability to
tolerate lung resection.
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Cite pulmonary testing parameters
that indicate a high risk of lung resection.
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Describe different methods and
equipment available for lung isolation.
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Select the proper type and size of
device for lung separation.
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Review the special considerations
for use of a right-sided double-lumen endotracheal tube.
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Explain how to verify that lung
isolation has been achieved.
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Discuss optimal ventilator settings
during lung isolation.
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List the differential diagnosis for
oxygen desaturation during lung isolation.
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Describe techniques for treating
oxygen desaturation during lung isolation.
TARGET AUDIENCE: Anesthesiologists
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Accreditation Statement
Mount Sinai School of Medicine is accredited by the Accreditation
Council for Continuing Medical Education (ACCME) to provide continuing
medical education for physicians.
Credit Designation: The Mount Sinai School of Medicine designates
each educational activity for a maximum of 2 AMA PRA Category 1 CreditsTM.
Physicians should only claim credit commensurate with the extent of
their participation in the activity.
It is the policy of Mount Sinai School of Medicine to ensure objectivity,
balance, independence, and scientific rigor in all CME-sponsored educational
activities. All faculty participating in the planning or implementation
of a sponsored activity are expected to disclose to the audience any
relevant financial relationships and to assist in resolving any conflict
of interest that may arise from the relationship. Presenters must
also make a meaningful disclosure to the audience of their discussions
of unlabeled or unapproved drugs or devices.
Disclosures
The authors, reviewer, and editor have no relationships with
pharmaceutical companies or manufacturers of products to
disclose. This educational activity may contain discussion of
published and/or investigational uses of agents for the
treatment of disease. Some uses of these agents have not been
approved by the FDA. Please refer to the official prescribing
information for each product for approved indications,
contraindications, and warnings.
CONTACT INFORMATION
Questions regarding course content may be directed to Dr. Elizabeth
Frost: ElzFrost@aol.com.
If you require technical assistance with completing this
course, please contact Continuing Education Online Customer Service
at 718-648-8080 or send e-mail to
ceo.contact7@proceo.com.
CALL FOR WRITERS
If you would like to write a CME lesson in Anesthesiology News,
please send an e-mail to Elizabeth A.M. Frost, MD, at
ElzFrost@aol.com
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