Hensley's Practical Approach to Cardiothoracic Anesthesia

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IV. Thoracic Anesthesia

IV. Diagnostic Techniques

A. Bronchoalveolar Lavage 1. Compatible with flexible bronchoscopy

2. Technique: Once the bronchoscope is wedged into the subsegmental bronchus of choice, sterile saline is instilled and then gently suctioned into a separate canister and sent to cytology. 3. Indications: Specimen acquisition for the diagnosis of various infectious, inflammatory, immunologic, and cancerous disorders 4. Complications: Rarely: bronchospasm, hypoxia, pneumothorax B. Transbronchial Needle Aspiration 1. Compatible with flexible bronchoscopy, EBUS, and robotic bronchoscopy 2. Technique: A needle is introduced through the bronchial wall and aspirates samples. 3. Advantages: Less invasive alternative to mediastinoscopy or mediastinotomy for sampling of mediastinal lymph nodes or masses; also with a higher diagnostic yield than mediasti noscopy 14 and high specificity for mediastinal lymph node staging. 15 Less invasive alterna tive to cervical mediastinoscopy, thoracoscopy, or thoracotomy for peripheral lung nodule sampling 4. Indications: Lung carcinoma, sarcoidosis, lymphoma, mediastinal and hilar node sampling 5. Complications: Hypoxia, hypercapnia, pneumothorax, airway bleeding, airway irritation, conversion to mediastinoscopy requiring a thoracic surgeon 16 C. Spray Cryotherapy 1. Compatible with flexible, navigational, robotic, and rigid bronchoscopy 2. Technique: Insufflation of liquid nitrogen through a flexible catheter via a bronchoscope to rapidly freeze tissue and induce cellular death and hemostasis 3. Indications: Treatment of obstructing endobronchial tumors and hemoptysis 4. Advantages: Compared to heat-producing methods (eg, laser therapy, electrocautery, ar gon plasma coagulation, photodynamic therapy), there is no airway fire risk and there is rapid hemostasis. 5. Complications: Hypotension, bradycardia, hemodynamic instability, cardiopulmonary ar rest, death 17 CLINICAL PEARL Due to high complication rates, spray cryotherapy (SCT) has lost popularity. Be aware of bradycardia, atrioventricular block (AVB), conduction pauses, pneumothorax, and bronchospasm. Invasive hemody namic monitoring and intraoperative transthoracic echocardiography may be required. D. Transbronchial Lung Cryobiopsy 1. Compatible with flexible, navigational, robotic, and rigid bronchoscopy 2. Procedure: Cryobiopsy has 1 second of contact time followed by 1 minute of tamponade via bronchial blocker of the sampled area before the next biopsy. Typically, two biopsies at two sites are performed, with significantly greater sample yield compared to traditional forceps biopsy. 18 3. Indications: Lung biopsy 4. Additional anesthetic considerations: General anesthesia with paralysis is required. A bronchial blocker is placed before the biopsy to tamponade the source of bleeding. If an ETT is used, the blocker is inserted via direct laryngoscopy before the intubation. The cuff of the ETT is used to keep the device in place. 5. Complications: Hemorrhage, pneumothorax, hypoxemia, bradycardia (from cold trans mission to myocardium and/or cardiac conduction system)

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