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Spotlight on Ketamine: From Pain Relief to Public Concern
Next SPPM Visual Pearls episode with Dr. Deepa Kattail now available!
Health Equity Curriculum for Anesthesia Residents
OA-SPA Ask the Expert - October 2024
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Question of the Day
A 63-year-old man with a 45-pack-year smoking history presents for video-assisted thoracoscopic right lower lobectomy for a lung mass. One hour following initiation of one-lung ventilation with a left-sided double-lumen tube, the patient’s oxygen saturation has decreased from 97% to 87% on FiO2 1.0. Which of the following interventions is MOST appropriate at this time?
Explanation
Hypoxemia occurs in approximately 5-10% of patients undergoing one-lung ventilation. Many maneuvers may be used to treat hypoxemia during one-lung ventilation. First, the fraction of inspired oxygen (FiO2) may be increased during an episode of hypoxemia. Generally, the lowest tolerated FiO2 is administered to prevent the development of atelectasis. Correct placement of the double-lumen tube should always be verified using fiberoptic bronchoscopy to ensure the tube has not migrated, which may occur during patient repositioning or manipulation of the nonventilated lung by the surgical team. Suctioning of the lumen to the ventilated lung may be performed to remove any secretions or mucous plugging which may be causing an obstruction. Applying positive end-expiratory pressure (PEEP) to the ventilated lung, ideally after a recruitment maneuver, may improve oxygenation by decreasing atelectasis. Administration of continuous positive airway pressure (CPAP) to the nonventilated lung at 5-10 cm H2O may be used to decrease ventilation/perfusion mismatch; however, this may interfere with surgical exposure, especially in a video-assisted thoracoscopic surgical procedure. Additionally, for CPAP to the nonventilated lung to be most effective, an initial recruitment maneuver to open the lung must be employed prior to application of CPAP. Thus, in the setting of hypoxia during one-lung ventilation, CPAP to the nonventilated lung is generally reserved for use after PEEP has first been applied to the ventilated lung. With moderate to severe hypoxemia, reinitiation of two-lung ventilation may be performed to temporarily improve oxygenation. Last resort maneuvers include clamping the pulmonary artery to the nonventilated lung (to divert blood to the ventilated lung, decreasing ventilation/perfusion mismatch) or even, in extreme situations, initiation of extracorporeal membrane oxygenation.
OA Series: October 2024
05:08
SPPM Visual Pearls
Spotlight on Ketamine: From Pain Relief to Public ConcernDeepa Kattail, MD MHS FAAP, The Hospital for Sick Children, Toronto, ON, Canada
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35:32
OA Global Health Equity Ask the Expert
Health Equity Curriculum for Anesthesia ResidentsSamuel Percy, MD, Children's Hospital Colorado, Aurora, CO
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