0:06

Behind the Knife, the surgery

0:08

podcast, relevant and engaging content

0:10

designed to help you dominate

0:12

the day. Hello

0:22

Behind the Knife listeners, we're excited

0:24

to announce the next addition to our

0:27

Behind the Knife Premium Offerings, the Cardiothoracic

0:29

Surgery Oral Board Review. Each

0:31

scenario includes two parts. Part

0:33

A is a perfectly executed oral board scenario

0:35

that mimics the real thing. Scenarios

0:38

are 5-7 minutes long and include a variety

0:40

of tactics and styles. If you are able

0:42

to achieve this level of performance in your

0:44

preparation, you are sure to pass the oral

0:46

exam with flying colors. Part

0:48

B introduces high yield commentary to each scenario.

0:50

For those of you that used our General

0:52

Surgery Oral Board Review series, the format will

0:54

be very familiar. When you hear

0:56

this sound, that

1:00

indicates the start of the high yield commentary.

1:03

This commentary includes tips and tricks to

1:05

help you dominate the most challenging scenarios

1:07

in addition to practical, easy to understand

1:10

teaching that covers the most confusing topics

1:12

based on the Cardiothoracic Surgery exam. Then

1:15

when you hear this sound, that

1:19

indicates we are returning back to the exam scenario.

1:22

We are confident that you will find this unique

1:24

dual format approach a highly effective way to prepare

1:26

for the test. I am pleased to

1:28

be joined by the lead editor for the project,

1:30

Dr. John Kuckelman. John, what led you to

1:33

want to be involved in this project? Thanks,

1:35

Driessen. And a big thank you to everyone

1:37

at Behind the Knife for lending us Cardiothoracic

1:39

Surgeons the Behind the Knife Platform and the

1:41

staff. While I was preparing for my

1:43

CT Oral Boards, it became obvious to me that there

1:45

wasn't a need for a course such as the one

1:48

we provide here. What is unique

1:50

about this platform is that it is

1:52

the only place where CT surgery trainings

1:54

can hear an example of a perfectly

1:56

executed oral board scenario followed by

1:58

an in-depth explanation of the procedure. of that

2:00

scenario's topics. It also

2:03

includes examples of alternate scenarios as well

2:05

as what things are acceptable to say

2:07

and what pitfalls you absolutely want to

2:09

avoid when taking the exam. All

2:12

told, we brought you 43 high-yield, five

2:14

to seven minute scenarios that if mastered

2:16

will ensure your ability to pass the

2:19

Cardiothoracic Oral Board exam come test day.

2:25

Behind the Knife, premium. Behind

2:28

the Knife, Cardiothoracic Oral Board

2:30

Review. Scenario, Hemoptysis and

2:32

Infectious Lung Disease. Developed

2:35

by John Cuckelman, read by John Cuckelman and

2:37

Jason Bingham. A

2:39

62-year-old who is being medically treated

2:42

for a multi-drug resistant tuberculosis presents

2:44

to the emergency department for hemoptysis.

2:47

Sputum culture at the time of admission

2:49

is positive for TB. He's

2:52

admitted to the MICU and you

2:54

have been consulted for the hemoptysis. How

2:57

would you like to proceed? Well,

3:00

first I would go immediately evaluate the patient.

3:02

I'd want to get a sense of their

3:04

hemodynamic stability. I want to quantify

3:06

how much blood the patient has been coughing up

3:08

and take a look at their current airway and

3:10

respiratory status. Finally, I

3:12

would be sure to review all their

3:15

labs, imaging, take a complete history, particularly

3:17

if they were on anything like blood thinners.

3:21

So the patient has been coughing up about two

3:23

cups of blood in the last 15 minutes. His

3:26

oxygen saturation is 84% on two liters of

3:28

nasal cannula. His heart rate is 110 and

3:30

blood pressure is 90 over 60. His

3:35

hematocrit is 20. The patient

3:37

is tachypneic. He is not on blood

3:39

thinners. What would you like to do next? All

3:42

right, well, first this is an airway emergency,

3:44

so he requires a definitive airway. So

3:47

using rapid sequence in a patient, I

3:49

would make sure that he received a

3:51

single woman endotracheal tube. After

3:54

confirming the placement with the

3:56

entire CO2 and inappropriate oxygenation,

3:58

I would prepare for flexible.

4:00

bronchoscopy. I'd also ensure

4:02

that he had large bore IV

4:04

access and start resuscitation with blood

4:06

products as well as reverse any

4:09

gliulopathies. You

4:11

start your bronchoscopy but are unable to

4:13

visualize any anatomy beyond the carina. The

4:16

source of bleeding does seem to be coming

4:18

from the right side. The patient continues to

4:20

have turbo oxygenating. Okay

4:23

so in that case I would advance the

4:26

ET tube into the unaffected main stem bronchus

4:28

which sounds like it would be the left

4:30

side in this case. I

4:32

would also place the bronchoblocker down the

4:34

right using a direct laryngoscopy through the

4:36

cords just outside of my ET tube.

4:39

Finally I would place the patient right

4:41

side down to prevent aspiration of blood

4:44

to the unaffected lung and continue my

4:46

resuscitation. The

4:48

patient appears to stabilize after these maneuvers.

4:51

What now? So

4:54

I'd maintain single lung ventilation

4:56

and I would consult interventional

4:58

radiology for angiography and bronchial

5:00

artery embolization. I'd also

5:02

want to get some more detailed imaging if

5:05

possible with a CTPA once the patient is

5:07

stable enough to go to the CT scanner.

5:10

Okay they are able to embolize the right

5:12

bronchial artery. The patient improves over

5:14

the following 24 hours with the

5:16

blocker in place on single lung ventilation. The

5:19

ICU gets a CT scan that shows a cavitary

5:21

lesion in the right upper lobe. Okay

5:25

so I would then plan to go

5:27

to the operating room for removal of

5:29

the bronchial blocker. I would

5:31

plan to have a rigid bronchoscope

5:33

available at this time for endobronchial

5:36

intervention if the bleeding is persistent

5:38

and I would discuss the possibility

5:40

that he may need a right

5:42

upper lobectomy if I'm unable to

5:44

control a bleeding endobronchial. Take

5:47

me through your rigid bronchoscopy. I

5:50

would have the patient supine with his

5:52

neck fully extended. I would have jet

5:54

ventilation in the room and ready for

5:56

use. We would pre-oxinate the patient prior

5:58

to extubation. and evaluates

6:00

the airway with a flexible scope

6:02

first and take down the bronchial

6:04

blocker at that time under direct

6:07

visualization. If bleeding

6:09

persists, then I would remove the

6:11

ET tube and blocker, place a

6:13

mouth guard and proceed with rigid

6:15

bronch and carefully place a size

6:17

8 rigid tracheal bronchoscope under direct

6:19

vision by identifying the

6:22

epiglottis and then the vocal cords. I'd

6:25

rotate the scope 90 degrees to pass

6:27

through the cords and once the rigid

6:29

scope was in place I would institute

6:31

jet ventilation and evaluate the airway with

6:33

the flexible scope. Let's

6:36

say you take down the blocker and all the

6:38

bleeding seems to be well controlled. What

6:40

would your plan be for this patient? So

6:43

this patient has had a massive

6:45

hematosis event from a right upper

6:47

lobe, cavitary lesion while being treated

6:49

for a multi-drug resistant TB. You

6:52

should undergo a right upper lobectomy. Ideally

6:55

I would first optimize him for this

6:57

resection and making sure that he had

6:59

good recovery from his hemoptysis event. So

7:02

he's been extubated without any further events and

7:04

is currently on room error. His hemoglobin is

7:07

now 9, his albumin is

7:09

3.5. Tell

7:11

me how you would do his lobectomy. I

7:14

would plan to do this via

7:16

open via serratus sparing posterior lateral

7:18

thoracotomy on the right through the

7:20

fifth intercostal space. Be

7:22

sure to harvest the intercostal muscle

7:24

during this dissection to buttress my

7:26

bronchial stop after performing a formal

7:28

right upper lobectomy. So

7:31

let's say you go to spread the ribs and

7:33

the lung is just plastered to the chest wall.

7:35

How would you handle that? So

7:38

in that case, I would likely

7:40

need to complete an extra plural

7:42

dissection to avoid contamination while completing

7:44

the resection. You're

7:47

finishing that case and you get a

7:49

consult from the ED for a 70-year-old

7:51

homeless patient who is presenting with fever,

7:53

elevated white count and a cough and

7:55

a CT scan showing a 6-centimeter abscess

7:57

in the superior segment of the lung.

8:00

left lower lobe. The emergency room physician

8:02

says he is otherwise healthy and he

8:04

should get it resected. So

8:07

I'd asked them to start that patient on

8:09

broad-spectrum antibiotics if they have not done so

8:12

already. I would then review the imaging and

8:14

go evaluate the patient with a focused history

8:16

and physical. So

8:18

as stated he's homeless and a poor

8:21

historian but he denies any prior

8:23

surgery and just admits to a cough and

8:25

malaise over the past week. He

8:27

does admit to daily alcohol use but

8:29

denies any hemoptysis or illicit drug use.

8:32

You review with his CT scan and

8:34

agree that there is a 6 centimeter

8:36

intra-prinkable lung abscess in the left lower

8:38

lobe without any other lesions

8:40

or effusions. So

8:43

in this case I would ask my

8:46

IR colleagues to evaluate for an image-guided

8:48

drain of his abscess along with continued

8:50

broad-spectrum antibiotics and I would then narrow

8:52

based on the cultures from the drainage.

8:56

When would you take this patient to the operating room?

9:00

So I would reserve resection if

9:02

the patient did not clinically improve

9:05

or if there was a complication

9:07

such as hemoptysis, rupture of the

9:09

abscess, causing an empaema or a

9:11

bronchopluorol fistula. Be sure to

9:13

listen to part V for high-yield commentary and

9:15

other tips and tricks. Behind

9:28

the Knife Cardiothoracic World Board

9:30

Review Scenario Hemoptysis and Infectious

9:33

Lung Disease Developed by

9:35

John Kuckelman, read by John Kuckelman and

9:37

Jason Bingham. A

9:40

62 year old who is being

9:42

medically treated for multi-drug resistant tuberculosis

9:44

presents to the emergency department for

9:46

hemoptysis. Sputum culture at

9:48

the time of admission is positive for

9:51

TB. He's admitted to

9:53

the MICU and you have been

9:55

consulted for the hemoptysis. How

9:57

would you like to proceed? Well,

10:00

first I would go immediately evaluate the patient. I'd

10:02

want to get a sense of their hemodynamic stability.

10:04

I want to quantify how much blood

10:07

the patient has been coughing up and take

10:09

a look at their current airway and respiratory

10:11

status. Finally, I

10:13

would be sure to review all their

10:15

labs, imaging, take a complete history, particularly

10:17

if they were on anything like blood

10:20

thinners. So

10:22

the patient has been coughing up about two cups

10:24

of blood in the last 15 minutes. His

10:27

oxygen saturation is 84% on two liters of nasal

10:29

cannula. His heart rate is 110 and blood pressure

10:31

is 90 over 60. His

10:35

hematocrit is 20. The patient is

10:37

tachypneic. He is not on blood thinners. What

10:39

would you like to do next? All right.

10:42

Well, first this is an airway emergency, so

10:44

he requires a definitive airway. So

10:47

using rapid sequence in a patient, I

10:49

would make sure that he received a

10:51

single woman endotracheal tube. After

10:54

confirming the placement with the

10:56

Entidle CO2 and inappropriate oxygenation,

10:58

I would prepare for flexible

11:00

bronchoscopy. I'd also ensure

11:02

that he had large bore IV

11:04

access and start resuscitation with blood

11:07

products as well as reverse any

11:09

equiagulopathies. Massive

11:13

amoptasis is defined as greater than 600 milliliters in 24

11:15

hours or greater than 100

11:18

milliliters per hour. For context,

11:20

a tablespoon is about 18 milliliters and

11:22

a Dixie cup is about 100 milliliters. The

11:25

examiner will be pretty clear, but any

11:27

amount of regular coffee up of pure

11:30

blood with hemodynamic or respiratory compromise should

11:32

be treated seriously. Approach

11:35

a scenario like you would a trauma

11:37

or sepsis patient by addressing the airway

11:39

breathing and circulation. The

11:41

first thing that needs to be done is to

11:43

protect the airway. Make sure to place at least

11:45

a 7.5 ET tube so

11:47

that you can utilize a therapeutic

11:49

bronchoscope for evaluation and potential treatment.

11:55

You start your bronchoscopy but are unable

11:57

to visualize any anatomy beyond the carina.

12:00

The source of bleeding does seem to be coming

12:02

from the right side. The patient continues to

12:04

have turbo oxygenating. Okay,

12:08

so in that case I would advance the

12:10

ET tube into the unaffected main stem bronchus

12:12

which sounds like it would be a left

12:14

side in this case. I

12:16

would also place a bronchial blocker down the right using

12:18

a direct laryngoscopy through the cords

12:21

just outside of my ET tube. Finally,

12:23

I would place the the patient right

12:25

side down to prevent aspiration of blood

12:28

to the unaffected lung and continue my

12:30

resuscitation. You

12:34

should know this algorithm cold before you take

12:36

your oral exams. Massive hemoptysis

12:39

can become part of nearly any

12:41

thoracic scenario. Initial steps

12:43

that can be used if the bleed

12:45

be localized to a segmental bronchus includes

12:47

flushing with isalene with epinephrine and wedging

12:49

the scope to try and tamp it

12:51

out the bleed. Fogarty

12:53

balloons can be used as a blocker in segmental

12:56

bronchi, but may be tricky to place

12:58

in an acute situation in the ICU.

13:01

Unless you have the appropriate connection, a

13:03

pediatric flexible bronchoscope and an 8-0 ET

13:05

tube in place, you will not be

13:08

able to place a blocker from within

13:10

the ET tube. Use

13:12

a laryngoscope to place the blocker

13:14

outside the ET tube and then guide it

13:16

into place with the bronchoscope. Once

13:19

this is done, you can guide your ET

13:21

tube over your bronchoscope and to

13:23

the unaffected main stem bronchus for single

13:25

lung ventilation. Do not forget

13:27

to place the patient with the bleeding side down.

13:30

This will temporize the bleeding in most

13:32

situations so that you can regroup and

13:34

resuscitate. The

13:38

patient appears to stabilize after these maneuvers.

13:41

What now? I

13:44

would maintain single lung ventilation

13:46

and I would consult interventional

13:48

radiology for angiography and bronchial

13:50

artery embolization. I would also

13:53

want to get some more detailed imaging if

13:55

possible with a CTPA once the

13:57

patient is stable enough to go to the CT

13:59

scanner. Embolization

14:03

of the bronchial arteries is all that is needed

14:05

in 90% of massive hemoptysis

14:07

cases to control the bleeding. Using

14:10

this and the above-mentioned maneuvers should almost

14:13

always be used in lieu of operative

14:15

resection as the mortality from a lobectomy

14:17

for massive hemoptysis is between 10 and

14:19

20%. Obtain

14:21

more detailed imaging as soon as the

14:24

patient is stable enough to get a

14:26

CT as this is crucial to understanding

14:28

the source of the hemoptysis as well

14:30

as the planning of any additional interventions.

14:35

Okay they are able to embolize the right

14:37

bronchial artery. The patient improves over

14:39

the following 24 hours with the blocker

14:41

in place on single lung ventilation. The

14:44

ICU gets a CT scan that shows a cavitary

14:46

lesion in the right upper lobe. Okay

14:49

so I would then plan to go

14:51

to the operating room for removal of

14:53

the bronchial blocker. I'd plan

14:56

to have a rigid bronchoscope available

14:58

at this time for endobronchial intervention

15:00

if the bleeding is persistent and

15:02

I would discuss the possibility that

15:05

he may need a right upper

15:07

lobectomy if I'm unable to control

15:09

a bleeding endobronchial. Be

15:13

thoughtful about your approach to removing the blocker.

15:16

Taking down the balloon but leaving the blocker

15:18

in place while in the ICU for a

15:20

period of time is also a reasonable approach.

15:23

If bleeding starts again you can simply reinflate the

15:25

balloon and go to the OR at that point.

15:28

It is prudent to discuss the potential need

15:30

for lobectomy at this point as that is

15:32

ultimately what may be needed to be done

15:34

if in the OR the bleeding persists. Take

15:40

me through your rigid bronchoscopy. I

15:43

would have the patient supine with his

15:45

neck fully extended. I would have jet

15:47

ventilation in the room and ready for

15:49

use. We would pre-oxinate the patient prior

15:51

to extubation and evaluate

15:53

the airway with flexible scope first

15:55

and take down the bronchial blocker

15:57

at that time under direct visualization.

16:01

If bleeding persists then I would

16:03

remove the ET tube and blocker,

16:05

place a mouth guard and proceed

16:08

with rigid brak and carefully place

16:10

a size 8 rigid tracheal brakoscope

16:12

under direct vision by identifying the

16:14

epiglottis and then the vocal cords. I'd

16:18

rotate the scope 90 degrees to pass

16:20

through the cords and once the rigid

16:22

scope was in place I would institute

16:24

jet ventilation and evaluate the airway with

16:26

the flexible scope. Knowing

16:30

the equipment and steps of a rigid brakoscope

16:32

is as important to the examiners as being

16:35

able to describe a bent hull. If

16:37

this is not something you have done in a

16:39

while then it is worth thinking through and rehearsing

16:41

the step. For homoptysis the rigid

16:44

scope affords better large bore suction

16:46

for visualization as well as rapid

16:48

introduction of ancillary tools

16:50

such as argon plasma coagulation.

16:55

Let's say you take down the blocker and all

16:57

the bleeding seems to be well controlled. What

17:00

would your plan be for this patient? So

17:02

this patient has had a massive

17:05

homoptysis event from a right upper

17:07

lobe cavitary lesion while being treated

17:09

for a multi drug resistant TB.

17:11

You should undergo a right upper lobectomy.

17:14

Ideally I would first optimize him for

17:16

this resection and making sure that he

17:18

had good recovery from his homoptysis event.

17:24

Surgical resection is indicated in patients

17:26

with multi drug resistant TB with

17:28

a cavitary lesion that has been

17:30

complicated by homoptysis. Other

17:32

indications for resection include development of

17:34

a bronchopluoro fistula, empyema, aspergilloma within

17:36

the cavitary lesion as well as

17:39

complete destruction of the lung itself.

17:41

Typically lung function studies will be

17:43

of limited use since you will

17:45

be removing non-functional lung. If

17:47

there is any question then a VQ scan

17:49

should be obtained. Most of

17:51

these patients present with some level of

17:53

malnutrition. If abled then it is not

17:56

unreasonable to place a feeding tube to

17:58

optimize their nutrition. He's

18:02

been extubated without any further events and is

18:04

currently on room error. His hemoglobin is now

18:06

9. His albumin is 3.5. Tell

18:10

me how you would do his lobectomy. I

18:13

would plan to do this via

18:15

open via serratus sparing posterior lateral

18:17

thoracotomy on the right through the

18:19

fifth intercostal space. Be

18:21

sure to harvest the intercostal muscle

18:24

during this dissection to buttress my

18:26

bronchial stop after performing a formal

18:28

right upper lobectomy. Very

18:32

rarely will you be able to perform a

18:34

sublobar resection for these types of cases. Minimally

18:37

invasive approaches are also not often feasible

18:39

due to the adhesive disease or scarring

18:41

in the hilum. The

18:44

scenario here specifically states that the

18:46

patient is sputum positive for multi-drug

18:48

resistant TB on admission. Robust

18:51

flap coverage of the bronchial stop is

18:53

mandatory in these cases to avoid the

18:55

complication of a bronchoplural fistula. So

19:01

let's say you go to spread the ribs and

19:03

the lung is just plastered to the chest wall.

19:05

How would you handle that? So

19:08

in that case, I would likely

19:10

need to complete an extraplural dissection

19:12

to avoid contamination while completing the

19:14

resection. Every

19:19

attempt should be made to avoid

19:21

plural contamination during the surgery. You're

19:26

finishing that case and you get a

19:28

consult from the ED for a 70-year-old

19:30

homeless patient who is presenting with fever,

19:33

elevated white count and a cough and

19:35

a CT scan showing a six centimeter

19:37

abscess in the superior segment of the

19:39

left lower lobe. The emergency room physician

19:41

says he is otherwise healthy and he

19:43

should get it resected. So

19:46

I'd ask them to start that patient on

19:49

broad spectrum antibiotics if they have not done

19:51

so already. I would then review the imaging

19:53

and go evaluate the patient with a focused

19:55

history and physical. So

19:57

as stated, he's homeless and poor histogram.

20:00

historian, but he denies any prior

20:02

surgery and just admits to a cough and

20:04

malaise over the past week. He

20:06

does admit to daily alcohol use but

20:08

denies any hemoptysis or illicit drug use.

20:11

You review with his CT scan and

20:13

agree that there is a 6-centimeter intra-prinkable

20:15

lung abscess in the left lower lobe

20:18

without any other lesions or effusions. So

20:22

in this case I would ask my

20:25

IR colleagues to evaluate for an image-guided

20:27

drain of his abscess along with continued

20:29

broad-spectrum antibiotics and I would then narrow

20:31

based on the cultures from the drainage.

20:37

Surgery is rarely needed for an isolated

20:39

pulmonary abscess. Indications for surgery are similar

20:42

to those discussed for the TB case.

20:44

Abscess is greater than 6 centimeters should

20:46

be considered for resection as well as

20:49

any lesions that are concerning for malignancy.

20:54

When would you take this patient to the operating room? So

20:58

I would reserve resection if the

21:00

patient did not clinically improve or

21:02

if there was a complication such

21:05

as hemoptysis, rupture of the abscess

21:07

causing an empyema or a bronchopluorol

21:09

fistula. Other

21:13

possible infectious scenarios to be

21:15

prepared for include Aspergilloma or

21:17

Mucor Mycosy. Aspergillomas are

21:20

not often present in the immunocompetent

21:22

patients and thus a thorough workup

21:24

for an immunocompromised condition should be

21:26

carried out in these patients. They

21:29

should be resected if associated with

21:31

any hemoptysis or have continued growth

21:33

on interval endemogy. Mucor

21:36

Mycosy will likely be presented in

21:38

an extremely immunocompromised patient or in

21:41

the setting of poorly controlled diabetes

21:43

in DKA. These infections

21:45

will characteristically be aggressive and

21:47

rapidly infect beyond anatomical borders.

21:50

Treatments should be equally aggressive with

21:52

surgical debridement of all the infected

21:54

areas of lung parenchyma and chest

21:56

wall, as well as high dose

21:58

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