Diaphragmatic plication

2021-06-24T01:54:18Z

LibbyWang: The anesthetic considerations in diaphragmatic plication for hemidiaphragm paralysis

{{Infobox surgical case reference
| anesthesia_type =General
| airway =ETT with lung isolation
| lines_access =PIV, Arterial Line
| monitors =Standard, Arterial Line
| considerations_preoperative =Possible hypoxia/hypercapnia, baseline atelectasis with possible dyspnea while supine
| considerations_intraoperative =- Lung isolation required
- Lateral decubitus positioning
- Ensure optimal respiratory mechanics prior to extubation
| considerations_postoperative =- Consider ICU given possibility of respiratory decompensation
}}

Plication of the diaphragm is a surgical procedure indicated for the treatment of diaphragmatic paralysis. The diaphragm is the primary muscle of inspiration, but its contribution varies based on position and sleep. The diaphragm is responsible for 56% of the tidal volume in the awake, supine patient and up to 81% during periods of deep sleep.<ref name=":0">{{Cite journal|date=2021-04-03|title=Plication of the Diaphragm: Background, Indications, Contraindications|url=https://emedicine.medscape.com/article/1970326-overview}}</ref>

Causes of diaphragmatic paralysis<ref name=":1">{{Cite web|title=UpToDate|url=https://www.uptodate.com/contents/causes-and-diagnosis-of-unilateral-diaphragmatic-paralysis-and-eventration-in-adults|access-date=2021-06-24|website=www.uptodate.com}}</ref>:

*Phrenic nerve injury due to stretching or cooling during cardiac surgery
*Herpes zoster, poliomyelitis and other viral infections
*Cervical spondylosis, cervical compressive tumors, blunt neck trauma, neck surgery, pneumonia, and iatrogenic embolization
*Motor neuron disease, myopathy, inflammatory myositis
*Malignancy
*Idiopathic

Diaphragmatic paralysis has many clinical implications including<ref name=":0" />:
*respiratory derangements (hypercapnia, hypoxia)
*reduced energy levels
*sleep disordered breathing during REM
*inability to fully expand lungs resulting in higher risk of pleural effusions, pneumonia, atelectasis
*with unilateral diaphragmatic paralysis patients are usually asymptomatic at rest, but may have exertional dyspnea and decreased exercise performance or when in lateral recumbent position with paralyzed side down
*orthopnea sometimes occurs, especially in patients with bilateral diaphragmatic paralysis

The goal of diaphragm plication is to flatten the dome of the diaphragm, which increases the volume of expansion. The surgical technique for these procedures can be robotic, laparoscopic, VATS, or open with either transthoracic or transabdominal approaches described in the literature<ref name=":0" />.

==Preoperative management==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Sleep disturbances, possible cervical spine disease as etiology of diaphragmatic paralysis
|-
|Cardiovascular
|Possible transthoracic approach with standard intrathoracic considerations
|-
|Respiratory
| - PFTs: Diaphragmatic paralysis is usually associated with a mild-to-moderate '''restrictive deficit''' on spirometry testing, with a reduction in forced expiratory volume, forced vital capacity, and maximum voluntary ventilation.
- ABGs: these patients may present with chronic hypercapnia or hypoxia

- CXR: atelectasis, hemidiaphragm elevation may be present

- Risk of cor pulmonale and pulmonary hypertension in setting of chronic hypercapnia and/or hypoxia

*
|-
|Gastrointestinal
|Possible laparoscopic approach
|-
|Hematologic
|Possible polycythemia given chronic hypoxemia<ref>{{Cite journal|date=1990-02-01|title=Diaphragmatic plication for unilateral diaphragmatic paralysis: A 10-year experience|url=https://www.sciencedirect.com/science/article/abs/pii/000349759090146W|journal=The Annals of Thoracic Surgery|language=en|volume=49|issue=2|pages=248–252|doi=10.1016/0003-4975(90)90146-W|issn=0003-4975}}</ref><ref>{{Cite web|date=2019-01-23|title=Neuromuscular Disorders Affecting the Thorax: Diaphragm Paralysis|url=https://www.pulmonologyadvisor.com/home/decision-support-in-medicine/pulmonary-medicine/neuromuscular-disorders-affecting-the-thorax-diaphragm-paralysis/|access-date=2021-06-24|website=Pulmonology Advisor|language=en-US}}</ref>
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

===Labs and studies===

*ABG
*PFTs
*CXR
*CT scan
*Depending on the degree and chronicity of hypoxia, may consider an echo for evaluation of pulmonary hypertension

===Operating room setup===

*Lung isolation technique available: either DLT or SLT with bronchial blocker
*Fiberoptic bronchoscope for lung isolation
*Arterial line

===Patient preparation and premedication===

*Consider pre-induction a-line on room air
*Premedication with midazolam as needed, consider avoidance of opioids for premedication given possible tenuous respiratory status

===Regional and neuraxial techniques===

*General anesthesia is required given the need for lung isolation, duration of the procedure, and invasiveness of the procedure
*Consider epidural or ESP catheter for postoperative pain control due to chest tube placement

==Intraoperative management==

===Monitoring and access===

*Standard monitors
*Arterial line
*2 large bore IVs

===Induction and airway management===

*Lung isolation technique available: either DLT or SLT with bronchial blocker<ref name=":1" /><ref name=":2">{{Cite journal|last=Kara|first=H. Volkan|last2=Roach|first2=Michael J.|last3=Balderson|first3=Stafford S.|last4=D’Amico|first4=Thomas A.|date=2015-11|title=Thoracoscopic diaphragm plication|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4669248/|journal=Annals of Cardiothoracic Surgery|volume=4|issue=6|pages=573–575|doi=10.3978/j.issn.2225-319X.2015.08.11|issn=2225-319X|pmc=4669248|pmid=26693159}}</ref>
*Fiberoptic bronchoscope for lung isolation
*Consider HOB 30° induction to optimize FRC
*Higher risk of atelectasis and mucus plug, consider early recruitment and frequent suctioning

===Positioning===

*Lateral decubitus with paralyzed diaphragm up<ref>{{Cite journal|last=Kara|first=H. Volkan|last2=Roach|first2=Michael J.|last3=Balderson|first3=Stafford S.|last4=D’Amico|first4=Thomas A.|date=2015-11|title=Thoracoscopic diaphragm plication|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4669248/|journal=Annals of Cardiothoracic Surgery|volume=4|issue=6|pages=573–575|doi=10.3978/j.issn.2225-319X.2015.08.11|issn=2225-319X|pmc=4669248|pmid=26693159}}</ref>

===Maintenance and surgical considerations===

*GETA
*Possible approaches: thorascopic, laparoscopic, robotically assisted thorascopic, open thoracotomy
*Chest tube will be placed at the end of the procedure
*Consider epidural or ESP catheter for chest tubes

===Emergence===

*Ensure complete reversal of muscle relaxant
*Would closely monitor tidal volumes during emergence given that this patient population is at high risk of respiratory compromise
*Lower threshold to maintain the patient on the ventilator due to high risk of respiratory compromise

==Postoperative management==

===Disposition===

* Floor or ICU depending if postoperative mechanical ventilation is required
** In one study, mechanical ventilation was discontinued from 2 to 12 days after plication with dramatic improvement in respiratory mechanics <ref>{{Cite journal|last=Kuniyoshi|first=Yukio|last2=Yamashiro|first2=Satoshi|last3=Miyagi|first3=Kazufumi|last4=Uezu|first4=Toru|last5=Arakaki|first5=Katsuya|last6=Koja|first6=Kageharu|date=2004-06|title=Diaphragmatic plication in adult patients with diaphragm paralysis after cardiac surgery|url=https://pubmed.ncbi.nlm.nih.gov/15312011/|journal=Annals of Thoracic and Cardiovascular Surgery: Official Journal of the Association of Thoracic and Cardiovascular Surgeons of Asia|volume=10|issue=3|pages=160–166|issn=1341-1098|pmid=15312011}}</ref><ref>{{Cite journal|last=Versteegh|first=Michel I. M.|last2=Braun|first2=Jerry|last3=Voigt|first3=Pieter G.|last4=Bosman|first4=Daniël B.|last5=Stolk|first5=Jan|last6=Rabe|first6=Klaus F.|last7=Dion|first7=Robert A. E.|date=2007-09|title=Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea|url=https://pubmed.ncbi.nlm.nih.gov/17658265/|journal=European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery|volume=32|issue=3|pages=449–456|doi=10.1016/j.ejcts.2007.05.031|issn=1010-7940|pmid=17658265}}</ref>
* The patients are generally discharged following chest tube removal. <ref name=":2" />
* On follow-up, success is indicated by either the repositioning of the diaphragm caudally on radiograph and resolution or improvement in symptoms.<ref name=":2" />

===Pain management===

* Consider epidural or ESP catheter for chest tubes

===Potential complications===

* Respiratory failure in setting of no improvement in diaphragm
* Pneumonia

==Procedure variants==

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|Surgical time
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|EBL
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|Postoperative disposition
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|Pain management
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|Potential complications
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==References==

[[Category:Surgical procedures]]

<references />

WikiAnesthesia - User contributions [en]

Diaphragmatic plication