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=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
* 2 large bore PIV, usually 18G
* A-line ideally placed on dependent upper extremity


=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
* Double lumen tube (usually left regardless of lung being resected) placed with DL or video scope and confirmed with fiberoptic bronchoscopy
* When lung is deflated, ventilator settings need to be adjusted to avoid hyperinflation of remaining lung.
** Consider switching to PCV and limiting peak inspiratory pressure to 30cm H2O, then titrate based on ETCO2.
** An alternative is halving the tidal volumes and increasing respiratory rate
** Adding 3-5 cmH2O of PEEP is common


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
* Lateral decubitus with surgical lung up.
* Axillary roll is needed
* Bed will be flexed
* Pillows between abducted arms (or specialty sling)


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

Revision as of 13:14, 24 October 2022

Pneumonectomy
Anesthesia type

General

Airway

DL ETT

Lines and access

2x PIV, A-line typically

Monitors

Standard

Primary anesthetic considerations
Preoperative

Patients often smokers with COPD, may have poor reserve Fiberoptic cart should be available prior to induction

Intraoperative

Consider PC to limit peak pressures during one-lung ventilation

Postoperative

+/- chest tubes postoperatively

Article quality
Editor rating
Unrated
User likes
0

A pneumonectomy is the surgical removal of an entire lung. It can be performed via VATS or thoracotomy.

Overview

Indications

  • Lung cancer
  • TB
  • Severe COPD
  • Bronchiectasis
  • Lung abscess

Surgical procedure

  • After a pneumonectomy, air fills the space previously occupied by the lung. This postpneumonectomy space (PPS) will change over time, as the body compensates with elevation of the hemidiaphragm, mediastinal shift towards the PPS, and hyperinflation of the remaining lung. At the same time, there is progressive resorption of the air in the PPS which is replaced with fluid.
  • Postoperatively, a chest tube is NOT always inserted, and the air is not always evacuated.

Preoperative management

Patient evaluation

System Considerations
Airway
Neurologic
Cardiovascular
Pulmonary May have poor reserve to begin.

Many patients are smokers with COPD

Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Operating room setup

  • Have DLT (39F for males, 37F for females typically) available, as well as equipment to place it (video scope, fiberoptic bronchoscope to confirm placement)
  • Have large hemostat or Kelly clamp to clamp DLT and drop or deflate the operative lung

Patient preparation and premedication

Regional and neuraxial techniques

  • Thoracic epidurals are common. Bolusing prior to incision helps with intraoperative and postoperative pain. (consider 5-8cc of 0.25% bupivacaine)

Intraoperative management

Monitoring and access

  • 2 large bore PIV, usually 18G
  • A-line ideally placed on dependent upper extremity

Induction and airway management

  • Double lumen tube (usually left regardless of lung being resected) placed with DL or video scope and confirmed with fiberoptic bronchoscopy
  • When lung is deflated, ventilator settings need to be adjusted to avoid hyperinflation of remaining lung.
    • Consider switching to PCV and limiting peak inspiratory pressure to 30cm H2O, then titrate based on ETCO2.
    • An alternative is halving the tidal volumes and increasing respiratory rate
    • Adding 3-5 cmH2O of PEEP is common

Positioning

  • Lateral decubitus with surgical lung up.
  • Axillary roll is needed
  • Bed will be flexed
  • Pillows between abducted arms (or specialty sling)

Maintenance and surgical considerations

Emergence

Postoperative management

Disposition

Pain management

Potential complications

  • Pulmonary edema
  • Right heart failure
  • Vagus nerve damage
  • Vocal cord damage from DLT insertion
  • Hemorrhage
  • Trauma to surrounding organs
  • Cardiac herniation postop (compression of SC and IVC decreasing venous return, large pressure drops)
    • Avoid patient lying laterally with postoperative side down

Procedure variants

Open VATS
Unique considerations Advantages: shorter hospital stay, smaller postop scars, earlier return to work
Indications
Position Lateral with operative side up Lateral with operative side up
Surgical time 2-4 hours 2-4 hours
EBL 200-750
Postoperative disposition
Pain management Higher postop pain Decreased postop pain
Potential complications

References

Top contributors: Olivia Sutton

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