Difference between revisions of "Pneumonectomy"
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(Created page with "{{Infobox surgical procedure | anesthesia_type = | airway = | lines_access = | monitors = | considerations_preoperative = | considerations_intraoperative = | considerations_postoperative = }} A pneumonectomy is the surgical removal of an entire lung. It can be performed via VATS or thoracotomy. == Overview == === Indications<!-- List and/or describe the indications for this surgical procedure. --> === * Lung cancer * TB * Severe COPD * Bronchiectasis * Lung a...") |
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{{Infobox surgical procedure | {{Infobox surgical procedure | ||
| anesthesia_type = | | anesthesia_type = General | ||
| airway = | | airway = DL ETT | ||
| lines_access = | | lines_access = 2x PIV, A-line typically | ||
| monitors = | | monitors = Standard | ||
| considerations_preoperative = | | considerations_preoperative = Patients often smokers with COPD, may have poor reserve | ||
| considerations_intraoperative = | Fiberoptic cart should be available prior to induction | ||
| considerations_postoperative = | | considerations_intraoperative = Consider PC to limit peak pressures during one-lung ventilation | ||
| considerations_postoperative = +/- chest tubes postoperatively | |||
}} | }} | ||
| Line 79: | Line 80: | ||
=== 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 | |||
=== 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. --> === | ||
* Generally it is preferred to keep them dry intraop/post-op. Volume can be replaced with albumin or blood rather than crystalloid | |||
* Open chest cases are particularly prone to hypothermia, so consider 2 warming blankets if possible | |||
* 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 | |||
**Increase FiO2 to 100%. This will not only increase your oxygenation, but it will help resorb the clamped lung and provide better surgical access | |||
==== Decreasing O2 sat management: ==== | |||
* This is a very common complication with one lung ventilation. | |||
* First attempt should be to manually ventilate the dependent lung by applying more PIP with inspiratory holds (recruitment maneuver) | |||
* Consider applying CPAP to the surgical lung for passive oxygenation | |||
* If failed, inform the surgeon and consider reinflating the surgical lung. Once the saturation returns to the desired baseline, you may drop the surgical lung again. | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
| Line 95: | Line 122: | ||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
* 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<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ||
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|+ | |+ | ||
! | ! | ||
! | !Open | ||
! | !VATS | ||
|- | |- | ||
|Unique considerations | |Unique considerations | ||
| | | | ||
| | |Advantages: shorter hospital stay, smaller postop scars, earlier return to work | ||
|- | |- | ||
|Indications | |Indications | ||
| Line 113: | Line 149: | ||
|- | |- | ||
|Position | |Position | ||
| | |Lateral with operative side up | ||
| | |Lateral with operative side up | ||
|- | |- | ||
|Surgical time | |Surgical time | ||
| | |2-4 hours | ||
| | |2-4 hours | ||
|- | |- | ||
|EBL | |EBL | ||
| | |200-750 | ||
| | | | ||
|- | |- | ||
| Line 129: | Line 165: | ||
|- | |- | ||
|Pain management | |Pain management | ||
| | |Higher postop pain | ||
| | |Decreased postop pain | ||
|- | |- | ||
|Potential complications | |Potential complications | ||
Latest revision as of 13:28, 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 | |
| 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
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
- Generally it is preferred to keep them dry intraop/post-op. Volume can be replaced with albumin or blood rather than crystalloid
- Open chest cases are particularly prone to hypothermia, so consider 2 warming blankets if possible
- 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
- Increase FiO2 to 100%. This will not only increase your oxygenation, but it will help resorb the clamped lung and provide better surgical access
Decreasing O2 sat management:
- This is a very common complication with one lung ventilation.
- First attempt should be to manually ventilate the dependent lung by applying more PIP with inspiratory holds (recruitment maneuver)
- Consider applying CPAP to the surgical lung for passive oxygenation
- If failed, inform the surgeon and consider reinflating the surgical lung. Once the saturation returns to the desired baseline, you may drop the surgical lung again.
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 |