Pneumonectomy
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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
Induction and airway management
Positioning
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 |