Sign in

Review Note

Last Update: 02/27/2025 04:34 AM

Current Deck: ACG Part 2::Thoracic SSU

New Card (Unpublished)

Currently Published Content

Front
Back

No published tags.

Pending Suggestions

Field Change Suggestions:
SS_TS 1.19 Outline the specific issues for perioperative management of patients for pneumonectomy

High morbidity and mortality R>L
Indications: bronchial carcinoma, haemorrhage, infection eg. TB, aspergillus

Preoperative workup (see thoracic case outline)
  • Cancer staging -PETCT
  • Reason for pneumonectomy (usually cancer so 4M’s:
    • Mass effect - lie flat, symptoms at rest, mass on bronchi, nerve compression (RLN) or vessels (SVC)
    • Metabolic - electrolytes, thyroid, paraneoplastic syndromes e.g. Lambert-Eaton syndrome (NSCLC - muscle weakness)
    • Metastasis - brain (do they have capacity), spine (epidural, regional), liver and renal (drugs/metabolism)
    • Medications - chemo (bleomycin -> O2 toxicity), cyclophosphamide and cisplatin (end organ damage, cardiac issues)
  • Thoracic RCRI and exercise stress testing depending on results
  • TTE, spirometry and DLCO essential
  • Three-legged stool of perioperative workup:
    • Respiratory Mechanical function: FEV1 and FVC, ppoFEV1 > 40%, 
    • Respiratory Parenchymal function: DLCO and KLCO, ppoDLCO > 40%
    • Cardiorespiratory reserve: Usually TTE +  CPET, aim VO2peak >15ml/kg/min (CPET mandatory if ppo <40% for either FEV1 or DLCO), shuttle walk test in come centres, result >400m approx 15ml/kg/min
    • Can also perform V/Q scans to further work up especially if low/borderline lung function: % ppoFEV1 = preop FEV1  x (100 - % perfusion to lung to be resected) / (predicted FEV1 corrected for age; sex & height)

Surgery:
  • Different approaches:
    • Standard: Affected lung removal only
    • Intrapericardial pneumonectomy: If tumour is close to/involves pulmonary arteries or near the left atrium, needs good surgeon/anaesthetist communication esp around clamping of PA
    • Extrapleural pneumonectomy: radical resection for mesothelioma, resection of lung, pleura, hemidiaphragm and hemipericardium + patch reconstruction (pretty rare)
    • Completion pneumonectomy: Removing remaining lung after prior resection
    • Carinal pneumonectomy: the excision of the lung and carina in patients with tumours of the distal trachea or carina
  • +/- rigid bronchoscopy after induction to ensure adequate bronchus length
  • Posterolateral thoracotomy 5th ICS
  • Pulmonary veins and artery ligated, PA trial clamp
  • Bronchus - DLT care, leak test, decision making RE: R vs L DLT
Anaesthesia:
  • Analgesia: 
    • Mid-thoracic epidural
    • Paravetebral catheter (usually by surgeon)
    • Multi-modal
  • Monitoring:
    • Standard
    • A-line
    • CVL on operative side (as risk of pneumothorax)
    • Temp. probe
    • Urinary catheter
  • Induction and maintenance
    • TIVA vs volatile, both fine but TIVA best for rigid bronch
  • Position:
    • Lateral decubitus + table break
    • Eye protection
    • Pressure points
    • Neck position
    • VTE prophylaxis via compression stockings 
    • Maintain normothermia via forced air warmer
  • Lung isolation and ventilation:
    • DLT or BB
    • DLT On opposite side to pneumonectomy i.e. left pneumonectomy = right DLT
    • Check position following/during insertion, then again after lateral positioning
    • BB will need to be withdrawn from bronchus before stapling
    • Ventilation: lung protective:
      • (i) Tidal volume: 5-6 ml kg1 (ideal body weight) 
      • (ii) Peak airway pressure: <35 cmH20 
      • (iii) Plateau airway pressure: <25 cmH20 
      • (iv) Aiming for normal PaCO2 
      • (v) PEEP: 5cm H2O 
      • (vi) Avoid hyperoxia, titrating FIO2 to maintain oxygen saturations of 94-98%
  • Haemodynamics:
    • Restrict IVF use, should not exceed 20ml/kg in first 24hrs - if excess increased risk of post-op pulmonary oedema, resp failure and mortality
    • Accept UO 0.5ml/kg/hr
    • Treat hypotension with vasoactive drugs
    • PA clamping: shunt to dependent lung 100% of CO -> cardiovascular collapse or excessive rise in CVP indicates RV failure -> unclamp, rule out other causes of CVS instability and repeat clamping - > if repeated RV failure may need to abort surgery as high risk of mortaility
  • Extubate:
    • Awake, warm, comfortable

Post operative:
  • ICU admission
  • Drains: 
    • Chest drain remains clamped to accumulate fluid in hemithorax; if unclamped can cause cardiac herniation (also NOT on suction)
    • Emergency management if left unclamped post op; clamp and call surgeons
    • Drain clamp intermittently removed for a few minutes every hour to assess for haemorrhage
  • Cardiac arrhythmias common (40%) (from pulmonary veins) usually AF, flutter, SVT
  • Post pneumonectomy pulmonary oedema:
    • High mortality if it occurs (50%)
    • More likely with right pneumonectomy
    • Leaky capillary beds within the remaining lung result in patients developing respiratory distress and hypoxaemia, usually within the first 72 h after surgery
  • Bronchopleural fistula:
    • Incidence post-pneumonectomy 4-20%
    • More likely with right pneumonectomy as right bronchus is supplied by single bronchial artery (left supplied by 2)
    • Right bronchial stump is exposed at the end of operation, surgeons cover it with a well vascularised tissue flap (intercostal muscle), left usually retracts behind aorto-pulmonary window
    • Other risks:
      • Prolonged post-op ventilation
      • Residual tumour in stump
      • Large diameter stumps
    • Early presentation::
      • Cough
      • Air leak from chest drain
      • Falling fluid level (on CXR)
      • New air-fluid level on CXR
    • Later presentations (>2 weeks):
      • Nonspecific signs and empyema
    • Treatment:
      • Draining pleural space if associated with empyema
      • Antibiotics
      • Surgical repair - condition should be optimised and stabilised but rarely need to proceed prior to stabilisation, difficult anaesthetic as cardiovascular collapse and need rapid lung isolation to avoid overspill from BPF into good lung
  • Cardiac herniation:
    • Associated with right pneumonectomy with stripping of pericardial sac or left intrapericardial pneumonectomy
    • Heart herniates through pericardial defect into post-pneumonectomy space
    • Mortality > 50%
    • Hypotension, shock, cyanosis, SVC obstruction, may have chest pain/SOB -> cardiac arrest
    • Need immediate surgery
    • While transferring to OT position laterally with surgical side up
  • Post-pneumonectomy syndrome:
    • the compression of the intact main bronchus due to a shift of the mediastinal structures. Occasionally, it cannot be resolved with posture, and a silicone space-filling prosthesis needs to be surgically introduced into the empty hemithorax

BJA anaesthesia for pneumonectomy

Terms of Service | Privacy Policy | Imprint (German)

Copyright © AnkiCollab. Website Template Designed & Developed by Quixlab 2018