Thoracic Surgery Guidelines (MMC)

Updated August 25, 2014
Author: Boyd

Description: Guidelines for esophagogastrectomy, lobectomy, pneumonectomy, thymectomy, and other intrathoracic procedures at MMC

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AM Briefing and Anesthetic Plan

  1. 0645 am briefing occurs in OR ( Dr. Weigel via telephone)
  2. Anesthetic Considerations: Discuss with Weigel
    1. EBUS/Bronchoscopy?  (if so, then place SLT first – usually 8.0 or 9.0)
    2. Double Lumen Tube necessary?
    3. Arterial line?
    4. Lower extremity IV?
    5. Be mindful of fluid management and tidal volumes (strategy will depend upon type of surgery and patient)
    6. Need for epidural (see next section)
  3. Pain Management
    1. Usually no epidural for robotic / VATS cases, however,
      1. All Robotic esophagectomies should be consented for epidural: risk of converting to open procedure
    2. There are some open procedures that require epidural. Verify at 0645 briefing if uncertain. Please be mindful of OR start times and have epidural placed early.
      1. If epidural, frequently will be “high thoracic” (i.e. T4-5) and need to cover through T7)
      2. Epidural solution is usually PCEA with combined local/opiate.  Specific solution may depend upon procedure/patient.
      3. For pneumonectomy/thoracotomy patients , plan on running the opiate (Dilaudid 10mcg/cc) and local anesthetic ( 0.625% Bupiv) components on two separate pumps so they can be adjusted independently. (See APMS Epidural Management Guidelines for details. Find the yellow trifurcated extension set (splitter) in the anesthesia work room.)
        epidural splitter
      4. Open esophagectomies, etc. can use single bag bupivicaine /hydromorphone mix as a PCEA - fluid volume is not typically an issue
  4. Post-Op Pain Management
    1. Hypotension: evaluated by APMS 0656 / CardioThoracic (CT) PA
      • With separate infusions, there is the option to D/C the Local Anesthetic
      • NEVER give fluid bolus unless discussed with CT PA

ESOPHAGECTOMY

  1. The Basics:
    1. All patients are Considered FULL STOMACH: 
      1. Keep head up ~ 15°.
      2. RSI (remember to keep the head up when changing from SLT to DLT in middle of case and maintain head up at end of case including PACU/CTICU
    2. Usually Arterial line (R arm may be 1st target of choice because will not be tucked during 1st portion of case)
    3. no central line
    4. Temp measured in bladder (use special Foley from Cardiac OR) (no esophageal temp probe)
    5. If Transhiatal approach (most cases), Azygos Vein at risk  --> need Lower Extremity IV for volume.  This IV will need an extension to reach. Some clinicians put this IV on a KVO Pump.
    6. Try to avoid phenylephrine or other vasoconstrictors (theoretical risk to anastomoses).  Fluids in general are preferred to maintain BP (several liters usually OK if necessary – d/w surgeon)
  2. Procedure Order:
    There are many approaches to perform an esophagectomy.  This section describes the laparoscopic, robotic-assisted thoracoscopic esophagectomy.  I recommend understanding the planned approach, as this sequence and detail may vary.
    1. RSI with SLT for EGD/bronch
    2. EGD with NGT placement by surgeon (will tape in place and be moved later)
    3. Place Lower Extremity IV and arterial line (L arm will be tucked initially, R arm extended during laparoscopic portion) during or just prior to the EGD
    4. Lower body bair hugger
    5. Laparoscopy of abdomen, partial gastrectomy, partial esophagectomy, (2-3 hours)
    6. Prepare for thoracoscopy, completion of esophagectomy
    7. One IV pole on Patient’s Left side - must have long IV/ETT to allow robotic docking
    8. Changing the SLT for DLT
      1. Aspiration risk remains. Keep head elevated, suction
      2. Options for placement of DLT:
        • direct visualization
        • tube exchanger
        • fiberoptic exchange over wire
      3. The regular blue exchange catheters will not work.  You need the long, soft tipped tube exchangers:
        • 14 Fr Tube Exchanger soft tip fits 37-41 DLT
        • 11 Fr Tube Exchanger soft tip fits 35 DLT
        • Need wire for 32 DLT (0.035 diameter wire 150cm) – and pedi fiberoptic scope
      4. Verify position of DLT by fiberoptic before and after turning
    9. Left lateral decubitus position for thoracoscopy.  (Right lung needs to deflate)
    10. Prep for thoracoscopy:
      1. Verify position of DLT by fiberoptic scope after turning
      2. Clamp appropriate lumen and open the vent to allow lung to deflate
      3. One Lung Ventilation (OLV) – Tidal Volume - 3-5cc/kg volume control, adjusted body weight for obese patients
    11. Near the end of thoracoscopy, surgeon will ask for ventilation of collapsed lung by clamping dependent (ventilating) side, and ventilating the collapsed lung.  This is usually very quick and then you revert back to OLV again.
    12. Communicate with surgeon about when to revert to two-lung ventilation - usually around time of parietal pleura closure.
    13. Surgeon will usually place intercostal nerve blocks at end of procedure.
    14. Plan to extubate.  Very important to avoid positive pressure mask ventilation post-procedure (risk to anastomoses)
    15. Consider suctioning both lumens of DLT and consider risk of aspiration (Head of Bed HOB elevated and able to protect airway)
    16. NGT must not be moved.  Please take extra care to secure well.
    17. Keep Head up for transfer from OR bed to recovery bed
    18. Patients usually go to PACU -      Keep Head up ~ 15° at all times
    19. High flow nasal cannula excellent option for patient who is extubated but marginal RR

 


PNEUMONECTOMY / Lobectomy Notes

  1. Goal is to restrict TOTAL IV FLUIDS TO < 1L for ENTIRE CASE
  2. Dr. Weigel usually is OK with Left DLT even if Left pneumonectomy (discuss at preop briefing)
  3. Usually will require pre-op epidural:
    • Epidural will usually need to cover T3-T7.  Muscle sparing incision runs from armpit ~ 10 cm  (T3 - T7)
    • Place early enough to check level before procedure begins. 
    • May have limited use of epidural intra-op due to planned fluid restriction.
    • Plan on separating epidural infusion into 2 separate bags/pumps
      • one with bupivicaine 0.0625% and
      • one with hydromorphone / dilaudid10mcg / cc
      • Separating Local and Narcotic allows easier management of post-op hypotension
  4. Arterial line
  5. Central line usually requested by Dr. Weigel for CVP monitoring post-op. Preference is for 7Fr double lumen in subclavian on side of pneumonectomy.  Plan on placing after bronch (if planned)
  6. Attempt very low tidal volumes (3-4mL/kg)
  7. When requested, DLT must be withdrawn to ensure that bronchial lumen does not get stapled into stump.  Withdraw under FOB guidance so that there is as much room as possible (several cm) between bronchial lumen and stump.  Pressure on stump is to be avoided (blown stump can be catastrophic).  Closed-loop communication recommended with surgeon.
  8. Goal is to extubate in OR with minimal coughing (remember the stump!). 
  9. Patient usually goes directly to CTICU
  10. Supraventricular arrhythmias are a common complication – especially in elderly patients. 
    • Amiodorone 150mg IV bolus over 10-15’; discuss timing with surgeon

OTHER THORACIC PROCEDURE PEARLS:

  1. Lobectomy – minimize fluids
  2. Decortication – fluids not a focus
  3. Thymectomy – need Lower Extremity IV (risk of innominate vein injury)
  4. Airway stent –
    1. 9.0 ETT allows stent deployment
    2. propofol infusion
    3. rigid bronch on back of airway cart
    4. fire risk (have saline available to put down ETT)
  5. Ventilatory goal TV 3-5 cc/kg good starting place
  6. Inflation of Collapsed (deflated) Lung:
    Any time re-expanding collapsed lung isolate that lung for reexpansion: ie move clamp from isolated lung to ventilated lung then reexpand  -  this minimizes risk of tension pnemo with re-expansion
  7. Expectation is to extubate all patients at end of case  obviously there will be exceptions but they should be rare
  8. Difficult Airway: Consider passing wire down Left Mainstem bronchus w/ FOB, then passing Soft Tip Tube Exchanger over wire, then DLT.
    1. The regular blue exchange catheters will not work.  You need the long, soft tipped tube exchangers:
    2. 14 Fr Tube Exchanger soft tip fits 37-41 DLT
    3. 11 Fr Tube Exchanger soft tip fits 35 DLT