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YOUR PATIENT

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An otherwise healthy 8-year-old male with a history of repeated pulmonary infections is scheduled for a thoracoscopic resection of a sequestered lung.

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PREOPERATIVE CONSIDERATIONS

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Sequestration of the lung can occur as a cystic or solid mass composed of nonfunctioning pulmonary tissue that does not connect to the tracheobronchial tree. Symptomatic patients usually present with recurrent pulmonary infections, while asymptomatic patients may be diagnosed from a routine chest radiograph. Two forms of sequestered lungs can be found. Intrapulmonary sequestration is a segment surrounded by normal lung tissue, with its blood supply from systemic vessels and drainage into the pulmonary veins. Extrapulmonary sequestration will have only its pleural sac, with the vascular supply being exclusively from the systemic system.

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Other anomalies are rare (<10%) with intrapulmonary sequestration, while foregut communication and other anomalies such as congenital diaphragmatic hernia, congenital adenomatoid malformations, and congenital heart disease are more common with extrapulmonary sequestration (about 50% of the cases). Extrapulmonary sequestration is more commonly diagnosed in infancy during the workup of the other congenital anomalies.

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Other congenital lung lesions that may require surgical interventions are congenital cystic adenomatoid malformation and congenital lobar emphysema.

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ANESTHETIC MANAGEMENT

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  • Use standard American Society of Anesthesiologists monitors and arterial line.

  • Ensure adequate IV access.

  • Anesthesia induction can be inhalational or intravenous.

  • Many surgeons request one-lung ventilation, which may be achieved using either a double-lumen tube (size permitting), a bronchial

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blocker, or endobronchial intubation with a regular endotracheal tube (ETT). We have found it easier in children requiring intubation with a 4.5-mm ETT or less to place the bronchial blocker outside of the ETT to avoid decreasing the lumen of the ETT and improve ventilation of the single lung. This can be achieved by first intubating the trachea with an appropriate-size tube, placing the bronchial blocker with fiberoptic guidance through the ETT, removing the initial ETT, and then intubating alongside the bronchial blocker. Always check the position of the ETT and the blocker with a fiberoptic bronchoscope, and recheck it in the lateral position. It is much harder to provide a good seal when placing a blocker down the right side because of the acute takeoff of the right upper lobe bronchus.

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POSTOPERATIVE CONSIDERATIONS

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Extubation of the trachea at the conclusion of the case should be planned, especially if a thoroscopic approach was used. Postoperative pain management needs to be addressed and is especially important after an open thoracotomy, since there may be pleural and muscle damage, possible disruption of the costovertebral joint, and intercostal nerve damage secondary to the surgery. One can consider a thoracic epidural that is placed preincision with its position verified using fluoroscopy, a paravertebral extrapleural catheter placed under direct visualization, or a pleural catheter. Because of the increased risk of placing a thoracic epidural in an anesthetized patient, one can consider placing a caudal catheter and inserting an epidural catheter up to the desired thoracic level with fluoroscopy or stimulation guidance. In adult patients, a paravertebral extrapleural catheter is as efficacious as a thoracic epidural and has fewer complications. Information about local anesthetic uptake from ...

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