- Preoperative evaluation with cardiac risk stratification
- Smoking history common
- Impact of preoperative smoking cessation on outcome is unclear, but smoking cessation should be encouraged
- Co-existing cardiovascular disease (CAD, HTN)
- If tumor
- Review imaging studies (CT-scan) to assess extent of tumor spread, tracheal/bronchial deviation or compression, lung atelectasis
- Assess for paraneoplastic syndrome
- At least one large bore IV
- CVL not routine; if significant blood loss anticipated, or for major lung resection, place CVL on side of thoracotomy (reduces impact of possible pneumothorax)
- Pulmonary artery catheter (PAC) if indicated (significant pulmonary HTN, cor pulmonale, LV dysfunction); ensure that PAC tip is in the dependent lung, and especially not in the area to be resected; if pneumonectomy performed, inflate balloon carefully, as significant hemodynamic compromise can ensue (reduced vasculature cross-section)
- Analgesia: Thoracic epidural, paravertebral block, intercostal blocks
- Very intense pain for 3–4 days following thoracotomy
- Epidural gold standard for postop analgesia. Place at intended thoracotomy level, or 1–2 levels lower, prior to induction. Test-dose 3 mL 1.5% lido with 1:200K epi to rule out intravascular placement. Do not load preoperatively
- Paravertebral block has the advantage of less/no sympathectomy and of not threatening the spinal cord; catheter placement possible
- Intercostal blocks, level of thoracotomy and 2 level up and down (ropi 0.5% 5 mL/level), can be performed by surgeon under direct vision; limited duration
- Cryoneurolysis takes 24–48 hours to be effective, but analgesia for over 1 month
- AFib prophylaxis:
- Continue β-blockers if patient already on them; reduce dose if epidural (Class I)
- Diltiazem reasonable if not on β-blocker preoperatively (Class IIa)
- Amiodarone reasonable except for pneumonectomy (toxicity concerns) (Class IIa)
- Lobectomy: 1,050 mg IV infusion over the first 24 hours after surgery (43.75 mg/h) then 400 mg PO BID × 6 days
- Esophagectomy: 43.75 mg/h IV infusion (1,050 mg daily) × 4 days
- Magnesium supplementation reasonable in combination with other medications (Class IIa)
- Flecainide and digitalis not recommended (Class III)
- Induction: preoxygenation, IV induction adapted to patient’s cardiovascular status
- Typically intubation first with SLETT to allow flexible bronchoscopy by surgeon; then exchange to DLETT
- One-lung ventilation: see Chapter 94
- Have multiple size DLETT available, FOB (for difficult airway as well as to verify ETT position), videolaryngoscope, etc. as needed
- Positioning: thoracic procedures (except for bilateral lung transplant) are performed in lateral decubitus. Dependent arm flexed, axillary roll, nondependent arm placed above head to pull scapula away from operative area; protect eyes and dependent ear, maintain neck neutral
- Maintenance: typically inhalational agent (minimal effect on hypoxic pulmonary vasoconstriction under 1 MAC) + opioid (sparingly if COPD) + NMB (to facilitate retraction); use high FiO2 and no N2O
- “Light” GA + epidural (load with 0.25% bupi/ropi in 5 mL aliquots)
- Deep anesthesia during rib spreading; possible vagal response at beginning of case, responsive to cessation of surgical stimulus, or IV atropine if fails
- Fluid management: restrict fluid as much as possible (only maintenance fluid + ...
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