Skip to Main Content

++

Preoperative

++

  • 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

++

Intraoperative

++

  • Monitoring
    • At least one large bore IV
    • A-line
    • 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 + ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.