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Preoperative

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  • 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

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Intraoperative

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  • 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 + ...

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