Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ Preoperative ++ Preoperative evaluation with cardiac risk stratificationSmoking history commonImpact of preoperative smoking cessation on outcome is unclear, but smoking cessation should be encouragedCo-existing cardiovascular disease (CAD, HTN)If tumorReview imaging studies (CT-scan) to assess extent of tumor spread, tracheal/bronchial deviation or compression, lung atelectasisAssess for paraneoplastic syndrome +++ Intraoperative ++ MonitoringAt least one large bore IVA-lineCVL 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 thoracotomyEpidural 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 preoperativelyParavertebral block has the advantage of less/no sympathectomy and of not threatening the spinal cord; catheter placement possibleIntercostal 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 durationCryoneurolysis takes 24–48 hours to be effective, but analgesia for over 1 monthAFib 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 daysEsophagectomy: 43.75 mg/h IV infusion (1,050 mg daily) × 4 daysMagnesium 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 statusTypically intubation first with SLETT to allow flexible bronchoscopy by surgeon; then exchange to DLETTOne-lung ventilation: see Chapter 94Have multiple size DLETT available, FOB (for difficult airway as well as to verify ETT position), videolaryngoscope, etc. as neededPositioning: 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 neutralMaintenance: 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 failsFluid management: restrict fluid as much as possible (only maintenance ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Download the Access App: iOS | Android Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.