anesthesia for non-cardiac thoracic surgery

ANESTHESIA FOR NON-ANESTHESIA FOR NON-CARDIAC THORACIC CARDIAC THORACIC

SURGERYSURGERY

CONSIDERATIONSCONSIDERATIONS

MARTHA RICHTER, MSN, CRNAMARTHA RICHTER, MSN, CRNA

OBJECTIVESOBJECTIVES

The student willThe student will Correlate physiological comorbidity issues Correlate physiological comorbidity issues

with the anesthesia care planwith the anesthesia care plan List position considerations specific to these List position considerations specific to these

surgical proceduressurgical procedures Describe the use of DLT and general Describe the use of DLT and general

considerationsconsiderations Identify factors to prevent exacerbation of Identify factors to prevent exacerbation of

pulmonary vasoconstrictionpulmonary vasoconstriction

PULMONARY FUNCTION PULMONARY FUNCTION CRITERIACRITERIA

Suggests high risk if:Suggests high risk if: FVC<50%FVC<50% FEV1 <2LFEV1 <2L FEV1/FVC <50%FEV1/FVC <50% RV/TLC >50%RV/TLC >50% Diffusing capacity <50% predictedDiffusing capacity <50% predicted PaCO2 >45 mmHgPaCO2 >45 mmHg

PFTS - RESTRICTIVEPFTS - RESTRICTIVE

PARAMETERPARAMETER INTRINSICINTRINSIC EXTRINSICEXTRINSIC

FVCFVC decdec decdec

FEV1FEV1 normalnormal normalnormal

FEV1/FVCFEV1/FVC normalnormal normalnormal

RV/TLCRV/TLC normalnormal increasedincreased

PFTS-OBSTRUCTIVEPFTS-OBSTRUCTIVE

PARAMETERPARAMETER asthmaasthma bronchitisbronchitisemphysememphysem

FVCFVC normalnormal normalnormal normalnormal

FEV1FEV1 decdec decdec decdec

FEV1/FVCFEV1/FVC decdec decdec decdec

RV/TLCRV/TLC incinc incinc incinc

CLINICAL S&S:Pulmonary CLINICAL S&S:Pulmonary hypertension, RVH, Cor Pulmonalehypertension, RVH, Cor Pulmonale

Prominent neck veins, prominent A Prominent neck veins, prominent A waves& perhaps prominent V waves on waves& perhaps prominent V waves on EKGEKG

Prom left parasternal heave & rocking Prom left parasternal heave & rocking motion synchronous with heartbeat may motion synchronous with heartbeat may be notedbe noted

Auscultate: pulm comp of 2Auscultate: pulm comp of 2ndnd heart sound heart sound increasesincreases

CLINICAL S&S cont’d.CLINICAL S&S cont’d.

High pitched, early systolic ejection clickHigh pitched, early systolic ejection click

Systolic ejection murmurSystolic ejection murmur

R-sided atrial S4 gallop indicating inc R-sided atrial S4 gallop indicating inc RVEDPRVEDP

Middiastolic R-sided S3 gallop, usually Middiastolic R-sided S3 gallop, usually clear evidence of impaired RV function. clear evidence of impaired RV function. Differentiated: gallops inc in intensity with Differentiated: gallops inc in intensity with inspirationinspiration

CLINICAL S&S cont’dCLINICAL S&S cont’d

Early diastolic, pulmonary regurg murmur Early diastolic, pulmonary regurg murmur ind functional impair secondary to dilation ind functional impair secondary to dilation of PA rootof PA root

Rt heart failure with chronic dependent Rt heart failure with chronic dependent edema, large tender liver, ascites, dilated edema, large tender liver, ascites, dilated distended neck veinsdistended neck veins

CXR in Pulmonary HTNCXR in Pulmonary HTN

Main pulmonary vessels dilatedMain pulmonary vessels dilated

Characteristic of COPD with hyperinflated Characteristic of COPD with hyperinflated lungs, low flat diaphragmlungs, low flat diaphragm

Evidence of RVH; clockwise cardiac Evidence of RVH; clockwise cardiac rotation, loss of air space behind the rotation, loss of air space behind the sternum on a lateral viewsternum on a lateral view

LV DYSFUNCTION LV DYSFUNCTION CONTRIBUTORSCONTRIBUTORS

Hypoxia, hypercarbia, acidosisHypoxia, hypercarbia, acidosis

CAD/valvular diseaseCAD/valvular disease

Systemic hypertensionSystemic hypertension

Ventricular interdependenceVentricular interdependence

Alterations in intrathoracic pressureAlterations in intrathoracic pressure

PREPARATION OF PT FOR PREPARATION OF PT FOR SURGERYSURGERY

PREOPPREOP PATIENT EDUCATIONPATIENT EDUCATION

Stop smokingStop smoking Breathing exercises/mucolytics&expectorantsBreathing exercises/mucolytics&expectorants BronchodilationBronchodilation

AminophyllineAminophylline

Cromolyn sodiumCromolyn sodium

ParasympatholyticsParasympatholytics

sympathomimeticssympathomimetics Weight reductionWeight reduction

INTRAOP GOALSINTRAOP GOALS

Minimize anesthesia timeMinimize anesthesia time

Control secretionsControl secretions

Prevent aspirationPrevent aspiration

BronchodilationBronchodilation

Intermittent hyperinflationIntermittent hyperinflation

POSTOP GOALSPOSTOP GOALS

Continue preoperative measuresContinue preoperative measures

Mobilize secretionsMobilize secretions

Early ambulationEarly ambulation

cough & deep breathingcough & deep breathing

analgesiaanalgesia

DRUG THERAPY-a reviewDRUG THERAPY-a review

SympathomimeticsSympathomimetics Beta agonists that inc formation of cyclic-Beta agonists that inc formation of cyclic-

AMP=bronchodilationAMP=bronchodilation

MetaproterenolMetaproterenol AlbuterolAlbuterol terbutalineterbutaline


ParasympatholyticsParasympatholytics

decrease intracellular levels of cyclic-decrease intracellular levels of cyclic-GMP , which modulate GMP , which modulate bronchoconstrictionbronchoconstriction

AtropineAtropine

Ipratropium bromideIpratropium bromide


Phosphodiesterase InhibitorsPhosphodiesterase Inhibitors Inhibits enzymatic breakdown of Cyclic-AMP, Inhibits enzymatic breakdown of Cyclic-AMP,

which increases cellular levelswhich increases cellular levels

AminophyllineAminophyllineTherapeutic bld levels 5-20ucg/mlTherapeutic bld levels 5-20ucg/ml

Loading 5-7mg/kg infused over 20 minLoading 5-7mg/kg infused over 20 min

Cont inf 0.5-0.7 mg/kg/hCont inf 0.5-0.7 mg/kg/h

DRUG THERAPY – a reviewDRUG THERAPY – a review

Steroid – reduce mucosal edema and Steroid – reduce mucosal edema and suppess inflammationsuppess inflammation

beclomethasonebeclomethasone

DRUG THERAPY – a reviewDRUG THERAPY – a review

Cromolyn sodiumCromolyn sodiumMast cell stabilizer preventing degranulation and Mast cell stabilizer preventing degranulation and release of histaminerelease of histamine

DRUG THERAPY - a reviewDRUG THERAPY - a review

DigitalisDigitalis Useful with left sided failure (CHF) or Useful with left sided failure (CHF) or

supraventricular dysrhythmias with rapid supraventricular dysrhythmias with rapid ventricular responseventricular response

REMEMBER THE RESPIRATORY REMEMBER THE RESPIRATORY MONITORSMONITORS

Breath soundsBreath sounds

Airway pressureAirway pressure

OxygenationOxygenation

ventilationventilation

REMEMBER THE CV MONITORSREMEMBER THE CV MONITORS

Precordial/esophageal stetheoscopePrecordial/esophageal stetheoscope

EKGEKG

Blood pressureBlood pressure

CvpCvp

PapPap

Art lineArt line

WHAT ABOUT POSITION WHAT ABOUT POSITION CONSIDERATIONS?CONSIDERATIONS?

POSITIONPOSITION

SUPINESUPINE

, ,

Clinical applicationClinical application

CardiacCardiac

MediastinalMediastinal

Major liver/vascular Major liver/vascular traumatrauma

Pericardial Pericardial tamponadetamponade

Lung biopsyLung biopsy

MORE POSITION MORE POSITION CONSIDERATIONSCONSIDERATIONS

POSITIONPOSITION

PRONEPRONE

CLINICAL CLINICAL APPLICATIONAPPLICATION

Anytime there is a Anytime there is a desire to prevent desire to prevent flooding to flooding to tracheobronchial tree tracheobronchial tree during proceduresduring procedures

TBTB

Pulmonary abscessPulmonary abscess

MORE POSITION MORE POSITION CONSIDERATIONSCONSIDERATIONS

POSITIONPOSITION

LATERAL LATERAL DECUBITUS-may DECUBITUS-may vary the obliqueness vary the obliqueness betw 45 to 135 deg to betw 45 to 135 deg to provide opt access provide opt access

CLINICAL CLINICAL APPLICATIONAPPLICATION

Standard thoracotomy Standard thoracotomy positionposition

Improves exposure in Improves exposure in certain cardiothoracic, certain cardiothoracic, vascular or vascular or gastroesophageal gastroesophageal proceduresprocedures

PHYSIOLOGY CONSIDERATIONS PHYSIOLOGY CONSIDERATIONS OF LATERAL DECUBITUSOF LATERAL DECUBITUS

Distribution of perfusionDistribution of perfusionDependent lungDependent lung

Distribution of ventilationDistribution of ventilationIndependent lungIndependent lung

blood flow increases more rapidly than ventilationblood flow increases more rapidly than ventilation

LATERAL DECUBITUSLATERAL DECUBITUS

PATIENT AWAKE, BREATHING PATIENT AWAKE, BREATHING SPONTANEOUSLYSPONTANEOUSLY Less Zone 1, more zone 2&3Less Zone 1, more zone 2&3 Blood flow to dependent lung >blood flow to Blood flow to dependent lung >blood flow to

independent lungindependent lung Ventilation greater in dependent lungVentilation greater in dependent lung Diaphragm of dependent lung pushed higher Diaphragm of dependent lung pushed higher

& stretched tighter& stretched tighter


PATIENT ANESTHETIZED, PATIENT ANESTHETIZED, SPONTANEOUSLY BREATHING, SPONTANEOUSLY BREATHING, CHEST CLOSEDCHEST CLOSED

Depend lung better perfusedDepend lung better perfused

FRC dec both lungsFRC dec both lungs

Depend lung becomes less compliant, upper lung Depend lung becomes less compliant, upper lung becomes more compliantbecomes more compliant

Increase in shunt and dead space ventilationIncrease in shunt and dead space ventilation


PATIENT ANESTHETIZED, PARALYZED, PATIENT ANESTHETIZED, PARALYZED, MECHANICALLY VENTILATED, CHEST MECHANICALLY VENTILATED, CHEST CLOSEDCLOSED

Depend lung better perfusedDepend lung better perfused

Vent to nondepend lung even greaterVent to nondepend lung even greater

Mech vent obviates effect of depend lung Mech vent obviates effect of depend lung diaphragm contractiondiaphragm contraction

Weight of abd contents physically restricts Weight of abd contents physically restricts expansion of dependent lungexpansion of dependent lung


PATIENT ANESTHETIZED, PATIENT ANESTHETIZED, SPONTANEOUSLY BREATHING, SPONTANEOUSLY BREATHING, CHEST OPENCHEST OPEN

MEDIASTINAL SHIFTMEDIASTINAL SHIFT

PARADOXIC RESPIRATIONPARADOXIC RESPIRATION


PATIENT ANESTHETIZED, PATIENT ANESTHETIZED, VENTILATION CONTROLLED, CHEST VENTILATION CONTROLLED, CHEST OPENOPEN

OPEN CHEST INCREASES COMPLIANCE OF OPEN CHEST INCREASES COMPLIANCE OF BOTH LUNGSBOTH LUNGS

Airway pressure dec in both lungsAirway pressure dec in both lungs

CI increases; no change in MAPCI increases; no change in MAP

CO2 elim greater from nondepend lungCO2 elim greater from nondepend lung

Dec amt of Zone 1 and dead space ventilationDec amt of Zone 1 and dead space ventilation


ADVANTAGESADVANTAGES Permits most complete access to hemithoraxPermits most complete access to hemithorax Length of incision can be easily extendedLength of incision can be easily extended Pt can be tilted forward/backward easilyPt can be tilted forward/backward easily Safest position for hilar dissectionSafest position for hilar dissection Permits control of hilar vesselsPermits control of hilar vessels


DisadvantagesDisadvantages Opposite hemithorax is inaccessibleOpposite hemithorax is inaccessible V/Q mismatchV/Q mismatch Contamination of dependent lungContamination of dependent lung Decrease FRC, airway closure & atelectasis Decrease FRC, airway closure & atelectasis

in dependent lungin dependent lung Injury from positioningInjury from positioning

SEPARATING THE LUNGSSEPARATING THE LUNGS

HOW:HOW:DOUBLE LUMEN ENDOTRACHEAL TUBEDOUBLE LUMEN ENDOTRACHEAL TUBE

UNIVENT ENDOTRACHEAL TUBEUNIVENT ENDOTRACHEAL TUBE

BRONCHIAL BLOCKERSBRONCHIAL BLOCKERS


WHY?WHY? To selectively ventilate/collapse a lung during To selectively ventilate/collapse a lung during

intrathoracic operationsintrathoracic operations

ABSOLUTEABSOLUTE Prevention of cross contam diseased to Prevention of cross contam diseased to

nondiseased lungnondiseased lung Redistrib ventRedistrib vent Required unilateral bronchopulm lavageRequired unilateral bronchopulm lavage


RELATIVE INDICATIONSRELATIVE INDICATIONSSurgical exposure for thoracic aortic aneurysmSurgical exposure for thoracic aortic aneurysm

Exposure for upper lobectomyExposure for upper lobectomy

Exposure for pneumonectomyExposure for pneumonectomy

Exposure for esophageal resectionExposure for esophageal resection

Exposure for subsegmental resectionExposure for subsegmental resection

COMORBIDITY & RISKCOMORBIDITY & RISK

Patients scheduled for thoracotomy are at Patients scheduled for thoracotomy are at inc risk of cardioresp failure or death if:inc risk of cardioresp failure or death if: Preexisting cardiopulmonary diseasePreexisting cardiopulmonary disease ObesityObesity Advanced ageAdvanced age TUMOR: eval for myasthenic syndrome, TUMOR: eval for myasthenic syndrome,

IADH(seen with small cell)IADH(seen with small cell) Consider pericardial involveConsider pericardial involve Consider pulmonary hypertensionConsider pulmonary hypertension

GA & ONE LUNG ANESTHESIAGA & ONE LUNG ANESTHESIA

No N2ONo N2O

Avoid hypoxemiaAvoid hypoxemia

CVP for infusion vasoactivesCVP for infusion vasoactives

Art LineArt Line

Ketamine infusion may be a choiceKetamine infusion may be a choice

Good muscle relaxationGood muscle relaxation

Be very particular about DLT placement after Be very particular about DLT placement after intubation AND after positioning changesintubation AND after positioning changes

GA & ONE LUNG ANESTHESIAGA & ONE LUNG ANESTHESIA

Hypoxia that occurs may requireHypoxia that occurs may requireGet an ABGGet an ABGMay need to revent the collapsed lungMay need to revent the collapsed lungCPAP to dependent lungCPAP to dependent lungPEEP if CPAP doesn’t helpPEEP if CPAP doesn’t help

Re-expand the deflated lung carefully at the Re-expand the deflated lung carefully at the conclusion of resection. Positive pressure is held conclusion of resection. Positive pressure is held at 35-40 cm H2O to allow surgeon to view suture at 35-40 cm H2O to allow surgeon to view suture lines and check to air leakslines and check to air leaks

Extubate(DLT); reintubate with normal ETT, continue Extubate(DLT); reintubate with normal ETT, continue emergence as indicatedemergence as indicated

CONTRAINDICATIONS TO DLTCONTRAINDICATIONS TO DLT

Lesion along the tube’s pathwayLesion along the tube’s pathway

Difficulty obtaining direct vision intubationDifficulty obtaining direct vision intubation

Critically ill pts who don’t tolerate apneaCritically ill pts who don’t tolerate apnea

Full stomach/inc risk of aspirationFull stomach/inc risk of aspiration

Any combination of aboveAny combination of above

REGIONAL/GAREGIONAL/GA

May use combined thoracic epidural with GAMay use combined thoracic epidural with GA

Level of thoracic epidural determined by surgeryLevel of thoracic epidural determined by surgery

Make sure a band of anesthesia exists after test Make sure a band of anesthesia exists after test dosedose

Utilizes min narcotics, lower gas concentrationsUtilizes min narcotics, lower gas concentrations

Enables quicker emergence/recovery with Enables quicker emergence/recovery with benefits of good analgesia benefits of good analgesia

RIGID BRONCHOSCOPYRIGID BRONCHOSCOPY

Performed for:Performed for: Removal FB, massive hemoptysis, dilate Removal FB, massive hemoptysis, dilate

tracheobronchial strictures, laser tracheobronchial strictures, laser bronchoscopy, stent placement, biopsy and bronchoscopy, stent placement, biopsy and staging of malignant processes, staging of malignant processes, establishment of an emergent airwayestablishment of an emergent airway


Worry about:Worry about:

Sharing the airway with the surgeonSharing the airway with the surgeon Requires extremely high vigilance and Requires extremely high vigilance and

excellent ongoing communicationexcellent ongoing communication Ventilating sidearm to maintain oxygenation & Ventilating sidearm to maintain oxygenation &

ventilationventilation

Arrhythmias, hypertension, hypoxemiaArrhythmias, hypertension, hypoxemia


Need to know:Need to know: Level of the lesionLevel of the lesion What is the lesion suspect forWhat is the lesion suspect for h/o ischemic processesh/o ischemic processes How do the lungs sound How do the lungs sound


Position: sitting or supinePosition: sitting or supineGlyco early – antisialogogueGlyco early – antisialogogueRoutine monitorsRoutine monitorsUsually sedation + topical, “spray as go”Usually sedation + topical, “spray as go”Use short acting drugsUse short acting drugsPostop hypoxemia will usually correct with Postop hypoxemia will usually correct with supplemental O2supplemental O2Keep the sedation light to avoid hypoventilation!Keep the sedation light to avoid hypoventilation!Remember laser precautions if the laser is the Remember laser precautions if the laser is the surgical methodsurgical method

FIBEROPTIC BRONCHOSCOPYFIBEROPTIC BRONCHOSCOPY

Allow evaluation of the tracheobronchial Allow evaluation of the tracheobronchial tree deeper than rigidtree deeper than rigid

Use for:Use for: Pulmonary disease diagnosis, staging Pulmonary disease diagnosis, staging

carcinomas, lavage/aspiration of thick carcinomas, lavage/aspiration of thick secretions in acute atelectasis, transbronchial secretions in acute atelectasis, transbronchial biopsy and brushingsbiopsy and brushings


Risks are related to reasons for procedure.Risks are related to reasons for procedure.

Goes up in patients with comorbidities of Goes up in patients with comorbidities of cardiac disease, severe hypoxemia and cardiac disease, severe hypoxemia and bleeding diathesis. bleeding diathesis.

Absolute contraindications may include Absolute contraindications may include unstable CV system, current life unstable CV system, current life threatening cardiac arrhythmias, and threatening cardiac arrhythmias, and severe hypoxemia.severe hypoxemia.


Problems during the procedure:Problems during the procedure: CoughingCoughing Hypertension usually b/o Hypertension usually b/o Tachycardia inad anes/topTachycardia inad anes/top

May require lung separation if bleeding May require lung separation if bleeding developsdevelops


EBL is usually negligibleEBL is usually negligible

Need to know from surgeon:Need to know from surgeon: Proceed thru ETT? (req 7.5-8.0)Proceed thru ETT? (req 7.5-8.0) Proceed next to ETT? (req 5.0-6.0)Proceed next to ETT? (req 5.0-6.0)

PNEUMONECTOMYPNEUMONECTOMY

INDICATIONS:INDICATIONS: Non-small cell lung CANon-small cell lung CA Drug resistant TB, mycobacterium, fungal Drug resistant TB, mycobacterium, fungal

infections, necrosisinfections, necrosis Trauma (last resort)Trauma (last resort)


Preop assessment may include:Preop assessment may include: How is their respiratory reserve? Check the How is their respiratory reserve? Check the

PFTsPFTs Is there Pulmonary HTN? b/o RV dys, valv Is there Pulmonary HTN? b/o RV dys, valv

dis, any arrythmias?dis, any arrythmias? Any concommitant CV dis?Any concommitant CV dis? Hoarseness? May indicate recurrent laryngeal Hoarseness? May indicate recurrent laryngeal

nerve involvementnerve involvement Eaton-Lambert syndrome = muscle wasting; Eaton-Lambert syndrome = muscle wasting;

may influence relaxant choicemay influence relaxant choice


PreopPreop Hydration, antibiotics, bronchodilators, place Hydration, antibiotics, bronchodilators, place

thoracic epiduralthoracic epidural Monitors: art line, CVP, PA on contralat sideMonitors: art line, CVP, PA on contralat side DLTDLT

Fluids: run dry; EBL usually 500ccFluids: run dry; EBL usually 500cc


Anticipate:Anticipate: Unrecognized flood lossUnrecognized flood loss Postop pulmonary edema, atelectasisPostop pulmonary edema, atelectasis DysrhythmiasDysrhythmias DVT & Pulm Emb occur 20%DVT & Pulm Emb occur 20% Persistent air leakPersistent air leak Excessive mediastinal shift = life threateningExcessive mediastinal shift = life threatening


MEDIASTINAL SHIFTS:MEDIASTINAL SHIFTS: IPSILATERALIPSILATERAL

Hypotension, arrhythmias, cardiac herniation, Hypotension, arrhythmias, cardiac herniation, pulmonary edemapulmonary edema

CONTRALATERALCONTRALATERALDec lung function, dec venous returnDec lung function, dec venous return

CHEST TUBES are kept clamped to CHEST TUBES are kept clamped to prevent this: brief unclamp for drainage of prevent this: brief unclamp for drainage of flds.flds.

LUNG REDUCTION SURGERY or LUNG REDUCTION SURGERY or PNEUMOPLASTYPNEUMOPLASTY

Palliation for terminal emphysema; Palliation for terminal emphysema; alternative to lung transplantalternative to lung transplantRisk with reactive airway disease, Risk with reactive airway disease, CAD and pulmonary HTNCAD and pulmonary HTNExclusions: pulm HTN, bronchospasm, LV Exclusions: pulm HTN, bronchospasm, LV dysfunct, bronchitis, inc sputum prod, dysfunct, bronchitis, inc sputum prod, persistent smoking, previous persistent smoking, previous thoracotomy/pleurodesis, obesity, thoracotomy/pleurodesis, obesity, cachexiacachexia

PNEUMOPLASTYPNEUMOPLASTY

FEV1 PREOP average 25-30% predFEV1 PREOP average 25-30% pred3-6% inhospital mortality3-6% inhospital mortality25% morbidity25% morbidity Air leaksAir leaks Resp failureResp failure Pulm embolismPulm embolism pneumoniapneumonia

Procedure goal: 20-30% lungs resect, reshaping Procedure goal: 20-30% lungs resect, reshaping diaphragm and chest wall. This allows improve diaphragm and chest wall. This allows improve lung recoil (dec LV & inc exp flow)lung recoil (dec LV & inc exp flow)


PREOPPREOP Maximize bronchodil therapyMaximize bronchodil therapy Minimize narcoticsMinimize narcotics Place thoracic epiduralPlace thoracic epidural Your goal is to extubate in the OR!Your goal is to extubate in the OR!


Monitors include art line, CVPMonitors include art line, CVPPrepare for DLTPrepare for DLTProcedure may begin with FOB by Procedure may begin with FOB by surgeon, then proceed with resectionsurgeon, then proceed with resectionResection may be unilateral / bilateralResection may be unilateral / bilateral““best side” firstbest side” firstRun them “dry”Run them “dry”Remember your PIPRemember your PIP


The need for reintubation and ventilation is The need for reintubation and ventilation is associated with extremely high morbidity.associated with extremely high morbidity.

anesthesia for non-cardiac thoracic surgery

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