Thoracic Surgery Service Manual

April 2005

Supported by a grant from I-Flow Corporation

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Thoracic Surgery Service Manual

University of North Carolina at Chapel Hill Department of Surgery

April 2005

Written with contributions from:

Alden M. Parsons, MD Ben Haithcock, MD

Winnie Lee, MD Ross Goldbaum, PA-C Ann Steagall, RN, OCN Brian Bednarski, MD Lindsee McPhail, MD

Nancy Moss, MD Stacy Bennett, MD

Britt A. Ritter, Pharm D, BCPS Becky Cicale, ARNP

Frank C. Detterbeck, MD Thomas M. Egan, MD

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Table of Contents I. Introduction to the Service 5 II. Reference 5 1) “Something’s not right....who do I call?” 2) Night call/crosscover 3) Common Thoracic CPT codes 4) Important CT Surgery phone#s III. Words of wisdom/rules of survival 8 IV. General service responsibilities 10 1) Rounds 2) Admissions 3) Inpatient consults 4) Clinic V. Conferences 12 1) MTOP Tuesday noon 2) Preop Conference 3) Cardiothoracic Division Conference 4) Cardiothoracic M&M VI. Clinic 13 1) Intern roles and expectations 2) What to think about 3) Sample clinic note VII. OR 15 1) OR expectations 2) Active study protocols to be aware of:

LCCC 0320 ADJ CHEMO IN STAGE I-IIIA LCCC 2012 NEO-ADJ CHEMO IN STAGE I/II VALID

3) Preop considerations, Postop care and Follow-up for common procedures: -Thoracotomy -Esophagogastrectomy -Thymectomy -Mediastinoscopy/Bronchoscopy -VATS Procedures -OnQ pain catheter placement -Lung Transplant (see Transplant chapter) 4) General postop considerations 5) Postop prophylaxis

6) Specific Follow-up instructions VIII. ICU care 22 1) Ventilator management 2) Postop pain control and sedation IX. Procedures 26 1) Chest tubes 2) Removal of Chest Tubes 3) Bronchoscopy 4) Central lines

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5) PA catheters 6) Thoracentesis X. Common medications 33 1) ICU meds 2) Transplant meds 3) Antibiotics XI. Transplants 35 1) Admission considerations 2) Preop specifics 3) Postop care 4) Postop specifics -CMV -Serum Drug Levels -Bronchoscopy -Rejection -Renal complications -GI complications 5) Role of Tx coordinators/pulm Tx service XII. Thoracic Surgery Reference 38 1) Lung CA -General points -Risk Factors for lung CA

-Broad categories of lung CA -Stage classification -Clinical Presentation -Evaluation/Diagnosis -Treatment/Outcomes 2) Esophageal CA 45 -General points -Stage classification -Clinical Presentation -Evaluation/Diagnosis -Treatment/Outcomes 3) Chest tubes 49 -Pleur-evacs -TPA 4) AFib 51 5) PFTs 54 -Basics -Review -Interpretation of Spirometry XII. Thoracic Surgery MSIII Guide 60 1) Objectives 2) Expectations 3) Specific Tasks 4) Weekly Schedule

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I. Introduction This manual is meant to be a succinct but relatively comprehensive guide for the intern on the thoracic surgery service. You should read it cover to cover during your first few days on service, then use it as a reference during your time on service. Thoracic is a very different experience for interns than most other services you will rotate on this year. You will have more responsibility, more OR time, may feel pulled in many directions and may occasionally feel overwhelmed. Refer to this manual often. It will give you a great deal of insight into how to take care of thoracic surgery patients, specific dos and don’ts, the attendings’ and chief resident’s expectations of you, and help you function more efficiently on the service. It is designed so that you can find the answer to just about any question you may ask yourself while on service. II. Reference 1) “SOMETHING’S NOT RIGHT….WHO DO I CALL?” The first answer to this question is, if something changes with a patient or deviates at all from the plan for the patient made by the team on rounds, LET THE CHIEF KNOW. If the CT fellow rotating on thoracic is in the OR, go to the OR to talk with him or her. If you have a patient emergency, call into the OR, or page the thoracic surgery PA, Ross Goldbaum, or one of the other CT fellows who may be immediately available to help. You can always call the patient’s attending, or the attending on call to resolve important issues, especially if the fellow is in the OR or otherwise unavailable. In addition, for specific issues or questions, there are other people associated with the service who can assist you: Contact What to call for Contact # When available Ross Goldbaum, PA General service ?s

Help with patients and procedures

Pager #216-0712 Weekdays

Ann Stegall, MTOP Clinic Coordinator

Scheduling of patients into MTOP clinic

Pager #216-4277 Office #966-1669

Weekdays

Ginny Ditzel, MTOP (499) and Benign Thoracic Clinic (088) Asst

Scheduling of outpatients, location of outside hospital films and records

Office #966-8128 Weekdays

Lung Transplant Coordinators: Becky Cicale Ken Davis

Any questions on management of lung transplant cases or patients

Becky pager #216-6741 Ken Pager #216-2412

Coordinator on-call 24 hours, 7 days/wk

CT Pharmacist: Britt Ritter

Inpatient medication questions

Pager #347-1468 Weekdays (on-call pharmacist during

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off hours) Pedar Noone, MD Attending, Pulmonary Transplant Consult team

Lung Transplant patient medication management questions

Dr. Noone 216-6174 or pulmonary fellow rotating on transplant

Weekdays, or on call pulmonary fellow on weekends

Bella Chauhan, CT office scheduling

Posting of OR cases or questions about OR schedule

Office #966-1868 Weekdays

2) NIGHT CALL – SIGNOUT AND CROSSCOVER Signout to the covering intern at the end of the day should be a printed service list along with a verbal signout on each patient detailing the issues of the day and what to notify the chief resident about. The intern on service should make sure that the cross-covering intern has a copy of the thoracic manual. 3) COMMON THORACIC CPT CODES: PROCEDURE CPT CODE Lobectomy via thoracotomy 32480 VATS Lobectomy 32663 VATS Wedge lung excision 32657 VATS Biopsy 32602 VATS pericardial window 32659 Mediastinoscopy 39400 Chamberlain 39010 Bronchoscopy 31625 Bronch with YAG laser debridement 31641 Pneumonectomy 32442 EGD with esophageal dilatation 43226 Thymectomy via sternotomy 21620 Esophagogastrectomy 2 Stage 43112 Double lung transplant 32853 Double lung transplant with cardiopulmonary bypass 32854 Decortication 32220 Excision of mediastinal tumor 39220 Lung resection with chest wall reconstruction 32525 VATS pleurodesis 32650

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4) IMPORTANT CT SURGERY PHONE #S

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III. Words of wisdom/rules of survival

These are just a few brief words of advice regarding your time on the Thoracic Surgery service. This rotation is considered the best rotation of your intern year and can be a great learning experience on many levels. It is the only rotation on which you as interns will have significant OR time, procedures and ICU exposure. Take advantage of this small team and intimate environment to learn the basics of thoracic surgery, which will benefit you throughout your surgery residency. With that in mind, here are a couple of brief words of wisdom to help you get started.

1. Don’t be afraid to ASK FOR HELP. As stated above, this is a busy rotation but you can learn a great deal if you just ask. The attendings and the fellows are excellent teachers and excellent resources . . . USE THEM.

2. Always keep the fellow informed about patient issues…this includes decisions

made by attendings in the absence of the fellow.

3. Chest tubes are the bread and butter of Thoracic Surgery - for each patient take note of the number of tubes, output (amount & nature), presence/absence of an air leak, and whether they are on suction or waterseal (see Chest Tube reference section).

4. Inserting chest tubes hurts. A lot. Sedation is often sabotaged by onset of severe

pain before the sedation has time to take effect. Dose them before you touch them (see Procedures chapter).

5. Never clamp a chest tube unless you do so temporarily to locate an airleak or are

about to pull it. 6. Dual chamber pleurevacs are no longer protected by water seal when one tube is

pulled and open to air. If you don’t understand the significance of this statement, see the pleurevac reference at the end of this manual. If, after reading that, you still do not understand this, please ask someone to explain it so that you do not become known as the “Pneumothorax Kid” after your first day on the service.

7. General chest tube management – every patient with a chest tube gets daily chest

x-rays while the tube is in place unless instructed otherwise. Usually, patients are placed to water seal when there is no air leak in the chamber. Dr. Egan usually prefers not to order a chest x-ray after patients are placed on water seal. Usually, chest tubes are pulled when there is no air leak, and the output is <200 mL/24 hours.

8. Thoracotomies – many patients on the service have had one and they are very

painful. Pain management is a key to rapid post-operative recovery. Be

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AGGRESSIVE about good pain control. Also, if a patient has been using 2 Percocet every 4 hours while awake, prescribing 20 Percocet at the time of discharge with a follow-up appt in 2 weeks will lead to an unpleasant quiz about your arithmetic skills.

9. Following up on #8: epidurals are excellent for post-op pain, do not allow the

epidural to be discontinued by the pain service on their a.m. rounds without the okay from the thoracic attending or the fellow.

10. This is Thoracic Surgery: make getting to the operating room your first priority.

You should be in the OR before the fellow.

11. The CTICU (and 4ANDS) are your home bases. The nurses are very experienced, especially in the CTICU, and can be very helpful. Treat them with respect because they can make your life easier.

12. The CTICU is run by the Cardiac and Thoracic Surgeons. In other words, you are

the critical care team. You are responsible for the patients. This is a great chance to learn some critical care as well as procedures such as a-lines and central lines.

13. Consults – are YOUR responsibility. Go see the consults and staff with the

fellow. These are also your patients. Be sure to monitor their CT output and daily CXRs.

14. Procedure supplies: the CTICU has all the supplies you need for chest tubes and

central lines. So be nice to the nurses. Theoretically you should try to get the supplies from the unit where the patient is, but in reality often you will need to stop by the unit.

15. Clinic is every Tuesday – come dressed appropriately and be ready for a

marathon.

16. Keep your patient list updated. It is a great tool for you and the team.

17. Don’t forget to use the Cardiac Surgery Residents as resources as well. They were in your shoes just a few months ago. They can help with procedures, answer questions about the ICU patients or anything else.

18. Dr. Egan does not allow toradol to be given to his patients, and feels strongly

about many other drugs– ask before you order any. 19. Lung transplant patients are a special subset. There are many medication issues

and conflicts with immunosuppressive agents. Interns should always check with the fellow or attending before ordering ANY medication on a lung transplant patient.

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IV. General Thoracic service responsibilities ROUNDS The timing for rounds will be determined by the fellow. Prior to rounds, check to see the cases scheduled for the day and determine if extra equipment will be needed (the bronchoscope from the pulmonary lab) and make sure that the cases are divided up such that an intern is available for each case. It is your responsibility to pre-round on all patients on the rounding list. This is most beneficial for you, to formulate your plan for the patient for the day. You will split up both the ICU and floor patients between the members of the team. Most importantly, talk to the cross-cover about the events from the night, and check with either the charge nurse or the RN taking care of the patient for important issues. Information to obtain on each patient should include the vital signs, 24 hour output from either chest tube or drains, changes that occurred during the last 24 hours, medications, lab values, pathology and culture updates. Each patient should be examined including the chest tube/drain site and any incisions that have been created by our service. During your exam, be mindful of any change in the amount of fluid or character of fluid drained by the chest tubes. Also during your assessment make sure that all connections for chest tubes are intact. After acquiring this information for each patient on the list, the patient should then be presented for rounds. During the presentation, do not just read data that is visible on the patient’s flow sheet. Information that should be mentioned should include any pertinent vital signs (i.e. fevers, significant changes in hemodynamics, chest tube output, or abnormal lab values). The presentation should be well organized by systems. During your presentation, the plan you formulated for the patient for the day should be discussed. After discussion of the patient with the team, a plan will be finalized and implemented. At the conclusion of rounds, convene with the fellow and quickly make sure that the plan for each patient is clear. You will then split the responsibilities of the day with your other team members. Briefly discuss the plan with the nurses and then carry out the required duties. If there are any questions at any point during the day concerning any of the patients, or the plans made on a.m. rounds cannot be accomplished, talk with the fellow early in the day. Throughout the day, periodically make mini rounds on the patients; make sure that all of the items to be done with each patient are performed and be abreast of any new issues concerning each patient. Let the fellow know of any significant changes that occur during the day. If there are any issues that you may not understand, ask. At the end of the day, after all cases are done and/or all patients have been seen in clinic, there will be formal evening rounds. Again, make sure any and all pertinent information has been gathered prior to making these rounds. After all of the work has been done for the day and rounds are over, any loose ends should be managed and then sign out the patients to the covering resident for the evening. Make sure that the resident knows which fellow is available for thoracic calls.

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ADMISSIONS Admissions to the Thoracic Service will come from the emergency room, operating room, clinic or from another facility. Let the thoracic fellow know of any admissions, even if the staff is aware. Discuss with the fellow the plan for the patient and any procedures that may be planned for the patient. The intern’s responsibility is to write and dictate a History and Physical, place in orders for the patient, and make sure any consents are signed (especially if the admission is for a lung transplantation). INPATIENT CONSULTS Consults will come on this service. Consultants may call you directly or may contact the fellow or staff first. It is your responsibility to see them as quickly as possible. Once you have seen and examined the patient and have gathered any pertinent data available (films, labs, etc.) let the fellow know of the consult. For your learning experience, devise a plan but do not implement this until after discussion with the fellow and staff. Any plans or changes that have been discussed concerning the consult patients should be discussed with the primary team prior to implementation. These patients should be added to the rounding list and should be seen on a daily basis with the remainder of the primary patients. CLINIC Clinic occurs every Tuesday and starts at 8:30 a.m. and continues until the last patient is seen (generally until 6 pm.) Both interns are required to be in clinic and dressed appropriately. All floor work must be done prior to clinic. Please refer to the Clinic section of the manual for details of clinic.

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V. Conferences MTOP Tuesday Noon Conference

• Tuesdays at 12:15, in RAD-ONC Conference Rm, Basement of Gravely Bldg. • Purpose is review and discussion of the evaluation and management plans for new

patients or patients who have unusual presentations or problematic issues. • If you see a new patient in clinic that morning, be prepared to give a concise presentation

at conference. This should include chief complaint, results of key diagnostic studies (e.g. CT scan, PET scan, bronchoscopies/endoscopies, PFTs, and path reports), smoking history, and, importantly, performance status. Become familiar with the four-level ECOG scale which is the accepted measure of a patient’s level of functionality, used when planning treatment for cancer patients. (see Lung Cancer Reference chapter)

• Often there is an excellent meal at this conference. Resist the temptation to overeat, and subsequently nap, shortly before you are rudely awakened to present your patient.

• Of note, the thoracic service has approval from the clerkship coordinator for medical students to miss their regularly scheduled lectures to attend.

Preop Conference

• Location and schedule is variable, but most often occurs on Thursdays • Conducted by a thoracic attending as a combination teaching rounds and opportunity to

confirm that patients are adequately prepared for surgery. You will be assigned patients to present by the chief.

• The attendings prefer one-sentence histories. For the purposes of surgery, key issues are the location of CT scans, the results of PFTs, and the predicted postoperative FEV1 of any patient scheduled for pulmonary resection. It is helpful to be familiar with the process of clinically staging lung cancers while evaluating a patient who might be a surgical candidate. Excellent references for this are:

• Book- Diagnosis and Treatment of Lung Cancer by Detterbeck et al • Chapter- ‘Lung Neoplasms’ by Detterbeck and Socinski in: Surgery: Basic

Science and Clinical Evidence, second edition, ed. Harvey Pass et al. • The Lung Cancer ref chapter of this manual.

Cardiothoracic Division Conference

• Friday mornings from 7-8 AM in OR classroom on 2nd Floor. • The chief residents rotate weeks to do presentations. If the thoracic chief is presenting a

case with outside films, the interns need to make sure they will have the film for the morning conference. Outside films are stored in the “MTOP Box” in Chest Reading Room across from Film Management in basement of Women’s Hospital. Make sure you sign the MTOP films out if you take them from there.

• House officers are picked by the chief who is presenting that day to interpret films supplied by the radiologists. These tend to be meat & potatoes issues, eg: tube & line placement, key CXR findings in common clinical scenarios.

Cardiothoracic M&MConference

• 2nd Thursday of the month in Wing C Conference Room • Fellows present.

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VI. Clinic INTERN ROLES AND EXPECTATIONS 1. Both interns are expected to go to clinic every Tuesday, be on time and participate.

Floor work such as paperwork for anticipated discharges should be done the day before as much as possible to facilitate both interns being on time to clinic on Tuesday mornings. Dress for clinic is workday clothes, no scrubs.

2. Interns should check the clinic board for patients that need to be seen. The patients

will be listed as by attending name. Red dots mean the patient needs to be seen, green means the patient is being seen and blue means the patient is ready for d/c. Choose a patient, replace the red dot with a green one and initial so that the attending knows who is seeing the patient. When the patient is ready for d/c replace the green dot with a blue dot and place all paperwork in the exam room door.

WHAT TO THINK ABOUT 3. Identify whether the patient is new or familiar, preoperative or postoperative (in the

recent or distant past), and who the referring physician is. 4. Patients returning after cancer operations are evaluated differently depending on how

far out they are from their surgery. For recent postop patients, be sure to check wound sites. Patients further out from their surgery are evaluated for evidence of recurrence. Most importantly, talk to the patient. Look for organ specific symptoms such as bony pain, neurologic symptoms, or pulmonary symptoms, as well as non-specific symptoms such as anorexia, weight loss, or night sweats; any of these new symptoms might suggest recurrent or metastatic disease. Examine them for new adenopathy. Also for patients further out from surgery, look for evidence of a new primary lung CA, as well as recurrent disease, by CXR.

5. For patients being evaluated for a new lung mass, assess risk factors for lung CA (see

Lung CA ref section). 6. Pull up the CXRs on PACS to compare old and new CXR. Attendings will want to

see these as well, but formulate your own idea of the CXR findings beforehand. Postoperative non-small cell lung cancer patients are seen q 3 months x 4, then q 6 months x 2, then q 12 mos with a CXR each time.

7. Make sure if a patient is enrolled in a study or clinical trial that they are seen by the

appropriate person and have blood drawn if needed. If questions, ask Ross. 8. Write clear, concise, readable notes (see example) that include specific dates of

diagnosis and operation with specific TNM stage, documented by a pathology report. Ask the attending if he/she would like for you to dictate the clinic note.

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SAMPLE CLINIC NOTE

65 yo WM Referring physician____________________________ S/P 6/15/92 LUL resection for T1NoMo (Stage I) squamous cell carcinoma Denies any new SOB, cough, hemoptysis, neurologic or bone symptoms, or constitutional symptoms such as fatigue, anorexia, weight loss No cervical/supraclav adenopathy; lungs clear CXR—no change from 6 mo ago (1/12/94) No evidence of recurrence RTC 6 months

9. To schedule an operation, call Bella (CT office) at 6-1868 with: Name/MRN/DOB Date of Admission Date of Operation Procedure Attending 10. Make sure that all f/u orders are written on the order sheet. If the patient needs to go to pre-care find a clinic nurse and give the pre-op w/u to her. She will make a copy for the clinic and one for you to keep in case it is lost. The patient must take the original to pre-care. If the patient needs to return to clinic later in the day note this on the board under the blue dot. Interns present each patient to the Chief Resident or Attending Surgeon. 11. Dictate all H & P’s on patients who are admitted from clinic. Order studies that the patient may need during the day as “outpatient orders” prior to their getting a bed assignment. CPOE ‘inpatient orders’ can only be implemented after the patient has a bed assignment in the system, which often creates long delays.

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VII. OR OR EXPECTATIONS The thoracic surgery service differs from many of the other services you will rotate on this year in that interns are expected to be in the OR and participate in cases every day. This is a vital part of your educational experience on the service. Plan ahead which intern will be in the OR for the day, and that intern should be in the room (usually OR 5, 6, or 11) when the patient arrives in the room, remain in the case until it is completed (unless you are paged out for a true patient emergency), then transport the patient to the PACU or CTICU. *Key point: You will have the opportunity to participate in the operations, but this is infinitely more likely to happen, and to a greater extent, if you know about the patient/disease/operation, are in the OR at the beginning of the case and stay the whole time, and seem interested in what is going on (even if you are not). In order to stay under the 80-hour work restrictions, you must plan which intern will be in the OR daily based on the overall amount of hours for each intern for that particular week. For example, the intern who has the upcoming weekend off should be the one designated to scrub for a case during the preceding week that may run late in the day or evening. The ‘weekend call’ intern should try to conserve his/her hours during the preceding week. ACTIVE STUDY PROTOCOLS TO BE AWARE OF FOR SURGICAL NSCLC PATIENTS:

1) LCCC 0320 ADJ CHEMO IN STAGE I-IIIA Patients with stage I, II, or IIIA NSCLC who are resected are randomized to receive adjuvant Carbo/Docetaxel or no adjuvant chemotherapy. 2) LCCC 2012 NEO-ADJ CHEMO IN STAGE I/II Patients with stage I or II NSCLC are randomized to receive neoadjuvant

(given preoperatively) GEM/Taxol or GEM/Carboplatin. 3) VALID (LCC0119) (Venous or Arterial Ligation and Intraoperative Dissemination of cancer cells)

Patients enrolled in this study will have preop, periop, and followup samples of blood, bone marrow, pleural lavage fluid collected to study micrometastatic disease in early stage lung cancer patients undergoing resection. Detection of small numbers of tumor cells in these samples will allow examination of the significance of intraoperative tumor manipulation, and will also be correlated with recurrence. This study is closed to new enrollment, but patients will still need follow-up blood draws at clinic visits at 6 mos, 12 mos and 24 months postop.

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PREOP CONSIDERATIONS, POSTOP CARE AND FOLLOWUP What follows is an outline of the general postop routine for the common thoracic surgery cases. For each one, the points listed are suggestions for you to think about at each stage- they are not written in stone and progress may depend on the patient’s individual circumstances. In all cases, make sure you DISCUSS WITH THE CHIEF any major orders before you write them. Common Thoracic Surgery Procedures: 1) Thoracotomy A thoracotomy, whether posterolateral or vertical muscle-sparing, is the most common thoracic incision. It is generally a very painful incision and requires aggressive pain control.

THORACOTOMY Preop considerations

●PFTs? ●Location of outside films? ●If risk factors for CAD, is pt on Beta Blockers? ●Is patient on anti-platelet/anti-coagulant drugs?

Day of Surgery ●Bring outside films to OR. ●Ancef (if not allergic) on call & SCDs

Immediate Postop period (POD#0)

●Admit to 4ADS unless you are told otherwise ●Chest tube to -20cm suction, check CXR ●Incentive spirometry q1hour, ambulation (PT consult if needed) ●Chest PT and nebs not as prophylaxis, but order if needed for incr secretions ●Order prn meds and POD#1 labs only if you have specific reasons ●Regular diet, medlock IV in PACU.

POD#1 ●Place chest tube to H2O seal on POD#1 if no air leak ●Wean O2 ●OOB

POD#2 and rest of hospital stay

●D/C central line ●Allow epidural to be removed by anesthesia only after cleared by thoracic attending and after other appropriate analgesia has been initiated. ●D/C foley 6 hours after epidural removed ●Remove pain ball when empty ●Consult rehab or social work

D/C and Follow-up instructions

●Discharge Medications: Assess requirements at discharge and prescribe 30 day supply of pain medication – do the math. Consider long-acting narcotics such as oxycontin, depending on the patient and the attending. ●PT should not drive or lift anything heavier than 10 # until first f/u appt. ●Remember: a constipated patient will hound you mercilessly, so all pts on narcotic painkillers should be discharged with prescriptions for Senokot and Colace. ●Remove Steri strips in 7 days. ●Call for signs and symptoms of wound infection ●Pt may shower after dressings are off, but should not immerse wounds in bath for two weeks, or at all if they are open or draining. ●For questions, call Ross Goldbaum at 966-3381 8a-5p or call Hospital Operator and and ask for Thoracic surgery resident on call. ●Pts on long-acting narcotics should be cautioned against abrupt discontinuation. Pts should be counseled to call several days before they run out of narcotic analgesics, since these can’t be telephoned in.

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2) Esophagogastrectomy Esophageal resection (partial or total) usually done with a gastric pull-up, and usually done for cancer, but occasionally for benign disease (i.e. stricture). See section XII for specific types of surgical procedures/approaches.

ESOPHAGOGASTRECTOMY Preop considerations

●Location of outside films? ●If risk factors for CAD, is pt on Beta Blockers? Needs workup? ●Is Patient on anti-platelet/anti-coagulant drugs?

Day of Surgery ●Bring outside films to OR. ●Unasyn 2g IV OCTOR & SCDs ●Make sure patient has at least a T&S, potentially a T&C for 2U PRBCs

Immediate Postop period (POD#0)

●Ask whether the patient should go to CTICU or 4ADS ●Order postop labs and prn meds only if you have a specific reason for ordering them ●Diet strict NPO ●Sign above bed “Do not manipulate NGT” ●After esophagectomy all patients should be maintained in reverse Trendelenberg, and will need to elevate the head of their bed at home to prevent aspiration. ●If extubated, don’t forget incentive spirometry (all pulm toilet stuff) ●SCDs ●Chest tube to -20cm suction, check CXR ●Write order to keep bed in reverse trendelenburg at all times ●Write order to call you if UOP <30 mL/hour ●If the patient has hypotension or low UOP postop, most likely will need volume. The cases are long, intraop resuscitation may not be adequate, and the patients often continue to 3rd space fluid.

POD#1 ●Will usually begin 10cc/hour JT feeds. Ask your chief. ●Increase activity- OOB to chair, ambulate 50 ft, PT consult if needed.

POD#2 ●If tolerating JT feeds, increase to 20cc/hour. ●KVO IVFs ●Increase activity to OOB TID, ambulate 200 ft x 3

POD#3 ●Increase JT feeds 40 cc/hour ●Increase activity ●Wean O2 ●Place chest tube to H2O seal

POD#4 ●Increase JT feeds to 60 cc/hour ●Possibly D/C epidural and foley- discuss with team.

POD#5 ●Barium swallow study ●NPO in AM for study ●Begin cycling JT feeds- run from 10pm to 8am at 60cc/hour. ●If barium swallow negative for leak, advance diet as tol & convert meds to PO.

POD#6 ●If tolerating JT feed cycling, increase rate to 70cc/hour 10pm-8am ●Remove chest tubes ●Remove JP drain ●D/C IVFs ●Consult social work to begin D/C planning

POD#7 ●Increase JT feeds by 10cc per day as tolerated to goal 100cc/h at night ●Remove staples ●Anticipate D/C home

D/C and Follow-up instructions

●Teach JTube care, tube feeding instructions, home health ●Call for signs or symptoms of wound infection ●Do not prescribe a medication unless the patient has been on that medication for at least 24 hrs prior to discharge. ●Continue appropriate preoperative medications (check admission H & P)

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●Patient should not drive or lift anything heavier than 10 # until first f/u appt. ●If the pt is requiring q4 hour pain meds, consider placing pt on a longer acting pain med BID dosed such as MS Contin or Oxycontin, with a short acting med such as percocet in between for breakthrough pain. ●Give the patient at least a month supply of pain meds at discharge. ●Remember: a constipated patient will hound you mercilessly, so all pts on narcotic painkillers should be discharged with prescriptions for Senokot and Colace. ●Pt may shower after dressings are off, but should not immerse wounds in bath for two weeks, or at all if they are open or draining. ●For questions, call Ross Goldbaum at 966-3381 8a-5p or call Hospital Operator and and ask for Thoracic surgery resident on call. ●Pts on long-acting narcotics should be cautioned against abrupt discontinuation. Pts should be counseled to call several days before they run out of narcotic analgesics, since these can’t be telephoned in.

3) Thymectomy This is usually done via sternotomy, for myasthenia gravis (MG), or for thymoma or thymic carcinoma.

THYMECTOMY Preop considerations

●Location of outside films? ●MG patients are always admitted to Neurology the day before for assessment of surgical candidacy and possibly for plasmapheresis.

Day of Surgery Bring outside films to OR. Immediate Postop period (POD#0-1)

●Admit to 4ADS (almost always go to floor) ●Order RT to check NIF (negative inspiratory force) and FVC in PACU and q8 hrs and document on flow sheet. ●Teach post-sternotomy sternal precautions (non-weight bearing of the upper extr) ●Chest tube (if there is one) to -20cm suction, check CXR ●Regular diet ●Myasthenics have special medication requirements and restrictions. The neurology resident on call should be paged in the immediate postop period to manage the patient’s myasthenic medications. ●Pay close attention to MG postop medication needs, which may include: Hydrocortisone 100 mg IV q 8 hrs (perioperative stress dose steroids if previously on steriods) AND/OR Cellcept, cyclosporine, Mestinon (follow the Neurology Service recommendations) ●Postop check serum K, and serum Mg q8hrs x 24hrs, then qd ●Order other postop labs on an individual basis if specifically needed.

POD#2 and rest of hospital stay

●Serum Mg qday for MG pts ●Continue to follow NIF and FVC ●Place chest tube to water seal when no air leak, remove when output <200 mL/24 hours.

D/C and Follow-up instructions

●Sternal precautions and no heavy lifting greater than 10# until first f/u appt. ●Call for signs or symptoms of wound infection ●Remember: a constipated patient will hound you mercilessly, so all pts on narcotic painkillers should be discharged with prescriptions for Senokot and colace. ●Remove Steri strips in 7 days. ●Pt may shower after dressings are off, but should not immerse wounds in bath for two weeks, or at all if they are open or draining. ●For questions, call Ross Goldbaum at 966-3381 8a-5p or call Hospital Operator and and ask for Thoracic surgery resident on call. ●Pts on long-acting narcotics should be cautioned against abrupt discontinuation. Pts should be counseled to call several days before they run out of narcotic analgesics, since these can’t be telephoned in.

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4) Mediastinoscopy/Bronchoscopy, Chamberlain procedure Mediastinoscopy is a procedure done through a small incision above the sternal notch through which a scope is placed for visualization and biopsy of lymph nodes along the trachea (stations 2L, 2R, 4L, 4R, and 7 at carina) which are suspicious for malignancy (>1cm on CT scan or hot on PET), or for other diagnostic needs. A Chamberlain procedure is done through an anterior chest wall incision (usually 2nd intercostal space) for biopsy of lymph nodes in the aorto-pulmonary window (stations 5 and 6).

MEDIASTINOSCOPY/BRONCHOSCOPY Preop considerations

●For Detterbeck have an active T&S. For Egan T&C 2 units PRBCs ●If risk factors for CAD, is pt on Beta Blockers? Need workup? ●Is patient on anti-platelet/anti-coagulant drugs?

Day of Surgery ●Bring outside films to OR. ●Ancef 1 gm iv 30 min before incision & SCDs

Immediate Postop period (POD#0-1)

●Check CXR 4 hours after case – can go to PCS w/order: may D/C after CXR cleared ● Usually pts go home on day of surgery of POD#1 unless they are inpatients for other issues.

D/C and Follow-up instructions

●Remove dressings in 48 hours. ●Remove Steri strips in 7 days. ●Pt may shower after dressings are off, but should not immerse wounds in bath for two weeks, call for signs or symptoms of wound infection ●For questions, call Ross Goldbaum at 966-3381 8a-5p or call Hospital Operator and and ask for Thoracic surgery resident on call.

5) VATS (Video-Assisted Thoracoscopic Surgery) Pulmonary Wedge Resection, Lobectomy (or other minimally invasive thoracic procedure) Pulmonary resections and other thoracic procedures can now often be done with a thoracoscope, with or without a small access incision.

VATS Preop considerations

●PFTs? ●Location of outside films ●If risk factors for CAD, is pt on Beta Blockers? ●Is patient on anti-platelet/anti-coagulant drugs?

Day of Surgery ●Bring outside films to OR. ●For VATS cases position waist directly over kidney break

Immediate Postop period (POD#0-1)

●Check CXR ●Chest tube (if they have one) to -20cm wall suction ●Regular diet ●Place chest tube to water seal if no air leak

POD#2 & rest of hospital stay

●Remove pain ball when empty ●Remove chest tube if output < 200mL/day

D/C and Follow-up instructions

●PT should not drive or lift anything heavier than 10 # until first f/u appt. ●Remember: a constipated patient will hound you mercilessly, so all pts on narcotic painkillers should be discharged with prescriptions for Senokot and colace. ●Remove dressings in 48 hours. ●Remove drsgs 48h, Steri strips in 7d, call for signs/symptoms of wound infection. ●Pt may shower after dressings are off, but should not immerse wounds in bath for two weeks, or at all if they are open or draining. ●For questions, call Ross Goldbaum at 966-3381 8a-5p or call Hospital Operator. ●Pts on long-acting narcotics should be cautioned against abrupt discontinuation. Pts should be counseled to call several days before they run out of narcotic analgesics.

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6) OnQ Pain Catheter placement The ON-Q Pain Buster is utilized to provide non-narcotic pain relief following thoracotomies and thoracoscopic procedures. The key components you will need to implement the ON-Q are as follows:

ON-Q Pain Buster kit: either PM026 (single line) or PM025 (dual line) Tegaderm Steri-Strips Bupivicaine (typically .5% plain, no epi) Tunneling device Long introducer

Hospital staff should be familiar with filling the device. Once the catheter has been put in place it is important to secure it with steri-strips. If this is not done, the catheter could slip out and the pump is rendered useless. Prior to breaking down a case, a tegaderm should be placed over the puncture site to reduce the chance of infection. It is important to be cautious about pulling on the catheter when removing ioban and drapes. The ON-Q will deliver therapy for 4-5 days. You will notice the catheter is empty when the "ball" reservoir is completely collapsed. It can be supplemented with oral medications, or if needed, PCA for breakthrough pain. The goal is to reduce the overall need for supportive narcotics so that the patients return to normal function as quickly as possible. GENERAL POSTOP CONSIDERATIONS 1) Dr. Egan prefers in general to keep post-pulmonary resection patients on the dry side

postop. Do not write them for maintenance IVFs. 2) Make sure the RNs know to call you for UOP<30mL/hour. If an Egan patient does

require a fluid bolus, use 100cc 25% albumin, or 250cc 5% albumin, NOT crystalloid.

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POSTOP PROPHYLAXIS

SPECIFIC FOLLOW-UP INSTRUCTIONS

• Schedule pulmonary resections, esophagogastrectomies, and thymectomies to f/u in 1 to 2 weeks at Gravely Clinic with a CXR.

• Detterbeck patients: f/u in Ross Goldbaum’s Monday clinic. • Egan patients: f/u in Tuesday MTOP clinic.

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VIII. ICU care VENTILATOR MANAGEMENT Rules/Considerations

1. Do I need to intubate my patient? If you are thinking that a patient needs intubating, they probably do. Always start with the simple:

• What are the vitals (tachy? hypertensive or hypotensive?) • Is the patient comfortably breathing (can they converse with

you, follow commands?) • Are they oxygenating well? (O2 sat) • Is their ABG okay? • What does their CXR look like? • Always think about WHY they are desatting/having respiratory

issues: 1. Pneumothorax 2. Pulmonary Embolism 3. Volume Overload/Pulmonary Edema 4. Pneumonia 5. MI 6. Narcotic Overdose (give Narcan)

2. Should I call? a. If you are thinking this, then the answer is likely yes b. Any time a patient is: looking worse, needs ICU care from floor, needs

intubating, is failing on current ventilator mode (abg’s getting worse) c. Who to call?

i. Fellow or Cardiac PGY2 ii. Senior In House, Junior In House, and Bed Commander are able to

help in an acute situation iii. Call a code and help will arrive if patient is crumping iv. The attendings want to be informed. It is OK to call the patient’s

attending or the thoracic attending on call- especially if the fellow is not immediately available.

The Nuts and Bolts of ventilator management 1. Indications: when to intubate ●again, this is a clinical judgment ●general parameters are: Resp rate> 35, PaO2 <60, PaCO2>50, and ph<7.2, HR>120 Neurologic status deteriorating 2. Modes of Ventilation:

Volume Control: ●Vent delivers a preset Tidal Volume (VT) at a preset frequency ●Uncomfortable mode, patients require heavy sedation and usually paralytics

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Assist-Control:

●Vent provides present tidal volume (VT)in response to a patient’s initiated breath. There is a pre-set backup rate if patient does not initiate a breath in time.

SIMV (Synchronous Intermittent Mandatory Ventilation) ●Patient receives a number of mechanical breaths with a pre-set tidal volume and pre-set rate ●Patient can breathe spontaneously between intermittent breaths delivered by the vent

Pressure Support: ●For each patient-initiated breath, the ventilator delivers a pre-set pressure, and the tidal volume (VT) is determined by the patient’s respiratory effort and lung compliance.

CPAP: ●Positive pressure is maintained throughout cycle of breathing. ●no pre-set VT or rate

PEEP: Maintenance of positive pressure (Positive End Expiratory Pressure) throughout expiratory cycle to prevent return of airway pressures to atmospheric pressure at end of expiration. This serves to keep bronchioles open and maintain or increase FRC (note: this is on the absite every year)

3. Ventilator Adjustment Two main categories of problems: Poor oxygenation and poor ventilation.

1) Oxygenation—controlled by PEEP and FiO2. ●FI02: in an acute situation, the FI02 can be increased. Goal is to keep FI02 40-50% or less. ●PEEP: helps reopen alveoli and splint them open. increase the PEEP if increased FiO2 requirement. Generally increase by 3-5, wean slowly when decreasing.

2) Ventilation—controlled by the RATE, Tidal Volume (VT) and the PS (pressure support). More simply, ventilation should be thought of in terms of ‘minute ventilation,’ which is RR (breaths/minute) X VT (in liters). Anything that increases minute ventilation should increase the effectiveness of ventilating the patient (i.e. reduce CO2). Rate and VT do this in obvious ways, PS affects ventilation by increasing the VT on patient-initiated breaths. Specifically, if:

●The CO2 is rising (respiratory acidosis): Increase the rate (by 2-5) Increase the PS (by 2-5) Increase the VT

●The CO2 is falling (respiratory alkalosis): Check to see if the patient is agitated or in pain Decrease the rate (by 2-5) Decrease PS (by 2-5) Decrease the VT

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4. Other issues: Increasing Peak Pressures: greater than 35 Is the patient agitated/bucking the vent- more sedation May need to change modes—pt may need paralysis Call fellow Has the CXR changed? New PTX, pneumonia, mucous plug? Is the chest tube accidentally clamped?

5. General Ventilator Settings: where to start Standard SIMV settings: Tidal Volume: 7-10 cc/kg is a ballpark volume but this may vary from

patient to patient depending on their lung compliance, type of resection, underlying lung disease etc- should individualize this based on each patient.

FiO2: 100% then wean for sats >92% Rate: IMV 10-16 PS: 10 Peep: 5 6. References

●Nurses---CTICU nurses can be your best friend. If they are telling you a pt is sick, they probably are. Make a plan or call a fellow.

●Respiratory Therapists—generally helpful in making vent changes. If going from one mode to another (SIMV—PC) and/or paralyzing a patient should trigger a call first

●ICU Manual (Blue Marino Text) Equations you may wanna know: Arterial Content 1.34 x Hb x Sa02 + (0.003 x Pa02) Ca 02 normal ==20 ml/dl Cardiac Index= CO/BSA Cardiac Output= HR x SV Oxygen Delivery= Ca 02 x CI Oxygen Consumption = C (a-v) O2 x CI Alveloar-Arterial difference= PA02 – Pa02 normal (A-a) Do2 = 50 mmHG Minute Ventilation= RR x TV References: 1) Marino, et al. ICU book (light blue). 2) Lung-protective ventilation strategies in acute lung injury. Crit Care Med. 2003 Apr;31(4 Suppl):S312-6. Review. PMID: 12682458 [PubMed - indexed for MEDLINE] 3) Management of sedation in mechanically ventilated patients. Curr Opin Crit Care. 2004 Feb;10(1):40-6. Review. PMID: 15166848 [PubMed - indexed for MEDLINE]

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POSTOP PAIN CONTROL AND SEDATION

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IX. Procedures CHEST TUBES (AKA THORACOSTOMY TUBES) What size? Of course, this depends on why you are putting it in. If it’s for fluid (e.g. hemothorax, empyema) you want a big one (i.e., 32Fr). If it’s for air (eg pneumothorax), it can be smaller (i.e., 24-28Fr.) ASK BEFORE OPENING THE TUBE. Where does it go? Again, depends on why you are putting it in, but if it’s in the thoracic cavity, it should be okay. Most often we place them 1-2 intercostal spaces below the nipple in the anterior axillary line. If it is for fluid, you want to try to direct it posteriorly. If it if for air, it will be most effective if positioned antero-apically.What do I need? A nurse to administer narcotics (sometimes benzos), thoracostomy tray, chest tube, 4x4s, betadine, 0 silk, cloth tape, sterile towels, sterile gown/gloves/mask, pleurevac, suction, 1% lidocaine 20cc (this is the most important part of pain control). ***MEMO by Peter Milano*** To avoid struggling in the MICU to find all of these supplies quickly for an “emergent” chest tube which you may frequently be called for, it’s a great idea to have a pillowcase full of these supplies ready to go. Peter states that he invented the time-honored practice of the under-the-callroom-bed-emergent-chest-tube pillowcase. Thank you, Peter. Where do I start? – Get the fellow first

• Position patient so that correct side is close to edge of bed, put his/her arm above the head. Prep out a wide area with betadine soaked 4x4s. Typically your finger width transverse incision will be in the anterior axillary line over the sixth rib, but this depends on whether you want an anterior or posterior tube. Think about the “trajectory” of the tube ahead of time…in other words, decide where you want the tube to enter the chest, then make your incision in a place that will point the tube where you want it to go, making sure you make a long enough skin tunnel so it will not leak air. Numb the area with lidocaine – make sure you get the rib as that hurts the most.

• Make your incision and using a Kelly clamp, bluntly dissect superiorly to the intercostal space you’re aiming for. Feel with your finger intermittently to ensure that you are going in the right direction. You want to hug the rib above – remember VAN runs on the inferior posterior surface of ribs. STAY ABOVE THE RIB. An intercostal artery injury during chest tube placement will lead to a significant hemothorax and likely a trip to the OR for evacuation.

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FIGURE 1: Technique of tube thoracostomy placement

• To get through the pleura you have to use some brute force – gentle pressure

doesn’t work, and in fact may just separate the pleura from the chest wall. You will know you are in when you get either a rush of air, blood, or fluid.

• Open the jaws of the Kelly wide while in the pleura to make your hole bigger. Stick your finger into the thorax, make sure you are actually IN the chest, and feel for adhesions – gently brush them away as you can.

• Take your Kelly clamp and guide the chest tube into the pleural cavity – holes go first and get the last hole into the chest cavity. If you feel resistance, don’t force it – you may be in the fissure. Pull back and redirect. It’s a good idea to have a Kelly clamp on the other end of the tube occluding it otherwise whoever is standing behind you (likely your supervising resident) will pay the price when the tube enters the fluid collection.

• You will notice condensation in the tube, which will confirm placement. Secure the tube in place with 2 0.0 silk sutures, making sure to occlude the incision.

• After it’s secured, hook the tube up to the pleur-evac. Tape the tubing connection with thin strips of cloth tape in an “H” so that you can still visualize the connection. Tape down the entrance site with lots of cloth tape to give it a seal. Create a mesentery of tape for the floundering remainder of the tube.

• Get a chest x-ray and check it. Good job! PULLING CHEST TUBES This seems obvious, but if it is not done right, there is potential to re-introduce air into the pleural space. What do I need? You will need a suture removal kit, Vaseline gauze, a boat of 4X4’s, and a roll of wide cloth tape. Important points: Ask the patient to take a deep breath and hold it (valsalva) as you pull the tube (as fast as you can). This way, they are less likely to suck in a breath and pull air into the pleural space as you are pulling the tube. Make sure the skin incision site opening or skin tunnel is occluded the entire time. The tube should be pulled quickly. Don’t let it linger in ‘no man’s land’ with air holes simultaneously inside and outside the chest.

“U” stitch

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Procedure: Remove the chest tube dressing, then cut the sutures. There may be a “U” stitch (see above diagram ‘D’) wrapped around the tube, if so, make sure you do not cut it. It should be tied to reapproximate the skin once the tube is removed. If there is no U stitch, then simply place the vaseline gauze on a 4x4, and hold it over the skin entrance site as you pull the tube out from underneath the gauze, then the skin incision will be occluded as the tube comes out. If there is a U stitch, you will need someone to occlude the tube tract with a finger while you pull the tube so that you can then tie the stitch. Place the cloth tape on all four sides of the gauze covering the skin entrance site, so that it is completely occlusive. BRONCHOSCOPY Why do it? Diagnostic (what type of pneumonia), Therapeutic (remove mucus plugs that are causing collapse), Biopsy of tumor, Diagnosis of postsurgical or posttrauma airway problems. What do I need? The bronch cart – It’s in the 6th floor PFT lab. The key is in the thoracic call room bedside table. Always get both a P and T scope. Always sign your name on the sign-out sheet. Procedure:

• If the patient is intubated, let respiratory know what you are doing – usually you place the patient on 100% Fi02 and a rate if they aren’t already on one. Turn up the pressure alarm because having the scope in the ETT will cause much higher airway resistance. Administer some benzos/anxiolytics and/or 10cc of 1% lidocaine down ETT.

• If the ETT is 7 or less, use the P scope. Put the trach adaptor on the scope, lube the end of the scope going into the ETT and insert it into the ETT. There is a lever on the scope that allows you to flex the tip. You will also have to rotate the scope (and your body) in order to direct it to the right or left as needed.

• To wash secretions out of the airways, inject 10-20cc of NS forcefully through the scope in the airway where the plugs are. Suck vigorously while moving the scope back out to mechanically pull the secretions away in addition to suction. Collect in a trap for culture.

• If you want a BAL, set up the BAL irrigation kit with a 250cc bag of NS (in drawer on cart. Wedge the scope in a bronchiole (usually the RML or lingual because they are anterior) and lavage sterile saline through the grey topped port using a 50cc syringe. Suck the saline back out with the syringe. Repeat five times.

• You can also hook the scope up to suction and remove mucus plugs – just remember that the suction on the scope is about the size of pin head.

Key points: • Wear a face shield – mucus in the eye is never very appealing. • The tracheal rings are always anterior, and the membranous portion has

longitudinal stripes – that’s how you determine right versus left.

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• If the patient desats, remove the scope. Remember, if you are sucking continuously, you will be removing most of the oxygen. Bag mask ventilate if necessary.

• After you are finished with the bronch, suck saline through the channel to clean it out, and put the scope in the dirty bin on the side of the cart. Fill out the charge slip that was attached to the scope and leave it with the cart. Fill out the bronch report form (in the top drawer) and put it in the chart. Take the bronch cart back when you are done – there aren’t many and it takes time to clean them.

• Bronchoscopes are expensive! Take care not to kink them excessively or let patients chew them to shreds.

FIGURE 2: ENDOBRONCHIAL ANATOMY

CENTRAL LINES Why do it? Inability to obtain peripheral access, need for CVP, TPN. What do I need? TLC kit, sterile towels, sterile drape, mask/gown/gloves, three blue TLC adaptors, tegaderm, 4x4s, 10cc screw top syringe, 16G needle, NS flush, and a roll. Labs? Coags and/or platelet count if suspicion of abnormality. Procedure:

• Let the nurse know what you are doing. Pick a side and a vessel – make sure the patient doesn’t have a known DVT, and take advantage of CTs that are already

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present. If the patient’s awake, explain to them what you’re doing. Place a towel roll between the patient’s scapulae and put them in Trendelenberg. Prep out the area with both IJV & SCV exposure.

• Prepare your sterile field. Put your blue caps on all the lumens, with the exception of the brown one – as that’s the one the wire will thread through. Flush each line. Use your four towels to drape out the area. Drape the body.

• Anesthetize the area of interest.

• Once you are sure you are in the vein, remove the syringe and pass the wire

through the needle. Watch for ectopy – if you see it, you’ve entered the heart. Just pull the wire back a bit. If it doesn’t thread easily, do not force it. Pull the wire back out, put the syringe back on and see if you still have flow. You may need to re-stick the vein.

• Once the wire passes, remove the needle over the wire, hold the wire in place. Knick the skin over the wire with the #11 blade. Dilate with the blue dilator – dilate the subcutaneous tissue, not the venotomy. When you dilate make sure the wire still moves back and forth so as to avoid back walling the vessel.

• Place the TLC over the wire. On the left you usually advance to between 15 and 17cm. On the right, it’s 13 to 15 cm. However, this can vary depending on the size of your patient.

• Put the blue cap on the brown port and flush them all. If one doesn’t flush it’s likely up against the vessel wall – just move the catheter a little to free it.

• Suture in the line well. You do not want to be called that it has come out. Dress with tegaderm. Get a chest x-ray and check it. Good job!

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Rules to live by: You can never be too shallow! Always keep the needle parallel to the floor. Never let go of the wire. If it doesn’t feel right, stop.

PULMONARY ARTERY CATHETERS (aka Swan Ganz Catheters) Why? To assess volume status, cardiac function, etc. What do I need? The same supplies as you would when putting in a triple lumen, along with a Cordis (introducer sheath) kit, and the swan. Procedure:

• First, you need to cannulate a vein with a sheath (Cordis). A Cordis is placed in the same manner as a triple lumen, except that the sheath and the dilator fit together, and you thread them over the wire as one unit. The ideal site for ease of getting the catheter into the PA is the Right IJ, followed by the Left SC, Right SC/IJ, and finally femoral.

• Make sure a nurse has set up the catheter-monitor connections. Test the balloon, flush the ports, shake it up and down to make sure there is a waveform on the monitor. Place the clear condom over the swan to maintain sterility when you are done.

• Advance the swan through the Cordis to 20cm – this is usually the location of the RA. Check for the appropriate waveform. Inflate the balloon.

• Advance the catheter into the RV (will see large oscillations), into the PA (will note a step up in diastolic pressure as well as a dicrotic notch denoting PA valve closure), until the catheter wedges (almost flat line.) See the figure below for the progression of the waveform from RA to wedged (left to right). Wedging usually occurs at 50-60cm.

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FIGURE 3: PA Catheter waveform changes with balloon advancement

• After you see the wedge, deflate the balloon. You should then see the return of

the PA waveform. Pull the protective sheath all the way over the catheter and secure to cordis.

• Usually, it’s never as easy as this. Never force the catheter. Sometimes placing the patient in trendelenberg or left lateral decubitus can help the swan float into the appropriate position. Certain disease states (e.g. pulmonary HTN, mitral/tricuspid regurg) can make it nearly impossible to float a swan. Fluoroscopy is an option.

THORACENTESIS Why? Drainage of the pleural space. What do I need? Thoracentesis kit, betadine, 4X4s, sterile gloves, gown, and an assistant. Procedure: Check the CXR to be sure which side you are tapping. Set the patient upright in the bed with legs off the side and leaning forward over pillow on a table top. Percuss both lungs, and use a pen to mark the upper extent of the dullness on the side to be tapped. Prep with betadine and drape with drape from kit. Pick a site above the rib 2 interspaces below the upper extent of the effusion and raise a wheal with lidocaine. Set up the thoracentesis needle with connector to aspirate fluid. MAKE SURE THE CLAMP AT THE BOTTOM OF THE COLLECTION BAG IS CLAMPED or else you will regret it. Pass the needle throught the subQ until you hit rib, then slide the needle just above the rib with back pressure until you aspirate the fluid. Pull the needle out carefully while advancing the plastic catheter in and hold steady while your assistant aspirates the fluid into the collection bag with a 60cc syringe and the ball-valve tubing mechanism. Make sure you collect some fluid separately to send to the lab for analysis (for chemistries, as well as separately to micro for gram stain and culture). Always drain the chest entirely to the extent possible. The incidence of postexpansion pulmonary edema is rare (1 in 200 patients) and is almost always easy to manage with some supplemental O2. Don’t forget to order STAT post-tap CXR.

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X. Common medications ICU MEDICATIONS

TRANSPLANT MEDS

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ANTIBIOTICS

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XI. Transplants

***The most important thing for you to remember: formulate your own plan, but do not give any orders on lung transplant patients

without first talking with the fellow or attending. ***

ADMISSION CONSIDERATIONS Our patients are on a national transplant waiting list with the United Network for Organ sharing (UNOS). Lungs are currently allocated based on the length of time on the list, ABO compatibility, and size matching, i.e.: height. On 5/1/05, this will change, and priority for lung allocation will be based more on how sick the listed recipients are. Most of the prospective lung transplant recipients will be called in to the Emergency room by the on-call transplant coordinator to receive their pre-op work up. In some cases the prospective recipient will be in-house, usually on 6 bed tower or in the MPCU or MICU, or patients may be hospitalized at another facility and transfer arrangements from that facility will be made by the on-call transplant coordinator. As opposed to some other centers, we will transplant patients who are on mechanical ventilation. We will not transplant patients if they have a fever of unknown origin unrelated to their lung disease, i.e.: Cystic Fibrosis exacerbation. Patients are also not good surgical candidates if they have renal or cardiac insufficiency. If we have in-house patients and these conditions exist, the attending pulmonary transplant physician and transplant surgeon will determine if the patient is an acceptable candidate for the surgery. Often times our patients will experience what we call “dry runs”- this happens when the procurement team or donor hospital physicians in collaboration with our thoracic transplant surgeon have deemed the lungs unsuitable for transplant after the patient has already been called in and the process is underway. This usually is a result of dropping PO2, or difficulty ventilating the lungs and/or purulent secretions on bronchoscopy. Often, the mechanism of injury in the donor patients, such as gunshot wound to the head, ICH, MVA, can result in aspiration pneumonia or fluid overload as a result of resuscitative efforts. PREOP SPECIFICS It is the responsibility of the on-call thoracic surgery intern to see the prospective recipient and perform an admission history and physical. The intern is often asked to post the case with the OR. The preoperative orders on available on the POE and the ER has hard copies of them as well. Cystic Fibrosis patients require a bowel prep with Golytely (as much as possible between the call to come in and the case), non CF patients who have not been NPO for 12 hours should have a Fleet enema. General lab work, EKG, and CXR are done in the emergency dept. The on-call transplant coordinator will assist you in antibiotic choices particularly for the Cystic Fibrosis patients (many of whom have pan-resistant organisms) and are on multi-drug regiments. The transplant

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coordinator will also assist you with immunosuppressive choices and dosing. These meds will need to go to the OR with the patients. Most patients will be on Cyclosporine, Azathioprine, and Methylprednisolone. We currently do not use any anti-thymocyte induction therapy. POSTOP CARE Post Operative Lung Transplant order sets are available on POE, hard copies are also in the CTICU and Lung Transplant office. Post operative care of the Lung Transplant Recipient differs from other cardiothoracic surgery patients in the following ways: 1) Patients are immunosuppressed. This will make them more prone to opportunistic infections. Infectious complications are the leading cause of both early and late mortality. All patients will be on protective precautions and those with pan-resistant organisms will be on contact precautions. 2) We do not allow fresh flowers in the rooms. Our patients are prohibited from consuming fresh uncooked fruits and vegetable as well as raw meats, fish and seafood during the early post transplant period. 3) All temperature elevations (>38.0) are thoroughly worked up as our patients have a decreased ability to mount a fever so any elevation can be significant. 4) Our Cystic Fibrosis patient population will often remain colonized with their “CF bugs” in their upper airways and sinuses after their lung transplant. For this reason many of them will remain on IV antibiotics for an extended time following their transplant. 5) Our patients sometimes experience a phenomenon called reperfusion injury. The lungs will appear “wet” on chest x-ray and will be less compliant to ventilation and oxygenation may suffer. This generally resolves within a few days and is often treated with diuresis. POSTOP SPECIFICS CMV: Cytomegalavirus is the most common viral pathogen affecting our transplant population. When patients are “CMV mismatched” - a negative recipient has received a positive organ - they are given IV Ganciclovir and CMV immune globulin (Cytogam) in the immediate postoperative period to prevent CMV infection. We will also be drawing weekly CMV viral loads to assess presence of CMV. Pulmonary medicine is currently involved in a Valganciclovir trial using oral Valganciclovir as a prophylaxis with all patients who are CMV positive or who have received a positive organ. The lung transplant coordinator will advise the team regarding which patients are enrolled in the study and will direct the CMV prophylactic regimen. Immunosuppressive Serum Drug Levels

Monitor immunosuppressive drug levels every day ie: Cyclosporine, or Prograf. Levels should be timed trough levels. This is not relevant when they are on a continuous IV infusion. When they are taking their meds PO or NG, levels must be drawn at 8 am just

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prior to their dose. The pulmonary transplant team will follow these levels and make recommendations on dosage adjustments. Caution: Increased seizure risk exists in those patients whose cyclosporine levels are high and have associated low magnesium levels.

Bronchoscopy Bronchoscopy is done at one week post op and as clinically indicated to view the anastomosis sites and to obtain transbronchial biopsies and bronchial alveolar lavage to assess for presence of rejection and infection. Rejection Diagnosed from transbronchial biopsies based exclusively on the presence of perivascular and interstitial mononuclear cell infiltrates. (T cell proliferation) Signs and symptoms are often difficult to discern from infection. Include: Fever, infiltrate, change in oxygenation status. Usually treated with IV steroids. Empiric therapy sometimes given when risk of transbronchial biopsy too high. Renal Complications Calcinieurin inhibitor (i.e. cyclosporine) toxicity. Cyclosporine causes vasoconstriction, leading to renal injury. Also increases profibrotic cytokines. Must do aggressive BP control and monitor levels closely. GI Complications Cyclosporine induced gastroparesis especially significant in the Cystic Fibrosis patient population. Beware of Bezoars. Active prophylaxis against GERD as studies have linked GERD to chronic lung allograft rejection. ROLE OF TRANSPLANT COORDINATORS AND PULMONARY TRANSPLANT TEAMS The Pulmonary Transplant Team will round on patients daily and make suggestions for immunosuppressive and antimicrobial management. They will also aid in ventilator management when necessary. The Lung Transplant Coordinators act as a liaison to the medical and surgical teams. They are responsible for post transplant medical teaching for the recipients and act as educational resources for the nursing and house staff. They also have a large outpatient responsibility and receive all referrals, coordinate evaluations, manage all patients postoperatively for the remainder of their lives. They take evening and weekend patient call and are the first lines of communication for the patients, families and medical staff. And again, to reiterate, the role of housestaff in the care of lung transplant patients is communication between the patients, thoracic team, coordinators and consultants. It will be a useful educational experience for you, but remember, do not independently initiate care plans or write orders without approval from the fellow or attending. The Lung Transplant Coordinators are Becky Cicale, NP, 216-6741, and Ken Davis, RN, 216-2412.

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XII. Thoracic Surgery Reference LUNG CANCER General points: ●Annual incidence 170,000; 160,000K deaths/year ●Lung CA is the most common cause of CA-related death in men and women ● Lung Ca accounts for more cancer deaths than the next 4 leading causes of cancer deaths combined (breast, colon, prostate and pancreas). ●Overall 5-yr survival 14% Table:1 Risk factors for lung cancer Tobacco exposure Lung CA is associated with tobacco use in 90% of cases

-active smoker 2000% increased risk over nonsmoker (corrected for other factors) -former smoker, quite 20 yrs ago: 200% increased risk over nonsmoker.

Environmental tobacco smoke Increased risk proportional to level and duration of exposure (typically 40% increased risk, range 20-70%).

Occupational exposures Arsenic, Beryllium, Bis(chloromethyl) ether, cadmium, chromium, nickel, polycyclic aromatic hydrocarbons, radon, vinyl chloride (very rare)

Genetic factors First degree relative family hx assoc with 2-6 fold increased risk, even in nonsmokers. (400% increased risk, corrected for other factors)

Gender Female higher risk (50% increased risk) Diet Increased intake of fruits and vegetables is associated

with reduced risk of lung cancer. Increased dietary fat is associated with an increased risk.

Chronic obstructive lung disease

Documented obstructive airways disease (FEV1 < 60%) is an independent predictor of lung cancer risk (400% increased risk, corrected for other factors).

Prior tobacco-related cancer Broad Categories of Lung Cancer Classifications: 1) NSCLC (Non-Small Cell Lung Cancer) (80%)

●most common histologic subtypes adenocarcinoma and squamous cell ●adenocarcinoma is most common overall, and in nonsmokers ●squamous cell is usually more central (closer proximity to lung hilum) and in smokers ●other histologic subtypes are large cell and Bronchoalveolar carcinoma (BAC)

2) SCLC (Small Cell Lung Cancer) ●SCLC divided into limited stage (LS) (in chest only) and extensive stage (ES) (when there are contralateral supraclavicular nodes or distant disease).

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●characterized by rapid growth and frequent extrathoracic mets ●microscopically cells contain neurosecretory granules ●almost all cases in patients with smoking history

3) Low grade tumors ●Carcinoid tumors, ‘typical’ (or ‘mature’) ●Mucoepidermoid tumors ●Adenoid cystic tumors ●all arise in tracheobronchial tree (except occasionally typical carcinoid)

3) Other unusual tumors ●Bronchioalveolar carcinoma (BAC) -palisading cells that spread along alveolar membrane -better prognosis than NSCLC -recur within lung parenchyma, less freq LN involvemt or distant mets ●Atypical carcinoids -worse prognosis than typical carcinoid tumors (more freq +LN, distant mets) but better than NSCLC -behave almost as aggressively as SCLC

Stage Classification: -SCLC: staged by a two-stage system as either limited stage (LS) or extensive stage (ES). Limited stage is defined as tumor confined to the thorax and mediastinum. Extensive stage is the presence of distant metastases or intrathoracic tumor that is beyond the definition of limited disease as outlined above. -NSCLC: staged by the TNM system. ●Clincal evaluation of a patient thought to have a NSCLC consists of all work-up prior to surgical resection, and results in the ‘clinical stage’ (“cI, cII or cT1N1M0”). Once the patient undergoes resection, the ‘pathologic stage’ (“pI, pII, or pT2N2M1”) can be determined (see table 2). ●Clinical TNM staging is based on information obtained through history and physical exam, radiographic evaluation, bronchoscopy and/or histologic diagnosis (if available) about the size of the tumor (T), the status the lymph nodes (N) (see figure 4 map of regional lymph node basins), or the presence of distant mets (M).

Table 2: Types of Staging Assessments Prefix Concept Definition c Clinical Prior to initiation of any treatment, using any and all information available (including mediastinoscopy) p Pathologic After resection, based on pathologic assessment y Restaging After part or all of the treatment has been given r Recurrence Stage at time of a recurrence a Autopsy Stage as determined by autopsy Based on AJCC/UICC nomenclature.

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Table 3: The TNM Staging System for Non-Small Cell Lung Cancer

T stage Concept Definition Tis Noninvasive focus Focus of in situ cancer T1 Small <3 cm or

Small primary tumor confined to the wall of the trachea or mainstem bronchus

T2 Larger More peripheral More central

>3 cm Visceral pleural involvement Tumor in lobar bronchus (atelectasis to hilum)

T3 More peripheral More central

Involving: ribs, diaphragm, mediastinal pleura, pericardium or phrenic nerve In mainstem bronchus (<2cm from carina)

T4 Extention to major adjacent structures or organs More diffuse

Involving: trachea, carina, esophagus, heart, SVC, aorta, vertebral body, recurrent laryngeal nerve Malignant pleural effusion Tumor with a satellite nodule in the same lobe

N stage Concept Definition N0 No nodal involvement No nodal involvement N1 Nodes within lung Involvement of nodal stations 10-14 N2 Ipsilateral mediastinal Involvement of nodal stations 1-9 (ipsilateral or midline) N3 Contralateral mediastinal

Supraclavicular Involvement of contralateral stations 2, 4 Involvement of supraclavicular nodes

M stage Concept Definition M0 Locoregional disease only No evidence of distant metastases M1 Disseminated disease Distant metastases present

Based on the 1997 American Joint Commission for Cancer and the Union Internationale Centre le Cancer (UICC) staging system. Table 4: Non-Small Cell Lung Cancer Stage Grouping

Stage T N M Additional groups

Ia T1 N0 M0 Ib T2 N0 M0 IIa T1 N1 M0 IIb T2 N1 M0 T3N0 IIIa T1-3 N2 M0 T3N1 IIIb T1-3 N3 M0 T4N0-2 IV Any Any M1 Based on the current AJCC/UICC staging system.

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Clinical Presentation: ●median age NSCLC presentation 65-70 ●90% are symptomatic ●60-80% of patients with NSCLC have stage III or IV disease at presentation ●2/3 of NSCLC are in the upper lobes ●equally distributed central and peripheral, regardless of histology Evaluation/Diagnosis: Patients evaluated by a surgeon in the MTOP clinic are often referred with a chest xray or CT finding suspicious for lung CA. The general algorithm for evaluation of these patients is as follows: 1) Begin with talking to the patient. Assess risk factors for lung CA and symptoms. Evaluate for both organ-specific lung symptoms as well as neurologic findings or bone pain, as well as constitutional symptoms – fever, fatigue, anorexia, weight loss, night sweats. The time period over which symptoms have developed is important, and examine the patient. 2) Review available films. Assess the interval change in the lesion (if previous films are available), and radiographic features of the abnormality- smooth borders, spiculated lesion, indistinct borders, size, location, presence of abnormal (>1cm) mediastinal lymph nodes (N2, N3- see figure 4 below).

●A spiculated lesion has an approx 80% chance of being CA, lobulated lesion 60%, and indistinct borders usually indicate an inflammatory process.

→With all of the above information, you should be able to have some idea of the

following three things which influence significantly the plans for the rest of the workup and treatment:

a) whether the patient likely has lung cancer b) a leaning toward NSCLC vs. SCLC (time period and aggressiveness indicate this) b) whether the patient likely has early stage or advanced stage lung CA 3) If you think the patient has early stage (I or II) NSCLC, then he/she may be a candidate for an operation. In stage I and II patients, the clinical evaluation is pretty good for ruling out systemic disease (false negative rate 5%). So these patients usually need intrathoracic staging only, by either CT scan, PET scan and/or mediastinoscopy (or a combination, depending on the overall clinical scenario), to rule out mediastinal disease (N2 nodes) which would make them stage III.

●CT guides suspicion of mediastinal adenopathy (where >1cm=abnormal LN) but: -CT carries a 40% false positive rate for mediastinal lymphadenopathy -for central tumors, there is a 20-25% false negative rate -CT lymph node findings should be pathologically confirmed by mediastinoscopy, CT-FNA, bronch-guided Wang needle, EUS-FNA ●Whether the lesion is ‘central’ or ‘peripheral’ on CT scan plays a role in

intrathoracic staging. For peripheral tumors, the FN rate of CT is low enough

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that if the CT does not show mediastinal nodes >1cm, this does not need to be confirmed by mediastinal lymph node biopsy. For central tumors, CT scan may have a FN rate as high as 25% for mediastinal lymph node involvement, requiring confirmation by mediastinoscopy, or needle aspiration by EUS or bronchoscopy. Positive N2 and N3 nodes on CT scan must also be confirmed by biopsy, due to a high false positive rate (40%).

●A histologic diagnosis of CA is not always obtained in early stage NSCLC patients until the time of resection, unless it is obtained at the time of mediastinal staging.

● Patients who are confirmed to have stage I or II NSCLC will be evaluated for surgical resection. After the determination is made that the tumor is resectable, the patient’s performance status (PS) (Table 5 below) and pulmonary function tests (PFTs) play a major role in whether the patient undergoes surgery. -Evaluation for surgery: determination of postoperative FEV1 (ppo FEV1):

if <0.8L or <40% predicted there is an associated increased perioperative mortality (applicable to open lobectomy only, not VATS lobe, segmentectomy)**see PFT reference chapter

Table 5: ECOG Scale - Performance Status Score Clinical Status 0 Asymptomatic 1 Symptomatic, but ambulatory (able to work) 2 In bed <50% of day (Unable to work, but able to live at home with some

assistance 3 In bed >50% of day (Unable to care for self) 4 Bedridden 4) If you think the patient potentially has advanced stage lung cancer with systemic or distant disease, then they will need further imaging to rule this in or out- good data from multiple sources that clinical evaluation has ~30% false negative rate if the clinical stage is III or greater. Extrathoracic staging usually involves a bone scan, a CT of the liver and adrenals, and a brain MRI or CT, and or PET scan. ●If the patient has presumed small cell lung cancer, or signs and symptoms of advanced stage NSCLC, a tissue confirmation of the diagnosis is obtained prior to initiation of chemotherapy or radiation from the easiest site: needle aspiration of a superficial lymph node, or transthoracic FNA or thoracoscopic biopsy of the lesion, cytological analysis of sputum or pleural fluid, or biopsy of a presumed metastasis. ●If imaging reveals a possible evidence of metastasis, diagnosis/staging by needle biopsy is done only if there appears to be only a solitary met, or if it has an atypical appearance, or if there is no tissue diagnosis already available. If it reveals the typical presentation and radiographic appearance of multiple mets then that is accepted by virtually everyone without further testing.

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FIGURE 4: Intrathoracic lymph node stations (from Detterbeck et al, Diagnosis and Treatment of Lung Cancer) Treatment/Outcomes: -SCLC: ●Primary treatment: LS= chemoRT (concurrent, early RT) ES=chemotherapy ●Untreated median surv: LS=12 wks ES=5-8 wks ●Complete tumor response to chemo (CR) seen in 50-75% in pts w/ limited disease, but 5yr overall survival still 15-20% ●XRT is done for local tumor control ●Prophylactic Cranial Irradiation (PCI)- given to pts w/ complete response(CR) to chemo since brain mets known to develop in 80% of SCLC pts -about 5% survival benefit w/ PCI

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-NSCLC: -if untreated the median survival is 6 months

Treatment by stage: **Below are generalizations about accepted standard of care for NSCLC patients by stage. However, extent of treatment is influenced a great deal by the patient’s performance status (see table 5). I and II: -Surgical resection

-In summary, this includes patients with T1 or T2 tumors, a negative mediastinum and no known distant disease. Exception to this is that T3N0 patients, who are node negative but have tumor involving chest wall, are also stage II and often resected.

-Adjuvant chemotx has recently become the standard of care for completely resected, selected LN negative pts after resection for NSCLC. This has been shown to lead to an absolute 5 year survival benefit of 4% over surgery alone.

-Surgical resection (Stage I and II disease) ●pneumonectomy- higher mortality rt 9% -pneumonia/resp failure, MI, empyema most common causes ●lobectomy- standard cancer resxn, mortality rt 3%

-‘sleeve’ lobectomies (removal of a section of airway or artery with reanastomosis of proximal and distal segments) are often done to avoid pneumonectomy

●non-anatomic resxns (segmentect, wedge, lumpectectomy) are assoc with increased local recurrence and decreased survival = not standard of care for a lung cancer resection. -5yr survival rts in surgically resected NSCLC pts:

stage I 60-70% stage II 40%

-This survival data is based on patients who had ‘R0’ (complete) resections (see Table 6 below) -Recurrence occurs in 33-50% of resected stage I and II NSCLC patients. The majority of recurrences are in distant sites.

III and IV: Standard treatment for stage III and stage IV disease=chemorads

-But, some IIIa patients may undergo surgical resection if they are clinically staged preop as stage II. 5-yr post resection survival for stage IIIa patients who are discovered to have stage IIIa disease at the time of resection is 25%.

Table 6: Residual Tumor after Treatment: accepted terminology for amount of tumor remaining after surgical resection.

Symbol Concept Definition R0 No residual No identifiable tumor remaining, negative surgical margins R1 Microscopic residual No gross tumor remaining, but microscopically positive margins R2 Gross residual Gross (visible or palpable) tumor remaining Based on AJCC/UICC nomenclature.[AJCC, 1998]

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ESOPHAGEAL CANCER General points: Major Subtypes 1) Epithelial -Adenocarcinoma -Squamous Cell Carcinoma 2) Mesenchymal -Leiomyoma (most common benign tumor esophagus) -Leiomyosarcoma

(smooth muscle cell tumor arises in muscularis mucosae or muscularis propria) -Rhabdomyosarcoma 3) Lymphoproliferative - Hodgkin’s lymphoma

-Malignant Non-Hodgkin’s lymphoma 4) Other -Melanoma Table 7: Most Common Esophageal Neoplasms

Major Subtype

Epithelial

Histology Adenocarcinoma -most arise in setting of Barrett’s metaplasia

Squamous Cell

Incidence Most common (increasing incidence) Accounts for >50% of esophageal tumors

Incidence decreasing

Common Location

90% distal esophagus

20% proximal esophagus 50% mid esophageal 30% distal esophagus

Risk Factors

-GERD -Barrett’s metaplasia -Smoking -Male sex -Obesity (BMI>30) -Acid hypersecretory States (ZES) -Cholecystectomy -LES-relaxing meds Note: -(no assoc w/ EtOH) -H.pylori and NSAIDs may be protective

-*EtOH + smoking (synergistic) -*Diets low in fruits and vegetables -Dietary aflatoxin -Achalasia -Caustic strictures -Zenker’s -Diverticulum -Esoph webs (Plummer-Vinson syndrome) -Prior radiation -Familial tylosis

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Staging Classification: Table 8: TNM Staging system for Esophageal Cancer

TNM Esophageal Cancer Primary tumor (T) TX: Primary tumor cannot be assessed

T0: No evidence of primary tumor Tis: Carcinoma in situ T1: Tumor invades lamina propria or submucosa T2: Tumor invades muscularis propria T3: Tumor invades adventitia T4: Tumor invades adjacent structures

Regional lymph nodes (N) NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Regional lymph node metastasis MX: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis Tumors of the lower thoracic esophagus

M1a: Metastasis in celiac lymph nodes M1b: Other distant metastasis Tumors of the midthoracic esophagus:

M1a: Not applicable M1b: Nonregional lymph nodes and/or other distant metastasis

*For tumors of midthoracic esophagus use only M1b, since these tumors with metastasis in nonregional lymph nodes have an equally poor prognosis as those with metastasis in other distant sites.

Distant metastasis (M)

Tumors of the upper thoracic esophagus:

M1a: Metastasis in cervical nodes M1b: Other distant metastasis

AJCC stage groupings Stage 0 Tis, N0, M0 Stage I T1, N0, M0

IIA: T2, N0, M0 T3, N0, M0 Stage II IIB: T1, N1, M0 T2, N1, M0

Stage III T3, N1, M0 OR T4, Any N, M0 IVA: Any T, Any N, M1a Stage IV IVB: Any T, Any N, M1b

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Clinical Presentation: ●Symptoms occur late – esophageal lumen must be reduced 50-75% prior to symptoms of dysphagia ●Usually present with advanced disease ●Weight loss is common ●May have anemia from chronic GI blood loss ●Tracheobronchial fistulas occur rarely as a late complication of local invasion of the tumor into the main stem bronchus Evaluation/Diagnosis: -Initial evaluation: History & physical, and if suggestive symptoms, UGI contrast study. Findings based on this evaluation are followed up with EGD and usually CT chest/abdomen and/or PET scan. -Histologic diagnosis: is often obtained by brush cytology or biopsy during EGD -Clinical Staging: Accuracy of diagnostic modalities for further defining TNM stage ●T: -CT scan overall 60-70% accurate -EUS 76-90% accurate -Thoracoscopy and/or bronchoscopy ●N: -CT accuracy <60% -EUS 70-86% accurate -mediastinoscopy -Thoracoscopy/Laparoscopy 81-95% accurate ●M: -CT accuracy 70-90% -PET- -Laparoscopy/Laparoscopic ultrasound: evaluation of peritoneal implants, liver, gastrohepatic ligament, gastric, or celiac lymph nodes -peritoneal washings r/o M1 disease -intraop U/S eval liver lesions -feeding JT -avoid unnecessary laparotomy Treatment/Outcomes: Patients with good performance status and no distant/M1 disease at initial surgical exploration should be resected w/ curative intent. Multimodality therapy is a consideration for all esophageal cancer patients except those with Barrett’s and high-grade dysplasia discovered on biopsy done during surveillance EGD. Overall 5yr survival for all patients with esophageal cancer is less than 10%. However, patients with early stage tumors, such T1 tumors that are completely resected, can have 5yr survival rates up to 60%.

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Surgical resection: The type of procedure and approach depends on the location of the tumor in the esophagus, as follows. For almost all esophageal resections, the stomach is ‘pulled up’ into the chest as the neo-esophagus. Some centers are doing esophagectomies minimally-invasively, with thoracoscopic and laparoscopic components. ●GEJunction tumors:

-left thoracoabdominal approach ●Distal esophageal tumors: -Ivor-Lewis=R thoracotomy + midline laparotomy w/ intrathoracic anastomosis -total esophagectomy by “three-hole” or transhiatal approach ●Mid-esophageal tumors: -Ivor-Lewis=R thoracotomy + midline laparotomy w/ high intrathoracic anastomosis or -‘three hole’ esophagectomy=-R thoracotomy, midline laparotomy and cervical anastomosis ●Prox thoracic esophageal tumors: total esophagect via 2 poss approaches: 1) Transhiatal blunt esophageal mobilization + cervical anastomosis -this approach is risky- potential for tearing the membranous trachea with blunt dissection of the esophagus. Most people would do ‘three-hole’, and have transhiatal as a 2nd tier option 2) ‘Three hole’ esophagectomy=R thoracotomy, ML laparotomy and cervical anastomosis ●Cervical esophageal tumors -Treated primarily with ChemoRT -rarely jejunal free flap in salvage surgery Multimodality treatment for esophageal cancer: ●Multimodality tx: Neoadjuvant chemorads (chemo +RT prior to surgery) -results in better complete resection rates, better local control -controversial survival benefit -5 yr survival rts w/ multimodality tx have improved to 40% overall, 75% in patients with complete response to preop chemo ●Adjuvant XRT alone (XRT after surgery): -no significant survival advantage -significant treatmt-related toxicity -usually used only when +margins or residual disease ●Adjuvant chemo alone (chemo after surgery): -no survival advantage ●ChemoRT alone (no surgery) -in non-operative candidates -median surv 9-24 months -5 yr surv 18-40% ●Palliative tx (symptomatic treatment for patients thought to be not curable): -dilation -photodynamic therapy -esophageal stents -bipolar electrocautery -laser ablative therapy -brachytherapy

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THORACOSTOMY TUBES (“CHEST TUBES”) 1) PLEUR-EVACS Study the diagram below. This is the original system designed for chest tubes which accomplishes three purposes with the three chambers: 1) collection of fluid draining through the tube, 2) a water seal to prevent air from flowing backwards through the system into the chest, and 3) regulation of the amount of suction from the wall that the intrathoracic cavity actually is exposed to. This is a closed system to maintain the sterility of the intrathoracic space, and keep external air from entering the pleural space. FIGURE 5: Concept of Tube Thoracostomy Drainage System

The current pleur-evac systems use the same priniciples but are put together into a compact system. The diagram below is a single chamber pleur-evac. The double chamber pleur-evacs function in the same way except that there are two connections for chest tubes, each with it’s own collection chamber. The important point about the double chamber pleur-evacs is that the chambers they connect to communicate with one another. Therefore, if you are not using one of the connections for a chest tube, the extra tubing should be clamped and/or knotted off securely so that no one can unclamp it. An open extra connection tubing would allow air to be introduced into the chest, bypassing the water seal chamber, and result in a pneumothorax.

From patient

To wall suction

COLLECTION CHAMBER WATER SEAL

CHAMBERSUCTION

REGULATOR

(3) (2)(1)

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FIGURE 6: Current UNC Hospitals Pleur-evac

The other very important point to be made about chest tubes is that the chest tube or connection hose to the drainage unit should almost never be clamped. Clamping the tube could even create a tension pneumothorax because air no longer has a way to exit the pleural space. The ONLY times a chest tube should ever be clamped is when you have injected TPA which should dwell in the chest for 4 hours. In this scenario, the patient must have orders written for frequent vital signs while the tube is clamped, and you should check on the patient often during this time yourself. 2) TPA Fibrinolytic agents such as TPA can be injected into chest tubes to facilitate drainage of intrapleural fluid collections. This is done most often for post-traumatic hemothorax, which is inadequately drained by a chest tube alone, and also for attempted non-op drainage of empyemas. TPA should be ordered from pharmacy as: “50 mg/120cc NaCl (divided into 2 60 cc syringes with catheter tips) to floor.” Give the patient some pain medicine or sedation as premedication - TPA injection can be uncomfortable. Needed supplies for injecting TPA are: sterile towels, a suture removal kit, betadine, 4x4 gauze boat, sterile gloves, and someone to help you. You should set up a sterile field around the connection between the chest tube and pleur-evac tubing. Betadine the site and have someone hold the pleur-evac tubing for you. Wearing sterile gloves, disconnect the chest tube, and inject the TPA out of both syringes into the chest tube. Place a hemostat or blue clamp onto the end of the chest tube, and reconnect the pleur-evac tubing (take the pleur-evac off of suction) so as to maintain the sterility of the connection. Talk with the patient’s nurse, and write orders for the patient to be rotated side to side, head up, and head down, every 30 minutes while the TPA is in place to attempt to distribute it throughout the pleural space. Also, as mentioned above, the patient should have orders written for frequent vital signs while the tube is clamped, and you should check on the patient often during this time YOURSELF.

To wall suction

WATER SEAL

CHAMBER

COLLECTION CHAMBER

From patient

SUCTION REGULATOR

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ATRIAL FIBRILLATION WHAT IS IT? The most common arrhythmia in adults and the elderly, AFib is disorganized electrical activity of the atria. Predisposing factors range from cardiac etiologies such as mitral valve disease, CHF, pericarditis to noncardiac factors such as thyroid disease, pulmonary embolism, alcohol ingestion, COPD, sepsis. Impulse origination in AFib is thought to be from atrial myocytes in close proximity to the pulmonary vein orificies in the left atrium. AFib is the most common supraventricular arrhythmia that develops in the postoperative setting. WHO GETS IT? Afib occurs in 12% of patients undergoing non-cardiac thoracic surgery, and most often onset is POD#2. Risk factors for the development of postop afib are: male sex, a history of CHF, cardiac arrhythmia, or PVD, and the use of intraoperative transfusion. Incidence of AFib in the postoperative setting increases with increasing age (>65), and increases with the extent of the pulmonary resection. COMPLICATIONS The development of postop afib is associated with a significantly increased postop mortality rate and with increased length of hospital stay and cost (Vaporciyan et al. JTCVS 127(3):779-86.) Patients with underlying cardiac compromise may have hemodynamic consequences from the onset of AFib, in particular patients with a rapid ventricular response, as their ventricular diastolic filling time is reduced (decreased preload) and consequently their cardiac output is depressed. MANAGEMENT Management of Afib is depends on the etiology, duration, and overall clinical presentation. Medical Management of Atrial Fibrillation For unstable patients: Patients who are significantly unstable with Afib require immediate electrical cardioversion. This is done in the ‘Synchronized” mode, starting at 50 joules and increasing (100J, 150J) if ineffective. This is done by placing the cardioversion pads on the patient’s chest in positions in which they are anterior and posterior to the axis of the heart. (see figure 7 below)

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FIGURE 7: Cardioversion pad placement

For hemodynamically stable patients: It is often the case that patients in the postoperative setting develop uncontrolled AFib with marginal hemodynamic depression which can be corrected with pharmacologic rate control to allow increased diastolic filling time. Beta-blockers and calcium channel blockers (see below) are effective for rate control. These medications do not technically convert Afib to sinus rhythm, but this may occur spontaneously with slowing of the rate to a physiologic range. The most commonly used antiarrhythmic drug used in the acute setting for Afib is amiodarone, which is often effective and generally regarded as safe, but when used over extended periods can have multi-system cumulative toxicities.

For patients in chronic AFib: Patients who remain in Afib chronically, or patients who are clinically ‘stable’ and have elective cardioversion planned by their cardiologist, are considered for systemic anticoagulation with coumadin. In patients with permanent Afib, prospective studies have demonstrated a significant reduction in stroke risk when patients are maintained on coumadin relative to patients treated only with aspirin. Below are the recent ACCP guidelines for which patients should be anticoagulated. ACCP guidelines for Antithrombotic Therapy in Atrial Fibrillation The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Singer et al, Chest. 2004;126:429S-456S 1) In patients with persistent or paroxysmal AF (PAF) [intermittent AF] at high risk of

stroke (ie, having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, age > 75 years, moderately or severely impaired left ventricular systolic function and/or congestive heart failure, history

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of hypertension, or diabetes mellitus), we recommend anticoagulation with an oral VKA, such as warfarin (goal INR 2.0-3.0).

2) In patients with persistent AF or PAF, age 65 to 75 years, in the absence of other risk

factors, we recommend antithrombotic therapy with either an oral VKA or aspirin 325 mg/d in this group of patients who are at intermediate risk of stroke.

3) In patients with persistent AF or PAF < 65 years old and with no other risk factors, we recommend aspirin, 325 mg/d.

4) For patients with AF and mitral stenosis, we recommend anticoagulation with an oral VKA.

5) For patients with AF and prosthetic heart valves, we recommend anticoagulation with an oral VKA; the target INR may be increased and aspirin added depending on valve type and position, and on patient factors.

6) For patients with AF of 48 h or of unknown duration for whom pharmacologic or electrical cardioversion is planned, we recommend anticoagulation with an oral VKA for 3 weeks before and for at least 4 weeks after successful cardioversion.

7) For patients with AF of 48 h or of unknown duration undergoing pharmacologic or electrical cardioversion, an alternative strategy is anticoagulation and screening multiplane transesophageal echocardiography. If no thrombus is seen and cardioversion is successful, we recommend anticoagulation for at least 4 weeks.

8) For patients with AF of known duration < 48 h, we suggest cardioversion without anticoagulation. However, in patients without contraindications to anticoagulation, we suggest beginning IV heparin or low molecular weight heparin at presentation.

Surgical Management of Atrial Fibrillation Surgical management of atrial fibrillation is evolving. Currently the most commonly performed procedures are the ‘corridor procedure,’ and the ‘maze procedure.’ Both procedures are focused on isolating one pathway from the sinus node to the AV node while interrupting other reentrant arrhythmias, to allow an increased ability for the atria to maintain normal sinus rhythm. These procedures are usually done in patients undergoing a planned cardiac surgery for valvular or ischemic disease. Radiofrequency catheter ablation for Afib has been associated with a significant incidence of recurrent Afib and pulmonary vein stenosis, but is on the horizon as an improving alternative therapy as more advanced mapping techniques are developed. References Runge, MS and Ohman, M, Netter’s Cardiology. Icon Learning Systems, Teterboro, New Jersey, 2004. Vaporciyan, A et al. Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients. JTCVS 127(3):779-86 Barbetakis, N et al. Is amiodarone a safe antiarrhythmic to use in supraventricular tachyarrhythmias after lung cancer surgery? BMC Surgery 2004. Singer et al, ACCP guidelines for Antithrombotic Therapy in Atrial Fibrillation,

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The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:429S-456S

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PULMONARY FUNCTION TESTS (“SPIROMETRY”) BASICS PFT’s are essential to preoperative evaluation of pulmonary function. This is the most important assessment of operative candidacy because respiratory failure is the most common cause of death in patients undergoing pulmonary resection. Pulmonary function can be assessed in 3 main ways: measurement of lung volumes, measurement of gas exchange ability, and measurement of exercise tolerance. Surgical resection changes pulmonary physiology, and can have both short term and long term detrimental effects on pulmonary function. The acute decrease in FEV1 (Forced Expiratory Volume in 1 second) that occurs with the actual removal of lung parenchyma can be calculated by the formula: Predicted Postop FEV1 (PPO-FEV1) = Preop FEV1 x (18 - #segments resected) 18 (total # segments) Alternatively, differential lung function can be determined radiographically by quantitative nuclear perfusion scanning. Determining the projected postoperative FEV1 is an indication of operative risk, and generally thresholds of FEV1 of 800 mL or 40% predicted (based on height and weight) have been widely accepted minimums defining prohibitive risk. However, it is important to know that there is little data supporting this, and although patients below these thresholds are high risk, each case must be looked at individually. Assessment of gas exchange (DLCO), exercise capacity (VO2max), and performance status also must be factored in. See below for explanation of DLCO. The DLCO threshold is also 40% predicted for prohibitive operative risk. Exercise capacity is measured by determining VO2max, or maximum oxygen consumption, during exercise. With increase in work, cardiac output, oxygen consumption by the tissues, and CO2 production all increase. The oxygen consumption increases until a plateau, known as VO2max, is reached. This value can be predicted for individuals based on age, gender, and height, as well as the type of work being performed. A VO2max of >15 ml/kg/min generally indicates a low perioperative mortality with lobectomy.

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REVIEW FIGURE 8: Lung Volumes and Normal Spirometric Values:

A brief review of the nomenclature for respiratory volumes: Lung Volumes Tidal Volume: Normal, spontaneous inhalation and exhalation. This volume makes use of only a small fraction of the vital capacity. Vital Capacity (or FVC, Forced Vital Capacity): The volume of a maximally exhaled breath. Functional Residual Capacity (FRC): The amount of air remaining in the lungs after normal exhalation. Residual Volume (RV): The amount of air remaining in the lungs after maximal exhalation (of FVC...therefore, total lung capacity (TLC) = FVC + RV). Spirometry Spirometry, the measurement of lung volumes, allows assessment of the physiologic and structural changes in the lung due to pathology. Commonly reported spirometric values are: FEV1 (Forced Expiratory Volume in 1 second): The volume of air expelled during the first second of a maximally forced exhalation. FVC (Forced Vital Capacity): As above, the total volume of a maximally exhaled breath.

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DLCO (Diffusion Capacity of Lung for Carbon Monoxide): Measurement of alveolar wall membrane permeability, determined by measuring the uptake of carbon monoxide. Reduced in emphysema due to loss of alveolar walls, and reduced in fibrotic lung disease due to decreased gas transfer across the air-blood interface. Affected by alveolar volume and hemoglobin level. Reported as a percentage of the predicted normal value, adjusted for body size. There is some evidence that low DLCO is an important risk factor for death after lung resection. POSTOPERATIVE PULMONARY PHYSIOLOGY Postoperatively, there is lung volume loss greater than actual loss of lung parenchyma. This is due to a combination of factors including an approximate loss of 50% of chest wall compliance, supine position, and an increased closing volume (or the lung volume at which small airways are no longer stented open and become collapsed). These physiologic effects can be visualized in the figure below. FIGURE 9: Lung Volumes and Spirometric Values in the Postoperative Period:

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FIGURE 10: Cough pressures in the post-thoracotomy period: Thoracotomy markedly decreases the strength of coughing resulting in further lung volume loss.

FIGURE 11: Flow-Volume Curves Spirometric results, and respirations being monitor on a digital ventilator are often displayed as flow-volume curves or loops, as can be seen below.

Figure 2

Graphical Data Display in Spirometry

Time

Vol

ume

FEV1

FVC

Vol

FEF75%

Flow

Insp

Exp

FEFmax or PEFR

FEF25%

FEF50%

Volume-time curve Flow-volume loop

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FIGURE 12: The effect of pathophysiologic change on Flow-Volume loops

Figure 3

Graphical Data Interpretation Spirometry

p p p

Normal Airflow obstruction

Extrathoracic obstruction

Fixed airway obstruction

FIGURE 13: Pulmonary function tests in COPD (emphysema): Note that the residual amount of air that can be exhaled in one second (FEV1) is decreased, the forced Vital Capacity is decreased, and the amount of air remaining in the lungs at the end of exhalation (the Residual Volume) is increased. All of these effects result from loss of elastic support of the airways, which allows the airways to collapse during exhalation, trapping air in the lungs.

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Significance of Abnormal Spirometric Values ↓ FVC -Indicative of reduced lung size, restrictive lung disease (e.g. interstitial lung disease, neuromuscular disease, chest wall disorder) or severe airflow limitation where the patient cannot continue to exhale long enough to complete emptying or airways collapse. -Restrictive disease characterized by reduction in TLC. This can be inferred when VC reduced and FEVI /FVC ratio is normal or increased. ↓ FEV1 -Indicative of airflow limitation (obstruction) or a severe restrictive process. -The earliest change associated with obstruction is in small airways (slowing in the terminal portion of spirogram, FEF75% or FEF25-75%). -In moderate obstruction there is involvement of larger airways FEF25% and FVC. -In severe obstruction all flows <30-40%, FEVI /FVC ratio <50%. FEV1 /FVC ratio -Decreased in obstructive disease. -Normal or increased in restrictive disease. -Mixed obstructive and restrictive disease cannot be confirmed on spirometry alone- lung volumes assessment is needed. Summary of patterns of dysfunction Obstructive Dysfunction -Earliest change in small airways – terminal portion of spirogram/ FEF75%. -As disease gets more advances, FEV1 reduced out of proportion to FVC Restrictive Defect -Reduced TLC, decreased FVC. -FEV1 /FVC ratio normal or increased. -In severe restrictive disease, FEV1 reduced.

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THORACIC SURGERY MSIII GUIDE OBJECTIVES

• Gain insight into the management of lung cancer, pleural problems. • Gain insight into the nature of multidisciplinary care • Develop ways of talking with patients about serious diagnoses • Understand management of pulmonary secretions • Maintain focus on issues preventing discharge during hospital course • Gain insight into thoracic bedside procedures • Gain insight into common thoracic operations

EXPECTATIONS

• Actively participate in rounds twice each day • Make focused presentations on rounds • Scrub in on all OR cases • Evaluate new and return patients in the clinic • Research a very limited patient care issue • Observe common bedside procedures

SPECIFIC TASKS

• Show initiative! Make yourself available, give us your beeper number etc. Keep looking for ways to participate in daily activities, don’t wait to be asked Dressings, bedside procedures, preparing for OR cases etc. It will be more fun and more worthwhile if you get involved.

• Manage hospital course for 2-3 in-patients Goal: learn to be concise; focus on the major issues; address them Present on rounds VS, I & O, Subj, Pertinent object. findings, (1 sentence for each) List the Issues preventing discharge List plan for addressing each issue that day Writing notes is not the main focus!

• Understand the management of pulmonary secretions Incentive spirometry, coughing Ambulation is crucial Nebulized fluid to thin secretions Chest physiotherapy and postural drainage

• Research clinical issue Goal: practice making quick research part of everyday clinical practice Pick a very limited topic Do literature search, get 2-3 papers

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Present on Thursday (≤ 5 minutes) Discuss how your patient fits or does not fit the situation

• Evaluate new patients in clinic Approach discussed before clinic starts, as pts are seen, and at MTOP conference Assess return patients in clinic For lung cancer patients: History (constitutional, brain, bone symptoms) to look for distant metastases CXR to look for new primary lung cancer

• Observe thoracic bedside procedures Bronchoscopy Mandatory; occurs in OR at start of virtually every case Chest tube insertion Mandatory; you must take initiative to get interns to page you Thoracentesis Done sporadically on cardiac and thoracic service Naso-tracheal suctioning Student should do this themselves

• Observe OR cases See, palpate anatomy of: Mediastinum (mediastinoscopy) Lung (Thoracotomy) Esophagus (Esophagogastrectomy) Understand the objectives of the operation

• Observe patient physician interaction Talking with patients about cancer is difficult for many physicians You should make use of the opportunity to observe such discussions

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WEEKLY MSIII SCHEDULE FOR THORACIC SURGERY ROTATION Monday 7:00 a.m. team rounds (this will vary from day to day – check w/ interns daily) Distribution of printed schedule/expectations at this time 7:30 Lecture 8:30 – scrub in on OR cases for that day Afternoon rounds Select 2-3 patients to follow in the hospital Select a focused clinical topic for presentation later in the week Tuesday 7:00 team rounds 8:15 MTOP clinic – review of list, films, make plan 8:30 clinic begins 12:00 MTOP Conference 1:30 Clinic resumes (MTOP and benign thoracic) Afternoon rounds after clinic Wednesday 7:00 team rounds 7:15 Grand Rounds 8:30 OR Afternoon rounds Thursday 7:00 CT conference (2nd Thursday is M&M, 4th Thursday is didactic) Variable times for rounds 10:00 (variable) preop conference Brief presentation of clinical topic Review experience/accomplishment of tasks Friday 6:30 team rounds 7:00 CT conference Complete tasks not yet accomplished OR cases Afternoon rounds