Case: Pneumonectomy

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[Planktonmd]

Stop the Coumadin until the INR is normal.
If that does not work then find out why he is coagulopathic and fix it.
The fact that the right main bronchus is totally occluded and the patient is doing reasonably OK predicts that he most likely will tolerate the pneumomectomy.
No further workup needed because this guy needs his cancer treated ASAP or it will kill him.
Bring him to the OR, place a thoracic epidural (assuming you fixed his coagulation), induce GA (unless you feel that you will have a real problem ventialting with mask), if he is as you said (history of difficult inrubation and not the best airway), then I would place a single lumen tube using Glidescope or asleep FOB then place a tube changer through the tube, take the tube out, insert a laryngoscope in the mouth to lift the soft tissue and feed the changer through the DLT's bronchial lumen, insert the DLT, take the changer out, insert FOB through the bronchial lumen and direct the tube to the correct position.
Don't forget to get an A line and adequate IV access.
End of story.

 

[Planktonmd]

On the day of surgery, the patient shows you a copy of an echocardiogram he obtained from an outside hospital, 2 weeks ago.

The echo reveals right ventricular hypertrophy, tricupsid regurg, right atrial enlargement, and preserved left ventricular function.

Does this alter your management of this patient?

So, he has a weak right heart, possibly secondary to pulmonary hypertension.
You will need to optimize the RV function and possibly treat the Pulomnary hypertension as much as possible before they clamp the pulmonary circulation.
A PA catheter is a good thing here and it will guide your management.
Dobutamine can be helpful here maybe with some NTG.
You might also consider some Viagra pre-op 😉
If the Pulm HTN is severe you might need a prostacycline infusion or even nitric oxide if you have it.
He still needs his lung removed though.

 

[Fastrach]

We've also been bolusing these pneumonectomy patients with amiodarone fairly routinely these days. Seems like almost all of em go into afib at some point or another. Good stuff.

 

[urge]

A pa cath is a good idea but most of them end up in the right side where they will clamp. You could try to re float it after they clamp but that's the period where you should be free to take care of the pt and not messing around with a pa that will not float.

TEE would be better.

If not comfortable with tee, a good old cvp would help you out. If cvp goes up pretty high you know that rv is not doing that great with the added afterload.

Oral board exam: Consider, along with surgeon, a balloon occlusion study to estimate rv function post op.

 

[urge]

We've also been bolusing these pneumonectomy patients with amiodarone fairly routinely these days. Seems like almost all of em go into afib at some point or another. Good stuff.

Are you serious?

 

[fakin' the funk]

A pa cath is a good idea but most of them end up in the right side where they will clamp. You could try to re float it after they clamp but that's the period where you should be free to take care of the pt and not messing around with a pa that will not float.

Do you need to wedge it? Or can you get by with PA pressure and using the PA diastolic, which you can get if you just get it past the RV waveform.

 

[urge]

Do you need to wedge it? Or can you get by with PA pressure and using the PA diastolic, which you can get if you just get it past the RV waveform.

Just the tip?

I don't play those games.

 

[Frank Rizzo]

just for a second... just to see how it feels!

 

[Bertelman]

 

[Intubate]

We've also been bolusing these pneumonectomy patients with amiodarone fairly routinely these days. Seems like almost all of em go into afib at some point or another. Good stuff.

I think a study came out recently for amiodarone to prevent post op afib in cabg patients and it didn't work-- made it worse I think. Sorry, no citation, but it was Anesthesiology or A&A .

 

[sevoflurane]

Look at FEV1. If less than 1800 then the patient may or may not have a post-op FEV1 of > 850 (likely needed for life) If it's less than this then you should consider split lung testing. If split lung testing showed an fv1 < 850 for the remaining lung you could move on to PA occlusion pressure. If the paco2 were to rise above 45, PaO2 drop below 60 and PA pressure rise aboe 40 then the pneumonectomy is probably not gonna fly.

You are looking to see if the patient is a candidate for a pneumonectomy.

 

[sevoflurane]

I may or may not order these tests as these numbers do not take into account the size of the patient. 750ml will kill a 7 foot tall, 300 lb. dude, but minght not kill a 4 ft. tall 45 kg. dudette. Really, your surgeon should have a discussion with the patient regarding these values and procede accordingly.

 

[dhb]

I think a study came out recently for amiodarone to prevent post op afib in cabg patients and it didn't work-- made it worse I think. Sorry, no citation, but it was Anesthesiology or A&A .

http://journals.lww.com/anesthesiol...ative_Intravenous_Amiodarone_Does_Not.25.aspx

 

[pgg]

I agree with plankton that if his right main bronchus is totally occluded that PFTs and split lung testing is unnecessary. He's already living on one lung.

But since you asked, here's my book answer/algorithm for pre-pneumonectomy pulm func testing -


The four PFT criteria cited most often when evaluating a patient for pneumonectomy are
FEV1 > 2 L
FEV1/FVC ratio > 50%
MVV > 50% predicted
RV/TLC ratio < 50%
If these criteria are not met, split lung function testing is indicated (xenon radiospirometry, V/Q scan). A predicted FEV1 > 800 mL is required for pneumonectomy.

If the predicted FEV1 from split lung testing is < 800 mL, a final test is to occlude the diseased lung's pulmonary artery. If pulmonary hypertension (> 35 mmHg) and hypoxemia (PaO2 <45) do not occur, the patient may tolerate the pneumonectomy.

The role of exercise testing is less clear. Inability to climb two flights of stairs identifies high risk. The 6-minute walk test (180 feet in 1 minute x 6) suggests a VO2max of 12 mL/kg/min favors a good outcome even if FEV1 is low. VO2max < 10 is associated with >30% short term mortality.

Room air blood gases have a limited role, but even mild preop CO2 retention (PaCO2 > 45) is associated with high mortality following pneumonectomy.

 

[Fastrach]

For all the amiodarone naysayers:

Ann Thorac Surg. 2009 Sep;88(3):886-93; discussion 894-5.
A randomized trial evaluating amiodarone for prevention of atrial fibrillation after pulmonary resection.
Tisdale JE, Wroblewski HA, Wall DS, Rieger KM, Hammoud ZT, Young JV, Kesler KA.

Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Purdue University, Indianapolis, Indiana 46202, USA. [email protected]
BACKGROUND: Atrial fibrillation (AF) occurs commonly after anatomic pulmonary resection. In this study, the efficacy of amiodarone for prevention of post-pulmonary resection AF was investigated. METHODS: One hundred thirty patients undergoing lobectomy, bilobectomy, or pneumonectomy were randomly assigned prospectively to receive amiodarone (n = 65) or no prophylaxis (control group, n = 65). The amiodarone group received 1,050 mg by continuous intravenous infusion over 24 hours, initiated at the time of anesthesia induction, followed by 400 mg orally twice daily until hospital discharge or for a maximum of 6 days. The primary endpoint was AF requiring treatment during hospitalization. Secondary endpoints included postoperative length of hospital and intensive care unit stays. RESULTS: There were no significant differences between the amiodarone and control groups in demographics, comorbid conditions, extent of pulmonary resection, or preoperative or postoperative use of beta-blockers or calcium-channel blockers. The incidence of AF was lower in the amiodarone group than in the control group (13.8% versus 32.3%, p = 0.02; relative risk reduction = 57%). There was no difference between the amiodarone and control groups in median length of hospital stay (7 versus 8 days, p = 0.79), but median length of intensive care unit stay was shorter in the amiodarone group (46 versus 84 hours, p = 0.03). There was no significant difference between the amiodarone and control groups in the incidence of pulmonary complications or other adverse effects. CONCLUSIONS: Amiodarone prophylaxis significantly reduces the incidence of AF after anatomic pulmonary resection, and is associated with a significant reduction in length of intensive care unit stay.

 

[HalO'Thane]

If the patient has complete occlusion of the right main bronchus and is supposedly breathing on one lung already, can't you just left mainstem intubate a single lumen ETT under fiberoptic guidance? That way you can still isolate the ventilated/dependent lung from the bleeding and secretions that the operation will cause without having to risk the use of a DLT in a difficult airway. If the tumor is anywhere near the carina then a right sided bronchial blocker may not be practical. When the surgeon is ready to test for a stump leak after the pneumonectomy you can pull the ETT back into the trachea (also under fiberoptic guidance) to apply valsalva.

On another note...how much experience have you guys had using bronchial blockers for pneumonectomies? (particularly in a difficult airway)

 

[sevoflurane]

Not a big fan if bronchial blockers.

 

[anesthesiadoc]

if he is as you said (history of difficult inrubation and not the best airway), then I would place a single lumen tube using Glidescope or asleep FOB then place a tube changer through the tube, take the tube out, insert a laryngoscope in the mouth to lift the soft tissue and feed the changer through the DLT's bronchial lumen, insert the DLT, take the changer out, insert FOB through the bronchial lumen and direct the tube to the correct position.
End of story.

If you were planning on pneumonectomy, you could conceivably fiberoptically bronch into the Left main stem and slide the tube accordingly, correct? (Since ventilating the R lung is going to be moot point if the surgical plan is accomplished). I've never done it this way, but often wondered why not.

 

[Planktonmd]

Yes but you will not be able to suction any blood or secretions coming out of the right lung during the surgery which might be OK too.

If you were planning on pneumonectomy, you could conceivably fiberoptically bronch into the Left main stem and slide the tube accordingly, correct? (Since ventilating the R lung is going to be moot point if the surgical plan is accomplished). I've never done it this way, but often wondered why not.

 

[Licoricestick]

Yes but you will not be able to suction any blood or secretions coming out of the right lung during the surgery which might be OK too.

With an already occluded R mainstem are you going to be suctioning much anyway?

 

[Planktonmd]

With an already occluded R mainstem are you going to be suctioning much anyway?

Probably not.