Complicated Case

[NavyFlightDoc]

This is something that has come up in my current practice, and I am just wondering how it might be addressed by some of you attendings/residents out there. For background, I am a Navy Flight Surgeon, headed to gas residency, but not there yet, so this isn't advice for a patient, just to answer my curiosity.

How do you go about providing anesthesia for a patient with a LEFT upper lobe mass that requires lobectomy, in a patient with a concommitant moderate PE on the RIGHT side? Patient is still on heparin, working on getting started with coumadin, and will likely have a greenfield filter for his active lower extremity DVT, as well.

I guess my question is what do you do when faced with a surgery which requires unilateral ventilation, in a patient with that type of contraindication? It seems like there are quite a few considerations for the anesthesia provider in that situation.

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[NavyFlightDoc]

sorry, a little more relevant information.

Young (50ish)
otherwise healthy, no chronic lung disease, non smoker.

 

[Jeff05]

the issue here is not really the LUL mass. you can do this case with a left sided double lumen tube. or with a blocker.

the real issue is maintaining adequate ventilation due to the deadspace created by your PE (high V/Q). The other issue is that the blood being diverted from the PE area may be going to the non-dependent (non-ventilated) lung, contributing to the shunt and causing hypoxia (which is a not-entirely well understood, multifactorial mechanism in PE). you'll have to deal with hypercarbia and hypoxia during the case. i'm not sure if you can know exactly how much until you isolate the lung.

100% o2, start peep 5 to dependent, cpap of 5 to non-dependent with some apneic o2 if needed. if the patient is tolerating you're good to go.
if patient is not tolerating a thrombectomy prior to the lobectomy may be indicated.

 

[Planktonmd]

Great question doctor,
This is not an emergency surgery so my approach would be to wait until the patient is more stable, let them place the IVC filter in the mean time so further PE's could at least be partially avoided.
Give the right lung a chance to improve, do some breathing exercises and incentive spirometry.
My guess: you will need a couple of months after the PE to say that the patient is as good as he will ever be to undergo this ELECTIVE surgery.
If after all that you proceed with surgery and the patient does not tolerate one lung ventilation then too bad, you do the surgery with 2 lung ventilation because: remember that one lung ventilation is only a relative indication for a lobectomy.
In that case he might need to remain ventilated post-op for a few days.

 

[BLADEMDA]

Great question doctor,
This is not an emergency surgery so my approach would be to wait until the patient is more stable, let them place the IVC filter in the mean time so further PE's could at least be partially avoided.
Give the right lung a chance to improve, do some breathing exercises and incentive spirometry.
My guess: you will need a couple of months after the PE to say that the patient is as good as he will ever be to undergo this ELECTIVE surgery.
If after all that you proceed with surgery and the patient does not tolerate one lung ventilation then too bad, you do the surgery with 2 lung ventilation because: remember that one lung ventilation is only a relative indication for a lobectomy.
In that case he might need to remain ventilated post-op for a few days.

I agree with you Plankton. Remember, we can use a little CPAP to the operative lung and a little PEEP to the non operative lung as well.

Why would the CT Surgeon proceed electively on an anti-coagulated patient for lung surgery? Why can't this patient wait a few months for surgery?

http://books.google.com/books?id=Lw...iNnKBA&sa=X&oi=book_result&resnum=9&ct=result

 

[BLADEMDA]

Thoracic operations are usually performed with the patient in the lateral position with selective one-lung ventilation (OLV) to the dependent lung. Even after the non-dependent, operated lung is intentionally collapsed it continues to be perfused with blood. Even under the best of circumstances this wasted perfusion, or “shunt”, remains 20–25% of cardiac output. Even so, the majority of patients undergoing thoracic operations are able to maintain adequate arterial oxygen tension (PaO2) during OLV. The extent of shunt is determined by many factors [1]. If hypoxia does occur during OLV then efforts are directed toward optimizing the matching of ventilation with perfusion (V/Q) in the dependent ventilated lung and/or increasing the oxygen content of the shunted blood returning from the collapsed lung.
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[urge]

This is not an emergency surgery so my approach would be to wait..

Exactly. I would wait 2 weeks or so. I don't see the point of doing the case with an acute PE.

Otherwise if you want to go ahead now, then try all the tricks in the book. If it works -fine, if it doesn't- fine too. There is always bypass. Thoracic surgeons are CT surgeons after all.

 

[proman]

I had almost this exact patient as an intern. Had a huge left lower lobe cystic mass causing mediastinal shift. Had been scheduled for IR to drain for diagnosis and therapy on a Monday. Came in on a Friday with dyspnea, found to have DVT/PE. Admitted, heparinized for 1 week, IVC filter, echo (mainly to eval EF, effusion and any tamponade). Tuned him up as best possible. Thoracic surgeon did a lobectomy, turned out to be mesothelioma. He did fine, probably because he had a small oxygen requirement preop. BTW, this was a private surgeon & anesthesiologist and no bypass capability. I wouldn't even think of starting coumadin in this patient.

Why does the OP pt need a lobectomy?

 

[NavyFlightDoc]

I guess the message is what I was thinking as well, that waiting would likely be best. And again, I am not managing this patient's care, just going through the thought processes. I guess the case boils down to 3 complicating factors:

1. Urgency of surgery - does the case need to be done immediately? Biopsy not quite back yet, so that will determine some of it, as few people want to wait a prolonged period of time if it turns out to be a high-grade tumor that is just itching to metastasize.

2. anticoagulated patient - certainly IV heparin and a heparin window would likely be used, rather than operating on a patient with an INR of 2-3.

3. lung surgery when the dependent lung already has a significant shunt, which will limit the oxygenation from that side - this was my real question, I guess. I didn't realize that two-lung ventilation was a reasonable possibility, which helps my thinking quite a bit.

Thanks for your thoughtful responses.

 

[narcusprince]

At what point would cardio pulmonary bypass be an option? If the PE was large and the tumor was diagnosed as a Stage I tumor and resection was critical?

 

[Tenesma]

you don't even need to put them on Bypass - just hook them up to ECMO...

i doubt the surgeon would do a lobectomy on a new PE patient... most thoracic surgeons are smart.