DLT and thoracic spine surgery

[Airlife91]

So we have a new surgeon who is starting to request lung isolation during thoracic spine surgeries. He’s primarily requesting it for big thoracic fusions and recently a corpectomy/fusion for epidural abscess. I remember this request a couple times in training, but it was rare.

They’ve been requesting it for some cases where I don’t think it’s reasonable - ie loooong cases with anticipated high blood loss, and covid+ patients. Even in patients without those issues, it’s a pain to manage a DLT while prone.

I haven’t looked extensively, but a quick search didn’t turn up much data justifying this practice.

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[MirrorTodd]

Why does he want isolation? Assuming these are posterior fusion since the pt is prone? What does the benefit of lung isolation do for him for those particular surgeries? Like is there really that much tissue excursion from double lung ventilation that it gets in his way?

 

[HalO'Thane]

So we have a new surgeon who is starting to request lung isolation during thoracic spine surgeries. He’s primarily requesting it for big thoracic fusions and recently a corpectomy/fusion for epidural abscess. I remember this request a couple times in training, but it was rare.

They’ve been requesting it for some cases where I don’t think it’s reasonable - ie loooong cases with anticipated high blood loss, and covid+ patients. Even in patients without those issues, it’s a pain to manage a DLT while prone.

I haven’t looked extensively, but a quick search didn’t turn up much data justifying this practice.

Never did a lung isolation spine case in the prone position. Did plenty of anterior Spine cases in training and a few as an attending but they are usually in the lateral position.
As MirrorTodd said I don’t see how lung isolation will help if you’re going prone.

Are you going anterior approach first and then posterior? If that is the case you can always put in a bronchial blocker to provide lung isolation for the anterior approach and then remove it and switch it to 2 lung ventilation for the posterior approach. That way you still have the option to keep the patient intubated if you were concerned how they will do postop.

 

[Hoya11]

So we have a new surgeon who is starting to request lung isolation during thoracic spine surgeries. He’s primarily requesting it for big thoracic fusions and recently a corpectomy/fusion for epidural abscess. I remember this request a couple times in training, but it was rare.

They’ve been requesting it for some cases where I don’t think it’s reasonable - ie loooong cases with anticipated high blood loss, and covid+ patients. Even in patients without those issues, it’s a pain to manage a DLT while prone.

I haven’t looked extensively, but a quick search didn’t turn up much data justifying this practice.

Just to play devils advocate, besides the COVID pos patients (which would be a NO from me too much airway exposure), what exactly are you concerned about? How does large EBL effect your DLT? You can still just abandon OLV and resume 2LV if you need to improve oxygenation in a pinch. Why does it matter how long the case is? I dont think I would have a problem with it as long as I was happy with the tube and ventilation prone once positioned.

 

[GassYous]

Same reason why I don't place 9.0 tubes routinely.

 

[Ronin786]

Is he worried about getting into the pleura? Had a vascular surgeon request that so we could drop the lung for some of his first rib resections. Guy also sucked and would schedule cases on Saturdays. So **** him.

 

[zizzer]

I agree that this doesn't make sense if not doing a transthoracic or transdiaphragmatic approach in the lateral position. The downsides of troubleshooting DLT problems in prone position and losing the helpful ventilation/perfusion matching you get in the lateral position seem to outweight whatever you get from surgical exposure in the prone position. If he's insistent on it still, just let him know you'll have to have a low threshold to reinflate both lungs.

 

[Volatile]

This seemed ridiculous to me. Just asked one of our spine surgeons about it, He said tell ‘em to go back to fellowship

 

[Lecithin5]

I don’t like it when (usually new) surgeons get too cute with their requests.

 

[Airlife91]

Thanks for the replies.
This specific case was a long, 10+hr case for an large thoracic epidural abscess. Done in prone position. He wanted DLT for the corpectomy portion to reduce likelihood of getting into the pleura, and increase surgical exposure.
My concern with the DLT was this guy was on NC @2Lpm, presumably because of covid. The chances of his O2 requirement going up after likely significant transfusion combined with the length of the case led me to be concerned about ability to extubate at the end. Basically, I said there was a reasonable chance this guy was going to the ICU intubated after the case.
So then we’re left with swapping a DLT for a single lumen tube in someone who has been a) prone for 10+hrs, b) transfused at least a fair amount, c) had a large lumen tube in his trachea for awhile. In short, not someone I was eager to swap an ETT at the end, due to concerns for airway edema, and already poor o2 reserve, etc.
Of course when I was in fellowship, we did those long descending aortic cases with a DLT and never had a problem. Still...the DLT seemed unnecessary and only provided more challenges.
*edited for typos

 

[Arch Guillotti]

Prone DLT? No way. Not a reasonable request.

 

[pgg]

They’ve been requesting it for some cases where I don’t think it’s reasonable - ie loooong cases with anticipated high blood loss, and covid+ patients.

You're doing elective spine cases on Covid+ patients? That seems even more idiotic than OLV for prone patients.

 

[Hoya11]

Thanks for the replies.
This specific case was a long, 10+hr case for an large thoracic epidural abscess. Done in prone position. He wanted DLT for the corpectomy portion to reduce likelihood of getting into the pleural, and I’m tease surgical exposure.
My concern with the DLT was this guy was on NC @2Lpm, presumably because of covid. The chances of his O2 requirement going up after likely significant transfusion combined with the length of the case led me to be concerned about ability to extubate at the end. Basically I said there was a reasonable chance this guy was going to the ICU intubated after the case.
So then we’re left with swapping a DLT for a single lumen tube in someone who has been a) prone for 10+hrs, b) transfused at least a fair amount, c) had a large lumen tube in his trachea for awhile. In short, not someone I was eager to swap an ETT at the end, due to concerns for airway edema, and already poor o2 reserve.
Of course when I was in fellowship, we did those long descending aortic cases with a DLT and never had a problem. Still...the DLT seemed unnecessary and only provided more challenges.

agree with you after that explanation.

you never want a DLT in a situation like that with swelling for that long

 

[sevo00]

Can you have a formal sit down with this surgeon with your more senior partners? I think this is not a reasonable request and he needs to be educated on why that its so he doesn't force a newbie down on the road who might be afraid to speak up

 

[Iso4ane]

What about a bronchial blocker? Or do you need bilateral isolation? (In which case, an EZ blocker.)

 

[Arch Guillotti]

What about a bronchial blocker? Or do you need bilateral isolation? (In which case, an EZ blocker.)

No. Discuss with partners, get 100% buyin from them. No OLV for a prone case.

 

[fakin' the funk]

Obviously a surgeon who routinely requests this either a) sucks or b) is a prima donna, and mostly likely both.

In this unusual case, I don't think I would place a DLT, even if I was holding out the possibility of lung isolation, given that high likelihood of hypoxemia and/or edema and/or mechanical difficulty in the prone position. A large single lumen ETT and bronchial blocker gives you the OLV option,
But,

My go-to here would be single lumen plus lower tidal volumes (eg 4-6/kg) if a modest degree of pleural "deflation" is actually need.

 

[Airlife91]

You're doing elective spine cases on Covid+ patients? That seems even more idiotic than OLV for prone patients.

Not elective. Epidural abscess.

 

[Airlife91]

Thanks for the replies, confirms what I already thought. Im a few years out of training but new-ish to my group, so I certainly won’t be making waves. That said, I’ll be bringing it up for a group discussion. My partners are all pretty sharp, so I’m sure we’ll get a good consensus on how to address it with this surgeon. Thanks for the input.

 

[Velefunt]

Thanks for the replies.
This specific case was a long, 10+hr case for an large thoracic epidural abscess. Done in prone position. He wanted DLT for the corpectomy portion to reduce likelihood of getting into the pleura, and increase surgical exposure.
My concern with the DLT was this guy was on NC @2Lpm, presumably because of covid. The chances of his O2 requirement going up after likely significant transfusion combined with the length of the case led me to be concerned about ability to extubate at the end. Basically, I said there was a reasonable chance this guy was going to the ICU intubated after the case.
So then we’re left with swapping a DLT for a single lumen tube in someone who has been a) prone for 10+hrs, b) transfused at least a fair amount, c) had a large lumen tube in his trachea for awhile. In short, not someone I was eager to swap an ETT at the end, due to concerns for airway edema, and already poor o2 reserve, etc.
Of course when I was in fellowship, we did those long descending aortic cases with a DLT and never had a problem. Still...the DLT seemed unnecessary and only provided more challenges.
*edited for typos

If OLV necessary, then I like Halo'Thane's idea of a bronchial blocker.

 

[secretasianman]

How do I not put this bluntly? This is rucking fetarded.