extubation post hemidiaphragm resection

[toughlife]

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tomorrow's first case:

59 y/o with metastatic renal cell CA and invasion of IVC scheduled for left radical nephrectomy, splenectomy, pancreatectomy, IVC thrombectomy and left hemidiaphragm resection.

Never had a pt like this before. Any advice for extubation?

 

[CanGas]

I think I would not be in a big hurry to extubate. There is no way this patient is going direct to the floor, they will be going to the ICU. It is a long case with plenty of opportunities for blood loss and fluid shifts both pre and post OR. I don't know about your ICU but I don't like delivering tenuous patients extubated in the early evening to a resident run ICU. I would do a standard big case setup (art, CVC, 2 big peripheral IV's on hot lines, +/- PAC if cardiac history) and a low thorasic epidural. Deliver the patient intubated to the ICU and let then have the night to settle down and/or declare themselves. You can then see what their pulmonary mechanics are like on their fancy ventilator and make the decision to extubate the next am if all is cool.