Interesting Thoracic Case

[cubs3canes]

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Hey all-

A new one for you.

78 yo male with esophageal ca for laproscopic resection. Hx of HTN, DM, GERD, ex-smoker. Thoracic epidural, a-line, R TLC.
Induction with propofol, 9.0 tube, desflurane. Place pt. in Left Lateral Decubitus. Cohen Bronchial Blocker into Right Main Stem Bronchus. Good OLV. Surgeon does a good job and gets the esophagus freed. Turn on epidrual after bolus..now riding great.
Finish right sided stuff with chest tube to suction.

Now to Supine. Back to Two lung ventilation. Reconfirm placement of tube 2 cm above corina with bronchoscope (Why not, it is fun). Insufflate the belly. Doing well. Laproscopic dissection.

All of sudden, the pressure drops to 60/40..HR low...I give some epi 15mcg..pressure comes up, but dips right back down..now slowly the airway pressures are increasing. I am getting 200 TV with a pressure of 40.

What happened? What would you do?

 

[pushthesux]

Hey all-

A new one for you.

78 yo male with esophageal ca for laproscopic resection. Hx of HTN, DM, GERD, ex-smoker. Thoracic epidural, a-line, R TLC.
Induction with propofol, 9.0 tube, desflurane. Place pt. in Left Lateral Decubitus. Cohen Bronchial Blocker into Right Main Stem Bronchus. Good OLV. Surgeon does a good job and gets the esophagus freed. Turn on epidrual after bolus..now riding great.
Finish right sided stuff with chest tube to suction.

Now to Supine. Back to Two lung ventilation. Reconfirm placement of tube 2 cm above corina with bronchoscope (Why not, it is fun). Insufflate the belly. Doing well. Laproscopic dissection.

All of sudden, the pressure drops to 60/40..HR low...I give some epi 15mcg..pressure comes up, but dips right back down..now slowly the airway pressures are increasing. I am getting 200 TV with a pressure of 40.

What happened? What would you do?

I'll bite.

Make sure there are bilateral breath sounds.
Make sure the insufflation pressure isn't jacked up.
Make sure the surgeons aren't doing anything down there to cause some sort of vagal response.
Make sure the chest tube is working.
Make sure the CVP hasn't really changed much.
Make sure the epidural has not been overdosed.

I can't put my finger on what might be happening, but I bet it has something to do with the insufflation pressures....maybe pneumomediastinum??

 

[cchoukal]

I can't put my finger on what might be happening, but I bet it has something to do with the insufflation pressures....maybe pneumomediastinum??

you just put your finger on it... Our center just started doing minimally invasive esophagectomies, and this has happened a couple times.

 

[Idiopathic]

id think tension pneumo 2/2 bronchial injury or pneumomediastinum 2/2 diaphragmatic injury.

btw, i have never put a 9.0 ETT in anyone. why not just a 39 DLT?

 

[aredoubleyou]

Hey all-

A new one for you.

78 yo male with esophageal ca for laproscopic resection. Hx of HTN, DM, GERD, ex-smoker. Thoracic epidural, a-line, R TLC.
Induction with propofol, 9.0 tube, desflurane. Place pt. in Left Lateral Decubitus. Cohen Bronchial Blocker into Right Main Stem Bronchus. Good OLV. Surgeon does a good job and gets the esophagus freed. Turn on epidrual after bolus..now riding great.
Finish right sided stuff with chest tube to suction.

Now to Supine. Back to Two lung ventilation. Reconfirm placement of tube 2 cm above corina with bronchoscope (Why not, it is fun). Insufflate the belly. Doing well. Laproscopic dissection.

All of sudden, the pressure drops to 60/40..HR low...I give some epi 15mcg..pressure comes up, but dips right back down..now slowly the airway pressures are increasing. I am getting 200 TV with a pressure of 40.

What happened? What would you do?

Hight thoracic pressures.
Turn off pressures to belly (do that as you're giving your pressors), insert chest tube (or i suppose needle to mediastinum if chest tube already in), fix the diaphagm if can find injury - either way its now an open case.

 

[cubs3canes]

First...nice. You got it right on the first guess. Pt with a left tension pneumo from pneumomedistinum. It all resolved with a left sided chest tube.

I love a 9.0 tube and a cohen bronchial blocker. As long as the RUL take off is not extemely proximal, it works really well. the surgeon also prefers it.

Cubs