Pneumonectomy

[Planktonmd]

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Since the trend has been thoracic anesthesia lately I am going to present this case I had today:
80 Y/o pleasant little old lady in the holding area for right pneumonectomy.
she has multiple lesions on the CT scan in the right lung with a clear left lung.
Her PMH is significant for HTN and COPD.
She can walk 3-4 blocks, climbs 1 flight of stairs and lives independently.
No known cardiac history.
She quit smoking 2 weeks ago 🙂
Standard labs are OK.
EKG shows NSR + PVC's otherwise normal.
PFTS were done and showed obstructive pattern that does respond to bronchodilators.
No other studies were done.
SPO2 on room air is 99 %
And I need to mention that she weighs 90 pounds and is 4' 5"

Are we good to go?
Do you need any further studies pre-op?
Walk me through your pre-op and intra-op plan.

 

[aredoubleyou]

Since the trend has been thoracic anesthesia lately I am going to present this case I had today:
80 Y/o pleasant little old lady in the holding area for right pneumonectomy.
she has multiple lesions on the CT scan in the right lung with a clear left lung.
Her PMH is significant for HTN and COPD.
She can walk 3-4 blocks, climbs 1 flight of stairs and lives independently.
No known cardiac history.
She quit smoking 2 weeks ago 🙂
Standard labs are OK.
EKG shows NSR + PVC's otherwise normal.
PFTS were done and showed obstructive pattern that does respond to bronchodilators.
No other studies were done.
SPO2 on room air is 99 %
And I need to mention that she weighs 90 pounds and is 4' 5"

Are we good to go?
Do you need any further studies pre-op?
Walk me through your pre-op and intra-op plan.

Check standard things like hypercarbia on ABG, Low FEV1/FVC on PFTs, and FEV1. If all ok, albuterol in holding area, thoracic epidural, 2 Ivs, A-line. Sounds like functional status not that bad, so outside of standard labs and type/ cross, bring her back.

Fentanyl, propofol. mask, roc. DL tube, prollyt a 32. I think the next size down is 20-something. If the 32 is too big and the other one is too little, gunna be a real pain in the butt, cause you're prolly gunna have to use bronch-blocker. Place your tube, spin the patient on the side, check your lung issolation, and put her on pressure control, keep the tv to where the surgeons happy but the patient is oxygenated.

Although its not the oral boards answer, I always put 5 peep to dependent lung (which I have yet to see actually hurt oxygenation). CPAP to operative lung if needed.

bolus epidural near the end, turn of the gas, wake her up. Sneak in a little albumin if her pressures are 60 systolic, otherwise, phenylephrine as needed.

 

[Noyac]

Check standard things like hypercarbia on ABG, Low FEV1/FVC on PFTs, and FEV1. If all ok, albuterol in holding area, thoracic epidural, 2 Ivs, A-line. Sounds like functional status not that bad, so outside of standard labs and type/ cross, bring her back.

Fentanyl, propofol. mask, roc. DL tube, prollyt a 32. I think the next size down is 20-something. If the 32 is too big and the other one is too little, gunna be a real pain in the butt, cause you're prolly gunna have to use bronch-blocker. Place your tube, spin the patient on the side, check your lung issolation, and put her on pressure control, keep the tv to where the surgeons happy but the patient is oxygenated.

Although its not the oral boards answer, I always put 5 peep to dependent lung (which I have yet to see actually hurt oxygenation). CPAP to operative lung if needed.

bolus epidural near the end, turn of the gas, wake her up. Sneak in a little albumin if her pressures are 60 systolic, otherwise, phenylephrine as needed.

I concur. Although, if her pressure will tolerate it I'd use the epidural throughout the case.

 

[Coastie]

i've had attendings use intrathecal opioids up front for these cases.

Any experience with that?

 

[Noyac]

i've had attendings use intrathecal opioids up front for these cases.

Any experience with that?

Works well.

 

[aredoubleyou]

I concur. Although, if her pressure will tolerate it I'd use the epidural throughout the case.

I think its half a dozen of one and six of the other, so if you dont run your epidural throughout you can bill for post op pain, otherwise its part of your anesthesia fee....thats the ONLY reason I wouldn't.

 

[Planktonmd]

Great answers.
Do we need a vq scan or other studies to decide if this patient will tolerate the pneumonectomy?
Anyone wants an Echo pre-op?
How about a stress test?
What if I add that room air ABG shows PO2 60, PCO2 50, PH 7.45? Would that change the plan?
Any need for a central line if she has adequate peripheral access?

 

[Gern Blansten]

I am thinking of a devastating post op complication specific to this case that we should all be aware of, but I don't want to spoil the case if you were going to discuss that.

 

[aredoubleyou]

Great answers.
Do we need a vq scan or other studies to decide if this patient will tolerate the pneumonectomy?
Anyone wants an Echo pre-op?
How about a stress test?
What if I add that room air ABG shows PO2 60, PCO2 50, PH 7.45? Would that change the plan?
Any need for a central line if she has adequate peripheral access?

No to the VQ scan, she passes the eyeball test from a mile away. All other data says go, dont go digging for confusing answers.

No echo, theres no functional status problem, no uncertainty regarding hearet vs lung causing low METS, etc

Wouldn't delay the surgery for a stress test, but would be suprised if she hadn't had one.

Your new ABG shows chronic hypercarbia - thats a no go on the surgery unless the surgeon can cook up a new indication with one of those VQ scans you were talking about 🙂 My oral boards answer is No, No, No.

Central line only if you cant get good IVs, shes got a bad heart, or the surgeon wants it for post op.

 

[Noyac]

I agree with RWU
No VQ that's up the to the surgeon if he wants one
Exercise tolerance is good enough
I don't see a need for the stress test
That ABG changes everything from what I can remember.
I'd place a central line however. They are more than likely going to need it post-op.

 

[deleted59964]

Your new ABG shows chronic hypercarbia - thats a no go on the surgery unless the surgeon can cook up a new indication with one of those VQ scans you were talking about 🙂 My oral boards answer is No, No, No.
.

for those of us who are new to this - can you please explain your concern?
thanks

 

[proman]

She's had PFTs, Plank just hasn't given us the numbers. FEV1 etc?

 

[aredoubleyou]

for those of us who are new to this - can you please explain your concern?
thanks

I think the text book indications are a paco2 over 45 is a no-go. More importantly, when I think of COPD I think of three things: functional status, hypoxia, and co2 retention. Any of those things are bad news for a COPD'er and you should be concerned that they cannot survivie on one lung. Usually you will see that the CO2 retainers have very severe COPD, and if you wanna take out a lung, its prolly a good idea to make sure the other lung is considerably better than the other operative lung. Although, my understanding is that it should take two bad lungs to retain co2

 

[thegasman]

I agree with RWU

I'd place a central line however. They are more than likely going to need it post-op.

I would not place it if I did not need it. A PICC line can be placed post op which has a lower incidence of complications (infxn) than the tlc that I don't need for this case anyway. If I could not get good peripheral access then I would place the line.

 

[periopdoc]

PICC lines do not have a lower risk of infection than central lines. They may have a slightly lower incidence of mechanical complications at the time of insertion (ie pneumothorax).

- pod

 

[thegasman]

PICC lines do not have a lower risk of infection than central lines. They may have a slightly lower incidence of mechanical complications at the time of insertion (ie pneumothorax).

- pod

I could be wrong, but my understanding was that picc lines have been shown to have longer time to development of infection vs cvc but overall incidence of infection was not different