What's your guys' approach to Right VAT/possible thoracotomy as far as putting pre op epidurals for post op pain control, art line. I haven't talked to this surgeon about possibility of opening a pt up, but obviously if it was just a thoracotomy, I'd def consider epidural barring any contraindications. I always try to place a DLT even for a VAT. Any thoughts appreciated. Thanks.
Right VAT/Thoracotomy
- Thread starter Sputnik80
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This is sometimes a political issue.
We have a surgeon who consents for VAT with possible thoracotomy. She proceeds to thoractomy in 70-90% of the cases. Placing an epidural in a patient for whom she is says she will only scope is like expressing no confidence in her ability to stay with just the scope. But we all know how often she proceeds to open, historically.
If the patient is at high risk for post-op pulmonary compromise, I will place one regardless of what she tells me. On the otherhand, if the patient is generally otherwise healthy, I won't place one, unless she tells me she thinks its needed.
In this way, I cover my high risk patients, but I am still receptive to her judgement.
I place arterial lines and DLTs for all of them.
We have a surgeon who consents for VAT with possible thoracotomy. She proceeds to thoractomy in 70-90% of the cases. Placing an epidural in a patient for whom she is says she will only scope is like expressing no confidence in her ability to stay with just the scope. But we all know how often she proceeds to open, historically.
If the patient is at high risk for post-op pulmonary compromise, I will place one regardless of what she tells me. On the otherhand, if the patient is generally otherwise healthy, I won't place one, unless she tells me she thinks its needed.
In this way, I cover my high risk patients, but I am still receptive to her judgement.
I place arterial lines and DLTs for all of them.
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Our rate of conversion to open is pretty low, so for VATS no epidural; they're usually pretty well-controlled painwise with IVPCA or scheduled narcs - and if it's not you can always put the epidural in post-op. BTW, why is your question about right side only - does that make a difference?
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A thoracic epidural gives you great pain control but can be overkill for just a VAT. I try to know from the surgeon what the chances are that he'll end up opening the chest.
If the chances are low (<25%) i'd do a paravertebral block.
DLT always A lines depends on the patient.
If the chances are low (<25%) i'd do a paravertebral block.
DLT always A lines depends on the patient.
D
deleted126335
Our cardiac surgeons know the value of an epidural in a thoracotomy patient. They are the also the ones who get dinged for an extended ICU course or hospital length of stay. We simply ask them if they would like an epidural for each VAT patient. They usually have a pretty good idea in whom they might need to open. We place them about 30% of the time. All get A-lines and double lumen ETT.
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During residency we'd rarely place epidurals for VATS (only if the surgeon thought the odds of opening were >~30%). In fellowship, however, the surgeons are far more aggressive with what is done via VATS. VATS-wedges usually don't get epidurals, but VATS-lobes and VATS-pneumonectomies definitely do. The port hole is much larger (like a quarter of a thoracotomy to get the lung out) and hurts a lot more than the wedge ports.
No doesn't really matter right/left. In this case its a right vat so I just mentioned it for the sake of completeness. I've never worked with this surgeon before so will definately have to communicate with him pre-op. I've learned that art lines are helpful, just all the retracting/possible bleeding can mess with hemodynamics.
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As mentioned, with VATS, I talk to my surgeons for all of them. It serves 2 purposes: making sure so I don't have to listen to "why did u do blah blah blah.... and #2 it keeps the surgeon informed so they feel included, and gives them some degree of control. Since I deal with many lower SES status pts, by the time they present, it's usually a very large mass not amenable to -oscopy, and open proceudure is indicated. So, in stark contrast to the 30% I read above, I am closer to 80-90%, and they are pretty sick, so epidurals make quite an appreciable difference in their ICU stay. Also, arterial line, and DLT for all of them. I just wish we could help people with addiction and poverty as easily, b/c our LOS would probably drop 25-30%.
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Pardon me for high-jacking the thread, but I am curious as to the perceived indication for an A-line in all VATS/thoracotomy patients. I have been very comfortable doing VATS, wedges, segments, and even lobes without a-lines in ASA 3 patients without medical indications (bad CAD, AS or PaHTN, etc.). Blood loss is infrequent and hypotension for epidurals can be anticipated and treated in the normal fashion...Are my surgeons spoiling me?
D
deleted126335
In adults, radial Alines are very low morbidity, can be placed quickly, have obvious benefits... I have never regretted placing one in my entire career. I have only regretted not placing one.
My general rule of thumb is, if they are in the chest or the head, they get an A line, with selective exceptions. some mediastinoscopies and burr holes.
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For me it's potential for hemodynamic instability with compression of major structures and/or need for blood draw for crit/abg. You're right, with a good surgeon the incidence of that stuff is pretty low, but in this case you know how the saying goes - better to have it and not need it...especially trying to place an aline in lateral postion; doable but awkward.
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its very difficult to get an art line in lateral position when they convert or when you need one and its very easy to get one in supine position before you start. no one will ever criticize you for getting one when you dont need it and its indefensible to not get one when you end up needing it.
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I have found myself doing a VATS that ended up getting into the pulmonary artery. 16G x1 and non-invasive BP cuff (no significant cardio/pulmonary disease). Had to split the chest and go onto CPB. Popped in an a-line like supersonic fast... cuz, as you know, you cant use a BP cuff on CPB. I didnt like the feeling of not having such a benign monitor on board. First time Ive ever gone onto bypass without a central line. 16G + a-line + sternal saw.
I have a low threshold to place a-lines in these cases. 9/10 of my mediastinoscopies get them.... ive even seen those go south (whole in the LA). You may work with excellent surgeons... but if you do enough of them, sh**t does tend to happen from time to time. I learned my lesson and I refuse to be caught behind the eight ball ever again.
My 2cents.
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Our surgeons are very good. Will often do 5+ VATS lobes in day. If I put an aline in every case, I'd soon be out of a job. I will do an aline only if they plan on taking the entire lung, or if the pt's PMH dictates. Might I get screwed some day? Yes, I might. Will I be able to get help quickly if needed and move on? Yes.
Tuck
Tuck
I always put alines in VATS wedges, lobes, and pneumonectomies. I see no reason not to. It takes all of about 30 seconds to place it and tape it in place. I do it for 2 reasons:
1) relatively high likelihood of hemodynamic instability and/or large blood loss. I've seen plenty of injuries to the PA that can be a disaster to deal with. It isn't common, but if you do enough it happens.
2) possible need for blood gas monitoring to determine readiness for extubation. These people have mostly crappy lung function preop and it isn't going to be any better postop. You can't always extubate them instantly at the end of the case and being able to check ABGs is nice in this situation.
So while an aline does have some morbidity associated with it, intrathoracic surgery has greater morbidity and I think the risk/reward benefit is on the side of placing the aline at the start of the case.
1) relatively high likelihood of hemodynamic instability and/or large blood loss. I've seen plenty of injuries to the PA that can be a disaster to deal with. It isn't common, but if you do enough it happens.
2) possible need for blood gas monitoring to determine readiness for extubation. These people have mostly crappy lung function preop and it isn't going to be any better postop. You can't always extubate them instantly at the end of the case and being able to check ABGs is nice in this situation.
So while an aline does have some morbidity associated with it, intrathoracic surgery has greater morbidity and I think the risk/reward benefit is on the side of placing the aline at the start of the case.
