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Gyorgy Frendl, MD, PhD Peri-Operative Management of Patients for Complex Thoracic Surgery Gyorgy Frendl, MD, PhD, FCCM Associate Professor of Anesthesiology.

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Presentation on theme: "Gyorgy Frendl, MD, PhD Peri-Operative Management of Patients for Complex Thoracic Surgery Gyorgy Frendl, MD, PhD, FCCM Associate Professor of Anesthesiology."— Presentation transcript:

1 Gyorgy Frendl, MD, PhD Peri-Operative Management of Patients for Complex Thoracic Surgery Gyorgy Frendl, MD, PhD, FCCM Associate Professor of Anesthesiology and Critical Care, Harvard Medical School Director of Research, Surgical Critical Care, Brigham and Women’s Hospital November 21-22, 2014 Kuwait

2 Gyorgy Frendl, MD, PhD Ann Intern Med. 2006;144:

3 Gyorgy Frendl, MD, PhD Types of Thoracic Surgical Procedures Esophageal Procedures: Esophagoscopy/PEG/Esophageal Dilation Laparoscopic Nissen Fundal Plication/ Myotomy Zenker's Diverticulectomy Esophagectomy (Iwory-Lewis vs Three Hole) Other: Pericardial Window Intra-Thoracic/Airway Procedures:  Minor procedures: Flexible Bronchoscopy Photodynamic Therapy (PDT) Tracheal Stents  Procedures with moderate stress:  Ridgid Bronchoscopy  Mediastinoscopy (Cervical or Anterior)  Thoracoscopic/Video Assisted Thoracoscopic (VAT) Wedge Resection  Bronchoscopic LASER Surgery  Tracheostomy  Thoracoscopic Sympathectomy  Major procedures:  Anterior Mediastinal mass/Thymectomy  Thoracoscopic/Video Assisted Thoracoscopic (VAT) Lobectomy  Open Thoracotomy for Lobectomy/Segmentectom  Tracheal Resection and Reconstruction/Carinal Resection  Pneumonectomy, Extrapleural Pnuemonectomy (EPP), Pleurectomy  EPP with Heated Chemotherapy and Protocol  Volume Reduction/Bullectomy  Bronchopleural Fistula Repair  Pleuroscopy, Pleurodesis, Poudrage, and Decortication  Clagget Window  Lung Transplantation

4 Gyorgy Frendl, MD, PhD Most Common Thoracic Surgical Procedures Bronchoscopy & Cervical Mediastinoscopy Thoracoscopy and/or VATS Thoracotomy for Lobectomy or Pneumonectomy Laproscopic GE Junction procedures (Nissen Fundoplication, Heller Myotomy) Esophagectomy

5 Gyorgy Frendl, MD, PhD Peri-Operative Atrial Fibrillation after Thoracic Surgery Atrial Fibrillation Wedge Resection< 4% Lobectomy/Pneum onactomy % Esophagectomy13-25% Lung Transplant39%

6 Gyorgy Frendl, MD, PhD Risk of 30 Day Mortality after Lung Cancer Resection Risk VariableOR SexMale > Female1.76 Age > > SideRt > Lt1.73 ProcedureBi-Lobectomy3.92 Pneumonectomy4.66 Volume> 20/year0.76

7 Gyorgy Frendl, MD, PhD Thoracic Surgical Procedure-Based Risk Categories

8 Gyorgy Frendl, MD, PhD FEV 1 < 40% N=70/600

9 Gyorgy Frendl, MD, PhD Focus of Pre-Operative Evaluation

10 Gyorgy Frendl, MD, PhD Preoperative Evaluation for Major Thoracic Surgery J Cardiothorac Vasc Anesth 14:202, 2000 “Three-Legged” Stool of Pre-Thoracotomy Respiratory Assessment Respiratory Mechanics Cardio-Pulmonary Reserve Lung Parenchymal Function 1.FEV 1 (ppo>40%)* 2.MVV, RV/TLC, FVC 1.VO 2 max (>15 ml/kg/min)* 2.Stair climb > 2 flights 3.6min Walk Test Exercise SpO 2 <4% 1.DLCO (ppo >40%)* 2.PaO 2 >60 3.PaCO 2 <45

11 Gyorgy Frendl, MD, PhD

12 Complete Pre-Operative Review Review: – The cardio-pulmonary status – PFTs, level of physical activity, use of inhalers, steroids, home O 2 – Chest radiograms, CTs (tumor size, location, degree of COPD, abscess, etc) pictures can tell a thousand words! – Prior anesthetic (also airway) history

13 Gyorgy Frendl, MD, PhD Preoperative Management Prior to Major Thoracic Surgery Smoking cessation (6-8 weeks prior) Increase physical activity, teach deep breathing exercise Cardiac evaluation (Peri-op beta blockade, ?EF, RV, PAP) – Risk for arrhythmias? Degree of COPD – effective treatment (inhalers, abx) Manage symptoms of paraneoplastic syndromes Pre-operative imaging – Airway compression? – Local extension? Predisposition to hypoxemia Pulmonary consolidation, atelectasis, pleural effusions

14 Gyorgy Frendl, MD, PhD Intra-Operative Management Induction and maintenance of anesthesia – appropriate for pt’s condition and surgery Airway – effective lung isolation techniques Monitoring strategies IV access Fluid management Pain management (intra-op, post-op)

15 Gyorgy Frendl, MD, PhD Inhalational Agents vs. TIVA

16 Gyorgy Frendl, MD, PhD Absolute indications for lung isolation

17 Gyorgy Frendl, MD, PhD Relative Indications for Lung Isolation

18 Gyorgy Frendl, MD, PhD

19 Physiology of Hypoxic Pulmonary Vasoconstriction Localized pulmonary vasoconstriction occurs in response to alveolar hypoxia Diverts blood away from poorly ventilated areas Exposure to chronic hypoxia (e.g. chronic lung disease) results in chronic vasoconstriction, vascular remodeling, and pulmonary hypertension

20 Gyorgy Frendl, MD, PhD Factors Inhibiting HPV Note: This will Increase Blood Flow to Operative Lung Very high PA pressures – Already bilaterally vasoconstricted Hypocapnia (low PaCO 2 ) Acidosis High mixed venous PO 2 Intravenous vasodilators – TNG, SNP, Beta-agonists, Ca-channel blockers, Minoxidil, Theophylline, Prostaglandin E 1 – (Contrast: B-blockers and COX-inhibitors enhance HPV) Inhalational anesthetics (esp. when > 1 MAC) All of these may inhibit vasoconstriction in the operative lung, leading to increased shunt

21 Gyorgy Frendl, MD, PhD Hypoxemia during OLV

22 Gyorgy Frendl, MD, PhD Anesthetic Goals for ALL Pulmonary Resections Safe induction – Avoid hypoxemia, hypercarbia, HD instability Isolate lungs to provide motionless operative field Satisfactory oxygenation and ventilation – Using the non-operative lung Appropriate invasive monitors and access Appropriate management of FEN and blood products Hemodynamic stability Prompt wean from mechanical ventilation Effective postoperative pain management

23 Gyorgy Frendl, MD, PhD Lung Transplantation

24 Gyorgy Frendl, MD, PhD Laparoscopic GE Junction Procedures Similar to other intra-abdominal laparoscopic procedures Often done for pre-transplant patients, chronic aspirators (NB: poor lung function) – Epidurals are mandatory for patients that are pulmonary “cripples” (adjuncts like a-line, bronchodilators, TIVA, reverse-able level of muscle relaxation maybe needed)

25 Gyorgy Frendl, MD, PhD Lung Volume Reduction Surgery (LVRS) Performed for severe COPD Patients have – Severe airway obstruction – Enlarged thorax >> disrupts respiratory mechanics Increased TLC, RV Decreased FEV1 Increased work of breathing Severe emphysema – FEV 1 < 0.75 L – 1 year mortality 30%

26 Gyorgy Frendl, MD, PhD Anesthetic Technique for LVRS Premedications: minimal to none Lung isolation mandatory – DLETT allows for both lungs to be sequentially operated on Large dead space results in anesthetic agent trapping – Propofol/Remifentanyl TIVA is our standard of care Despite thoracoscopic incisions, epidural is necessary, may supplement with NSAIDs Ventilation parameters: – Slow RR – Long I:E – Permissive hypercapnia May require intermittent reinflation of operative lungs

27 Gyorgy Frendl, MD, PhD Overall Risk Mitigation Strategies Poor pre-op lung function or very poor functional status – Is the procedure necessary, can the patient improve if procedure is delayed? – Consider regional anesthesia (alone or with GA), minimize narcotics – TIVA, Minimal muscle relaxants – wait for full recovery – Higher level of criteria for extubation (alert, cooperative, good strength, adequate MV and ET CO 2 ) – If not meeting criteria, delay extubation (PACU, ICU) – If acceptable, consider post-op NIPPV Major blood loss – Sufficient IV / central access – A-line for monitoring/labs – Blood in the OR, readily available – High flow systems to transfuse with temperature control – Helping hands

28 Gyorgy Frendl, MD, PhD Post-Thoracotomy Anesthetic Management ppoFEV1%= FEV1% X (1-%lung tissue removed/100) >40% 30-40% <30% Extubate in OR if: Pt awake, warm and comfortable Consider extubation based on: Exercise Tolerance, DLCO, VQ Scan, assoc. diseases Staged weaning from Mechanical ventilation Thoracic epidural (avoid narcotics) J Cardiothorac Vasc Anesth 14:202, 2000 Avoid if Possible

29 Gyorgy Frendl, MD, PhD Post-Op

30 Gyorgy Frendl, MD, PhD Summary The patients usually have complex co-morbidities The procedures are complex Patients almost never improve their pulmonary function (often worsen) post procedure Communication with surgeons, pulmonary specialists, and nurses is essential Set realistic expectations for patients and families Pre- and post-op physico-therapy and pulmonary rehab is essential Just do your best!

31 Gyorgy Frendl, MD, PhD Thank You! Questions?

32 Gyorgy Frendl, MD, PhD Anesthetic Goals for BPF Patients Minimize airflow across the fistula – decrease airway pressures during inspiration, decrease mean intra-thoracic pressures Adequate gas exchange in the un-affected lung Avoid tension PTX Protect the remaining (healthy) lung from contamination (as BPF spaces are always infected) Expansion of the remaining ipsilateral lung after the procedure

33 Gyorgy Frendl, MD, PhD Broncho-Pleural Fistula – Anesthetic Strategies

34 Gyorgy Frendl, MD, PhD Anesthetic Considerations for BPFs Water seal chest tubes for induction – Large BPF may make ventilation impossible ( risk of PTX) Chose appropriate induction strategy – inhalation induction vs. awake fiberoptic ETT insertion vs. awake LMA vs. asleep induction (short acting meds) – Single lumen ETT vs. DLT Place ETT so it excludes (isolates) fistula to: – Allow Independent lung ventilation – Allow positive pressure ventilation (bronchoscopy for ETT position) – Avoid cross-contamination (turn fistula-side down/dependent position) Consider high frequency ventilation if safe lung isolation is not feasible

35 Gyorgy Frendl, MD, PhD Recommended Risk Reduction Strategies

36 Gyorgy Frendl, MD, PhD Bronchoscopy / Cervical Mediastinoscopy These are “chip-shot” ambulatory cases, right? – About once a year, they biopsy the pulmonary artery The mediastinoscope can compress the right innominate artery – Obtain large bore IV access (even though they go home the same day) & ensure Blood Type & Screen is done – Place the IV and pulse oximeter on the RIGHT, BP cuff can go on the left – IV will need extension tubing – You won’t have access to the patient to monitor twitches Err on the side of deep paralysis – the patients should not move at the time of the surgeon biopsying near vital organs

37 Gyorgy Frendl, MD, PhD Thoracoscopic Lung Resection and VAT Generally small incisions, VAT incisions can be larger – Thoracoscopic Lung Resection >> keyhole – VAT >> keyhole + mini thoracotomy Maybe segmentectomy or lobectomy Depending on pulmonary function, may consider: – A-line pre-op (or after induction) – Placing pre-op epidural, especially for VAT – Consider TIVA (based on residual lung function)

38 Gyorgy Frendl, MD, PhD Strategies for Open Lobectomies and Pneumonectomies Strategies: – Pre-op large bore IVs, thoracic epidural and a-line – Test the level after test dose, before you induce – Central venous or Swan-Gants/PA catheter – Lung isolation (DLL ETT) Plan an anesthetic most likely to extubate from – Proprofol / Vecuronium / Desflurane / Remifentanil / Epidural analgesia

39 Gyorgy Frendl, MD, PhD Anterior Mediastinal Mass

40 Types of Masses Anterior MediastinumAnterior Mediastinum 1. Thymoma 2. Mesenchymal tumors 3. Dermoid cysts 4. Lymphoma 5. Thyroid/parathyroid tumors Middle MediastinumMiddle Mediastinum 1. Pericardial cysts 2. Bronchogenic cysts 3. Lymphomas Posterior MediastinumPosterior Mediastinum 1. Neurogenic and enterogenous tumors/cysts 2. Aortic aneurysms 3. Paravertebral abscesses

41 Flow volume loops VARIABLE EXTRATHORACIC OBSTRUCTION VARIABLE INTRATHORACIC OBSTRUCTION FIXED UPPER AIRWAY OBSTRUCTION

42 Anesthetic Implications Tracheobronchial obstruction Tracheobronchial obstruction *Maintain spont vent *Tube placement beyond obstruction *Fem-fem bypass/ECMO Compression of the heart Compression of the heart SVC obstruction SVC obstruction *Preop med. irradiation *Arterial line, central line (fem) *Large bore IV access (lower ext) *Avoid a/w trauma, coughing, straining, supine positions Myasthenia GravisMyasthenia Gravis mass

43 Gyorgy Frendl, MD, PhD Anterior Mediastinal Mass – Rescue Strategies

44 Gyorgy Frendl, MD, PhD Ann Intern Med. 2006;144:

45 Gyorgy Frendl, MD, PhD Outcomes after Thor Surg Procedures


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