Thoracic Anesthesia for Seniors · Cerebral oximetry and thoracic surgery, Current Opinion in...
Transcript of Thoracic Anesthesia for Seniors · Cerebral oximetry and thoracic surgery, Current Opinion in...
Thoracic Anesthesia for Seniors
Dawn Desiderio, MD
Acting Chair Department of Anesthesiology and
Critical Care Medicine
Memorial Sloan-Kettering Cancer Center
New York, New York
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Disclosures
NONE
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Total Thoracic Operative Cases in 2014 2139
Total Thoracic Operative Cases in 2014 (Age 71-80) 424
Total Thoracic Operative Cases in 2014 (Age >80) 129
Total Lobectomy 467
Total Lobectomy Open 207
Lobectomy Open (Age 71-80) 60
Lobectomy Open (Age >80) 12
Total Lobectomy VATS 197
Lobectomy VATS (Age 71-80) 64
Lobectomy VATS (Age >80) 12
Total Lobectomy Robotic 63
Lobectomy Robotic (Age 71-80) 16
Lobectomy Robotic (Age >80) 4
MSK Experience
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Total Esophagectomy Open 57 Esophagectomy Open (Age 71-80) 11 Esophagectomy Open (Age >80) 2 Total Esophagectomy VATS 5 Esophagectomy VATS (Age 71-80) 0 Esophagectomy VATS (Age >80) 1 Total Esophagectomy Robotic 33 Esophagectomy Robotic (Age 71-80) 4
Esophagectomy Robotic (Age >80) 2
Total Thoracic Operative Cases in 2014 2139
Total Thoracic Operative Cases in 2014 (Age 71-80) 424
Total Thoracic Operative Cases in 2014 (Age >80) 129
MSK Experience
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Agenda
One Lung Ventilation
Ventilation Strategies
Specialized Monitoring
Epidural Pain Control
Conclusion
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Indications for Lung Isolation: OLV
Bleeding
Infection
Lung Lavage
Bronchopleural fistula
Blebs
Minimal Invasive Surgery - VATS
Robotic Surgery
ABSOLUTE
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Techniques of OLV
Endobronchial Intubation
Single or Double Lumen Tube
Univent Tube
Bronchial Blockers
Fogarty 8-14F Catheters
Arndt Endobronchial Blockers
Cohen Tip Deflecting Blocker
EZ Blocker
Fuji Blocker
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Double Lumen Tube Considerations : I
Size : Gender, Patient Size, Airway Anatomy
Large Tubes 39, 41
Better for Secretions
More Difficult to Place
More Trauma
Small Tubes 35, 37
Easier to Place
Conditions for OLV ?
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Anesth Analg 2008;106:379 –83
Practice Patterns in Choice of Left Double-Lumen Tube Size
for Thoracic Surgery
Amar D, Desiderio DP, Heerdt P, Kolker A, et al.
300 adults undergoing Thoracic Surgery
Prospective Study
Comparing use of 35FR DLT to Conventional Goal
Combined incidence of transient hypoxemia, inadequate OLV , or need for DLT repositioning did not differ
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Double Lumen Tube Considerations : I
Left versus Right DLT
Indications: Thoracic Aneurysm Surgery
Endobronchial Tumors
Pneumonectomies
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Double Lumen Tube Considerations : II
Placement
FOB Availability
Airway Assessment
Movement during Surgery and Positioning *
Need to Change at the End
Tube Exchanger
Trauma
Endobronchial Tumor
Difficult airway/ Intubation
Known versus Unexpected
*Desiderio DP, Burt M, Kolker A, Fischer M, Et Al. The Effects of Endobronchial cuff inflation on double-lumen endobronchial tube movement after lateral decubitus positioning. J Cardiothorac Vasc Anesth 1997;11:595-598
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Placement of DLT
1. Insert Blue Cuff of Endobronchial Lumen
through the Cords
2. Turn DLT to Appropriate Side Remove Stylet
3. Position until Resistance Met
4. Inflate Tracheal and Bronchial Cuffs
5. Assure Breath Sounds Bilaterally and End Tidal
CO2
6. Clamp Tracheal side 12
Placement of DLT
Breath Sounds
Correct
Check FOB Balloon Depth
Incorrect
Reposition FOB/ Blind
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Fiberoptic Bronchoscopy
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Lung Isolation: Right Sided Tubes
More difficult to position: decrease margin of safety
Away from the compress bronchus during aortic aneurism
Tumor in the left main bronchus
Positioned under direct bronchoscopy
Teaching
Right Side Tube Blockers
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Bronchial Blockers
Indications
Upper airway pathology:
difficult intubation
laryngeal disease
Lower airway pathology:
prior tracheal/pulmonary surgery
anatomical abnormality
bronchial compression/obstruction
Cardiac & vascular procedures
Multiple surgical approaches
Pediatric patients 17
Bronchial Blockers
Requires fiberoptic bronchoscopy
Learning curve
Limitations:
Secretion removal in operative lung
Rate of lung collapse
Movement likely
Advantages:
Institute any time / any position
Lobar collapse
Postoperative intubation/ventilation
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Univent
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Guide Loop- Arndt
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Adapter
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Cohen Tip Deflecting Blocker
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COOK
60cm 3cm
Soft flexible tip
COOK
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Amar D, Desiderio DP, Bains MS, Wilson RS. A Novel Method of One Lung Isolation using a Double Bronchial Blocker Technique. Anesthesiology 2001;95:1528-30
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EZ-BLOCKER
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Bronchial Blockers
Bronchial blockers are an important adjunct for
lung isolation.
A variety of devices and approaches are
currently available.
Limitations of this approach must be carefully
considered.
Expertise with fiberoptic bronchoscopy is
essential.
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INTRAOPERATIVE VENTILATION
Avoid low-volume injury and over distention challenging with robotic surgery
TV 6-8 cc/kg
Avoid high Inspiratory Peak Airway pressures
< 30 cm H2O
PEEP 5 cm H2O
Postoperative Pulmonary Complications Pathophysiology leading to lung Injury
Mechanical Ventilation
• High TV over distention, Low TV atelectasis, High Pressure
Surgery/Inflamation
• Epithelial cell injury
Respiratory Muscle weakness
• Muscle relaxants
Fluid/ pulmonary edema
Ventilation Strategies
Serpa Neto et al. Anesthesiology 2015; 123
Protective versus Conventional Ventilation for Surgery A Systematic Review and Individual Patient Data Met-Analysis
M Eikermann, T Kurth. Anesthesiology 2015;123 Apply Protective Mechanical Ventilation in the Operating
room in an Individualized Approach to Perioperative Respiratory Care
D Amar, H Zhang, A Pedoto, D Desiderio et al. Submitted for publication
Protective Lung Ventilation and Morbidity after pulmonary Resection : A Prospective Observational Study
Specialized Monitoring Cerebral Oximetry
Mahal I, Davie SN, Grocott HP. Cerebral oximetry and thoracic
surgery, Current Opinion in Anesthesiology 2014;27(1):21-27
First described in Cardiac Surgery
Research sparse in thoracic
Desaturation common related to various physiological disturbances
Relationship cerebral desaturation and adverse postoperative outcomes
Protocol : Cerebral Oximetry use in Robotic Esophagectomy Surgery MSK Experience
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Epidural Anesthesia
Post operative Pain Control
Facilitates early extubation
Reduces risk of Cancer Recurrence ???
Vaghari BA, Ahmed OI, Wu CL. Regional Anesthesia-Analgesia
Relationship to cancer Recurrence and Infection. Anesthesiology Clin 2014;32:841-851
Perioperative immune function
Multi disciplinary approach attenuate immunosupression
No definitive answer yet
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Future Trials
The effect of adding Introperative Regional Anesthesia on Cancer Recurrence in Patients Undergoing Lung Cancer resection.
Randomized double blind controlled trial
18-85 yr diagnosed primary non small cell scheduled for curative tumor resection
Disease free survival up to 5 years post surgery
Est completion 2018
Outcome Research Consortium, Kurtz A, Cleveland Clinic
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Future Trials
Randomized open-label controlled trial
25-80 yrs diagnosed non small cell lung cancer scheduled for VATS lobectomy
Overall survival up until 5 years after surgery
Lee YC from National Taiwan University Hospital
Completion 2018
Thorascopic Lobectomy Using Thoracic Epidural Anesthesia versus General Anesthesia for Lung Cancer Patients
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Conclusions
Increasing Robotic and VATS Thoracic Surgery
Absolute Indication for OLV
Innovative Monitoring to improve outcome
Ventilatory Strategies to reduce post operative pulmonary complications
Epidurals to improve Outcome
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