Gyorgy Frendl, MD, PhD

Peri-Operative Management ofPatients 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, 2014Kuwait

Gyorgy Frendl, MD, PhD

Ann Intern Med. 2006;144:581-595.

Gyorgy Frendl, MD, PhD

Types of Thoracic Surgical ProceduresEsophageal 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

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

Gyorgy Frendl, MD, PhD

Peri-Operative Atrial Fibrillation after Thoracic Surgery

Atrial Fibrillation

Wedge Resection < 4%Lobectomy/Pneumonactomy

12.5-33%

Esophagectomy 13-25%Lung Transplant 39%

Gyorgy Frendl, MD, PhD

Risk of 30 Day Mortality after Lung Cancer Resection

Risk Variable OR

Sex Male > Female 1.76

Age

>70 3.38

>80 9.94

Side Rt > Lt 1.73

Procedure Bi-Lobectomy 3.92

Pneumonectomy 4.66

Volume > 20/year 0.76

Gyorgy Frendl, MD, PhD

Thoracic Surgical Procedure-Based Risk Categories

Gyorgy Frendl, MD, PhD

FEV1 < 40% N=70/600

Gyorgy Frendl, MD, PhD

Focus of Pre-Operative Evaluation

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. FEV1 (ppo>40%)*

2. MVV, RV/TLC, FVC

1. VO2 max (>15 ml/kg/min)*

2. Stair climb > 2 flights3. 6min Walk Test• Exercise SpO2 <4%

1. DLCO (ppo >40%)*2. PaO2 >60

3. PaCO2<45

Gyorgy Frendl, MD, PhD

Gyorgy Frendl, MD, PhD

Complete Pre-Operative Review

Review:

– The cardio-pulmonary status

– PFTs, level of physical activity, use of inhalers, steroids, home O2

– Chest radiograms, CTs (tumor size, location, degree of COPD, abscess, etc)• pictures can tell a thousand words!

– Prior anesthetic (also airway) history

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

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)

Gyorgy Frendl, MD, PhD

Inhalational Agents vs. TIVA

Gyorgy Frendl, MD, PhD

Absolute indications for lung isolation

Gyorgy Frendl, MD, PhD

Relative Indications for Lung Isolation

Gyorgy Frendl, MD, PhD

Gyorgy Frendl, MD, PhD

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

Gyorgy Frendl, MD, PhD

Factors Inhibiting HPVNote: This will Increase Blood Flow to Operative Lung

• Very high PA pressures– Already bilaterally vasoconstricted

• Hypocapnia (low PaCO2)• Acidosis • High mixed venous PO2

• Intravenous vasodilators– TNG, SNP, Beta-agonists, Ca-channel blockers, Minoxidil, Theophylline,

Prostaglandin E1

– (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

Gyorgy Frendl, MD, PhD

Hypoxemia during OLV

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

Gyorgy Frendl, MD, PhD

Lung Transplantation

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)

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– FEV1 < 0.75 L – 1 year mortality 30%

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

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 CO2)– 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

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 extubationbased on: Exercise

Tolerance, DLCO, VQScan, assoc. diseases

Staged weaning from Mechanical ventilation

Thoracic epidural (avoid narcotics)

J Cardiothorac Vasc Anesth 14:202, 2000

Avoid if Possible

Gyorgy Frendl, MD, PhD

Post-Op

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!

Gyorgy Frendl, MD, PhD

Thank You!

Questions?

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

Gyorgy Frendl, MD, PhD

Broncho-Pleural Fistula – Anesthetic Strategies

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

Gyorgy Frendl, MD, PhD

Recommended Risk Reduction Strategies

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

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)

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

Gyorgy Frendl, MD, PhD

Anterior Mediastinal Mass

Types of Masses

• Anterior Mediastinum1. Thymoma2. Mesenchymal tumors3. Dermoid cysts4. Lymphoma 5. Thyroid/parathyroid tumors

• Middle Mediastinum1. Pericardial cysts2. Bronchogenic cysts3. Lymphomas

• Posterior Mediastinum1. Neurogenic and enterogenous tumors/cysts2. Aortic aneurysms3. Paravertebral abscesses

Flow volume loops

VARIABLE EXTRATHORACIC OBSTRUCTION

VARIABLE INTRATHORACIC OBSTRUCTION

FIXED UPPER AIRWAY OBSTRUCTION

Anesthetic Implications

• Tracheobronchial obstruction*Maintain spont vent*Tube placement

beyond obstruction*Fem-fem bypass/ECMO

• Compression of the heart• 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 Gravis

mass

Gyorgy Frendl, MD, PhD

Anterior Mediastinal Mass – Rescue Strategies

Gyorgy Frendl, MD, PhDAnn Intern Med. 2006;144:581-595.

Gyorgy Frendl, MD, PhD

Outcomes after Thor Surg Procedures