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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