Always loose lots of fluid and they tend to be relatively under-resuscitated by end of op.
+/- pre-med temazepam 10-20mg
Peripheral access 14/16G
Start remi at 0.1mcg/kg/min
Sit up for thoracic epidural
Supine, full monitoring inc. BIS
co-induction with propofol + sevo. 1mg/kg roc.
Miniman bagging. DLT using asleep fibre optic intubation technique.
Top-up epidural 10ml of 0.25% l-bupivicaine.
Intra-op: O2/air/desflurane. Remi at 0.1mcg/kg/min.
IVI + arterial line
Propofol & remi TIVA induction -> maintenance
(or remi in mcg/kg/min or ml/hr)
Insert ventilating bronchoscope. Attach Sanders Jet Ventilator. Beware of loose connection, kinks in tubing
Jet ventilate 10-12 bpm. Allow expiration
Pause as needed e.g. laser
Suction + Insert LMA
– POSITION WELL
– count up from L2/3 and also down from C7 spinous process (major prominence in neck) to identify level
– if under GA try 3 different spaces before resorting to para-median approach as patient is not awake to be a marker of danger
– maintain thumb of non-needling hand on spinous process above space
– feed epidural to that natural curve tends to take it cephelad
– tunnel catheter (less movement, earlier marker of infection):
- nick in skin prior to needling
- feed 16G gelco sub-dermally in lateral direction approx 5cm
- cut off end obliquely
- pass through catheter without touching skin
- CAREFUL NOT TO CUT EPIDURAL CATHETER
– PM @ LGH
Adv: Best for ventilation/control of each side.
Dis: bulky therefore not in difficult intubation, tracheostomy
2. Single lumen ETT with bronchial blocker
Adv: Use in (pot.) difficult airway, tracheostomy, if ETT already in situ e.g. ICU.
Dis: More specialised kit and technique. Needs fibreoptic scope.
3. Single lumen ETT advanced into main bronchus ( + fibreoptic if left sided)
Adv: Useful in emergency with most simple/available kit.
Dis: no control over non-intubated lung.
Left-sided DLT: less likely to be malpositioned (obstruct RUL)
Right-sided DLT: easier to insert, necessary if proximal left main bronchus is occluded
Stylet in bronchial lumen
Remove stylet once tip is through the cords
Left-sided DLT: rotate to the left. Right-sided DLT rotate to the right
Checking – Clinically
1. Treat as single lumen tube. Inflate tracheal cuff and check for equal air entry, normal compliance, no leak
2. Test bronchial lumen. Clamp tracheal limb of catheter mount. Open port to feel leak diasappear. While ventilating inflate bronchial cuff (2ml) until leak disappears. Single lung should ventilate.
3. Test isolated ventilation of contra-lateral lung. Clamp bronchial limb and open port. Opposite lumb should ventilate.
Checking – Bronchoscope
1. Tracheal lumen. Observe bronchial cuff just distal to carina in proximal main bronchus
2. Bronchial cuff. Observe correct placment of Murphy’s eye at RUL orifice.