Category Archives: thoracic

Lobectomy recipe

+/- pre-med temazepam 10-20mg

Peripheral access 14/16G

Midazolam 0.5-2mg

Start remi at 0.1mcg/kg/min

Art line

Sit up for thoracic epidural

Supine, full monitoring inc. BIS

Epidural test-dose

Pre-O2

co-induction with propofol + sevo. 1mg/kg roc.

Miniman bagging. DLT using asleep fibre optic intubation technique.

+/- CVP

Top-up epidural 10ml of 0.25% l-bupivicaine.

Intra-op: O2/air/desflurane. Remi at 0.1mcg/kg/min.

JB, GGH

Thoracic epidural tips for lateral / GA

– 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

 

OLV

Options:

1. DLT

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.

DLT

Simple principles:

Left-sided DLT: less likely to be malpositioned (obstruct RUL)
Right-sided DLT: easier to insert, necessary if proximal left main bronchus is occluded

Insertion:
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.