Tag Archives: thoracic

Pulmonary hypertension

mean PAP > 25 mm Hg

Classification:

  1. Pulmonary arterial e.g. IPAH, systemic sclerosis, congenital heart disease
  2. Secondary to left heart disease
  3. Secondary to chronic lung disease
  4. Chronic thromobo-embolic
  5. Multifactorial/unknown

ECHO features:

  • Estimation of sPAP in Apical 4-Chamber view. PH likely if estimated sPAP>50 mm Hg
  • Other features of PH: dilated right side chambers, reduced RV function, RVH, enlarged PA, abnormal inter-ventricular septum motion

Management:

  • Ca-channel blockade
  • Prostacyclin
  • Endothelin receptor antagonists
  • NO
  • PDE-5 inhibitor
  • TREAT PRIMARY CAUSE
  • consider (CTPA) +/- treat VTE
  • diuretics

http://www.escardio.org/guidelines-surveys/esc-guidelines/guidelinesdocuments/guidelines-ph-ft.pdf

 

Subclavian CVC – ‘safe method’

This method allegedly reduces the risk of puncturing apex of pleura and causing pneumothorax.

Steps:

(Usual pre-procedure steps and positioning)

– Place finger (A) in supra-clavicular notch at junction of medial 1/3 and lateral 2/3 of clavicle

– Entry point 1.5-2.0cm below junction of medial 2/3 and ┬álateral 1/3 of clavicle

– Angle needle towards finger (A) just under clavicle, walking off if necessary. Often hit subclavian vein in this trajectory.

– If no puncture then systematically re-orientate needle towards supra-sternal notch in stepwise fashion.

This method should avoid breaching the pleura

– JB, GGH

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

Radical Cystectomy Recipe

Issues:

Long/major-op
Laparotomy – usually umbilicus to pubis, may be longer
Potential major blood loss
Anastomoses
Prolonged ileus

Recipe:
Xmatch 4 units/fluid warmer/cell salvage
Large bore IV
Awake epidural @ T10. Test does 3ml of mix (of 20ml 0.25% levobupivicaine + 100mcg/2ml fentanyl)
GA/ETT ( – 2mcg/ml fentanyl, less propofol)
Asleep art line/CVC +/- CO monitor

Dex/paracetamol
Des
Just before KTS: Top-up epidural with 5ml mix/5ml H20/5ml mixRun epidural infusion 0.125% l-bupivicaine + 2mcg/ml fentanyl 4-8ml/hr.

At end bolus 5 ml of epidural infusion.
Ondansetron
Alternative:
Run remi intra-op then epidural at end/extubation
Adv: can switch off if major haemorrhage to avoid hypotension
Dis: May be difficult to wean remi->epidural and establish post-op analgesia reliably

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.