A 52-year-old male is undergoing a right pneumonectomy for squamous cell carcinoma.
a) What pre-operative respiratory assessments would be helpful to assess his risks for the
surgery and post-operative course? (20% marks)
b) Outline your post-operative management for this patient with regards to:
ii. Fluid management (40% marks)
Three days after the operation he re-presents to ICU with new onset shortness of breath and hypotension, requiring intubation and mechanical ventilation
c) Give a differential diagnosis for his deterioration. Outline how you would manage his
a) What pre-operative respiratory assessments would be helpful to assess his risks for the surgery and post-operative course?
• CXR and ABG’s
• FEV 1 and diffusing capacity for carbon monoxide (DLCO)
• Calculated predicted postoperative (PPO) FEV 1 and PPO DLCO
• 6-minute walk test
b) Outline your management for this patient with regard to:
i. Post-operative Analgesia: Multimodal approach to analgesia
• Satisfactory analgesia can be achieved with i.v. opioids; however, their beneficial effects might be counterbalanced by the risk of respiratory depression, mild attenuation of the cough reflex, and diaphragm elevation due to bowel distension.
• The Opioid-sparing effect of a Regional techniques and avoidance of possible side effects of systemic analgesics may be advantageous in increasing tidal volume and vital capacity, and improving diaphragm activity- Epidural, Para vertebral analgesia, Intrathecal and intercostal block.
• Nonsteroidal anti-inflammatory drugs, especially Ketorolac may be used to supplement opioid analgesia. These drugs work synergistically with opioids and have no respiratory depressive effects. Disadvantages include platelet and renal dysfunction. Concern over renal dysfunction in patients in whom restrictive fluid administration is the norm means NSAID’s are often avoided.
• Ketamine, gabanoids
• Paracetamol at recommended doses, along with rescue doses of Tramadol, may be proposed as a valid analgesic regimen
iii. Post-operative fluid management
• Patients routinely extubated post op and may need minimal iv fluids
• Potential risk of postoperative lung injury with liberal fluid administration.
Give a differential diagnosis for his deterioration?
• Surgical Complication:
• Infectious causes
• Other complication:
Outline how you would manage his ventilation
Mechanical ventilation may increase the risk of bronchial stump disruption, bronchopleural fistula, persistent air leakage, and pulmonary infection.
• Protective ventilatory settings with small tidal volumes (Vts) and positive end-expiratory pressure (PEEP) should be applied to reduce the risk of ventilator-induced lung injury
• Prolonged mechanical ventilation may be associated with a significant risk for pneumonia every effort should be made to promote fast weaning from invasive airways.
• Acceptable rather than normal ABG targets
• Single lung ventilation may be required if there is a bronchopulmonary fistula
Causes of early deterioration with haemodynamic instability and dyspnoea:
"Outline how you would manage his ventilation" is a strangely worded question, as the answer would be strongly dependent on what the causes of the respiratory failure is. Let us try to answer this as if it did not matter why the patient was being ventilated. The basic principles (from Lytle et al, 2008) would be:
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Powell, E. S., et al. "A prospective, multicentre, observational cohort study of analgesia and outcome after pneumonectomy." British journal of anaesthesia 106.3 (2011): 364-370.
Slinger, Peter. "Update on anesthetic management for pneumonectomy." Current Opinion in Anesthesiology 22.1 (2009): 31-37.
Mesbah, A., J. Yeung, and F. Gao. "Pain after thoracotomy." Bja Education 16.1 (2016): 1-7.
Bialka, Szymon, et al. "Comparison of different methods of postoperative analgesia after thoracotomy—a randomized controlled trial." Journal of thoracic disease 10.8 (2018): 4874.