Monitoring
- Lines usually placed on site of surgery where possible to allow easier access
- Ensure wide-bore peripheral access
- Arterial line usually used for blood pressure monitoring and arterial sampling intraoperatively
- Central line may be recommended on a case by case basis for vasopressor infusions given goal of limited fluid therapy, particularly for larger resections such as pneumonectomy
- Catheter and temperature probe essential
Positioning
- Left or right decubitus position with a table break
- Requires fastidious checking of eye protection, pressure points, and neck position
- Tube position should be rechecked with bronchoscopy after positioning
- Compressions stockings and intermittent pneumatic calf compression devices should be used for DVT prophylaxis
Conduct
- Rigid bronchoscope may be performed prior to pneumonectomy
- Requires isolation and one-lung ventilation for surgical access
- Ventilation should be performed to minimise the risk of lung injury:
- Low tidal volumes based on ideal body weight
- Relatively high PEEP
- Low driving pressures
- Avoidance of hyperoxia
Fluids & Haemodynamics
- Fluids should be restricted whilst avoiding hypovolaemia:
- Excess fluid independent risk factor for postoperative pulmonary oedema
- No clear evidence for benefits of goal directed fluid therapy in lung resection surgery
- In the event of hypotension:
- Haemorrhage must be excluded
- Hypotension secondary to epidural infusion should be treated with vasoactive drugs
Analgesia
- Regional anaesthesia useful for intraoperative and postoperative analgesia:
- Single shot:
- Paravertebral block (anaesthetist or surgeon)
- Intercostal blocks
- Erector spinae plane block
- Serratus anterior block
- Retrolaminar block
- Intrapleural analgesia (via drain)
- Continuous:
- Paravertebral infusion
- Epidural infusion
Intrapleural Infusion
- Single shot: