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