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Oral case 131

Created: 4/3/2005

A 72-year old 60 kg man is scheduled for resection of right lung cancer with an associated bronchopleural fistula caused by erosion of the cancer. He is a chronic smoker. The chest radiograph reveals a right-sided empyema. He is dyspenic, and coughs copious quantities of purulent sputum. Blood pressure is 110/80 mmHg, pulse is 115 bpm, respirations are 30, and temperature is 39 degrees centigrade.

 Preoperative Evaluation

I. General assessment

1. What is the significance of the productive cough?

2. Why is he dyspenic?

3. What is the significance of his temperature?

II. Specific pulmonary evaluation

1. Would you require preoperative pulmonary function tests? Explain.

2. What information is available from a flow-volume loop?

3. Would you measure the pulmonary artery pressure preoperatively? Explain.

4. Would there be any advantage to having chest tube placement preoperatively? Explain.

 Intraoperative Course

I. Monitors

1. Which special monitoring devices would you use for this case?

2. You desire to place a pulmonary artery catheter. How can you place it into the left side?

3. What additional information will a pulmonary artery catheter give in this case?

II. Airway and anesthetic drug management:

1. Would you use a double lumen endotracheal tube? Explain.

2. Which type and size double lumen tube would you use?

3. How do you recognize proper tube placement?

4. What are disadvantages of a double lumen tube?

5. What drugs would you use to induce this patient? Explain.

6. Which agents would you use for maintenance? Explain.

7. Would you use spontaneous or controlled ventilation?

III. Intraoperative hypotension

1. After induction, the blood pressure falls to 60/40 mmHg, and the pulse is 40 bpm. What is your differential diagnosis?

2. What is your treatment?

3. There is no urine output. Would this affect your management of hypotension?

IV. Massive blood loss

1. There is a high rate of constant blood loss secondary to inflammatory tissue disruption. Assess the magnitude of the blood loss.

2. What are your approaches to replacement?

3. Does the presence of lung disease affect your fluid management? Explain.

 Postoperative Care

I. Postoperative ventilatory care

1. The patient remains hypoxemic. Why?

2. What is the etiology of pulmonary edema following a pneumonectomy?

3. What ventilatory settings would you use?

Adding positive end-expiratory pressure can improve alveolar function, as pulmonary edema prevents the alveoli from functioning normally. Oxygenation is usually improved once a pressure of between 5 and 15 cm H2O is added. Beginning with the addition of 5 cmH2O would be most appropriate.

4. The patient fights the ventilator. What can you do?

 Postoperative Pain Relief

1. How would you provide postoperative analgesia? Explain.

2. Compare and contrast thoracic epidural, intercostal blocks, and parenteral narcotics.

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