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Transcript of thoracotomy
A 71 y/o Hispanic male with a previous medical history significant for
3rd Degree AVB with pacemaker placement ‘06
110 pack per year smoking history
Presented to PCP in 11/09 with c/o dyspnea on exertion and lethargy Evaluation revealed a depleted pacemaker battery.
Pre-op testing was completed for surgical procedure Surgical Plan:
Thoracotomy with biopsy and possible wedge resection Pre-operative Evaluation of Thoracotomy Patient
Labs and Tests History & Physical
The patient does not appear to be in any acute respiratory distress
Room Air Saturation - 96%
Quit smoking 3 months prior to procedure
Increase A:P diameter
+ Cough with moderate sputum production
No objective symptoms of Cor pulmonale
METS>4 Incidental Finding: Nodule in left upper lung. PET SCAN showed increased FDG uptake Labs & Tests
Right Heart Catheterization
PFT's Effects of Cigarette Smoking
Decreased mucociliary function
Increased pulmonary epithelial permeability
Increased closing capacity
Increase in proteolytic enzymes Anesthetic Plan
Pre-operative placement of A-line and CVP catheter
Smooth anesthetic induction
Placement of DL ETT
Placement of Magnet
Thoracic spinal with Bupivacaine and Duramorph
Al-Askar, F., et-al, Intrerpreting pulmonary function tests: Recognize the pattern and diagnosis will follow. , Cleveland Clinic Journal of Medicine. 2003, Oct;70(10): 866-881.
MacNee W., Pathophysiology of cor pulmonale in chronic obstructive pulmonary disease. Part One., American Journal of Respiratory Critical Care Med. 1994, Sep;150(3):833-52.
Rodrigo, C., The effects of cigarette smoking on anesthesia., Anesthesia Progress. 2000; 47: 143-150. Case Progression
Lined in Pre-op
In the OR @ 0800
Anesthesia Ready @ 0830
Incision @ 0845
Re-inflate lung @ 1000 Chronic Bronchitis vs Emphysema Patient exsanguinated in excess of 3 Liters within 3 minutes.
BP rapidly decompensated
Pulse-ox was unreadable
ETCO2 was nonexistent
But...Pacer was firing Chemical Code
Hetastrach, Albumin and Crystalloids rapidly infused until blood was available
Epinephrine IV + gtt
Pacemaker Now What?
Pneumonectomy? Thinking Ahead
What will happen when we re-inflate the lung?
What will the sequelae be?
What can we do to prevent it? Bring-Back
Two days later the patient returned to the OR
Fulminant Cor Pulmonale
Patient coded and was pronounced Take-homes