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Jennifer Black

on 13 February 2011

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Transcript of thoracotomy

Anesthetic Care of the Patient undergoing thoracotomy Patient Presentation
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
Physical Examination
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
Stress Test
PFT's Effects of Cigarette Smoking
Increase CO
Increase mucus
Decreased mucociliary function
Increased pulmonary epithelial permeability
Decreased surfactant
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
Extubation Sources
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
Anesthetic off
Hetastrach, Albumin and Crystalloids rapidly infused until blood was available
Epinephrine IV + gtt
Levophed gtt
Vasopressin 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
Full transcript