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Perioperative management of patients for pneumonectomy (Hx (Cancer 4 Ms…
Perioperative management of patients for pneumonectomy
Resectable lung disease
Still local or locoregional in scope and can be encompassed in a plausible surgical procedure
Operable patient
Someone who can tolerate the proposed resection with acceptable risk
Morbidity 3-4%
Major resp complication 15-20%
Cardiac complication (arrhythmia, ischaemia) 10-15%
Hx
If >70 AHA recommends TTE to exclude PHT
Cancer 4 Ms
Mass effect (obst, abscess, SVC syndrome, tracheobronch distortion, Pancoast tumour, nerve paresis)
Metabolic effects (Lambert-Eaton syndrome, hypercalcaemia, hyponatraemia, cushings)
Metastases (brain, bone, liver, adrenal)
Medication (Chemotherapy, pulm tox, card tox, renal tox)
Cardiac
Intermediate risk procedure, peak ischaemia risk day 2-3
30-50% arrhythmia in first post op week
Periop cardiology evaluation if major factors for increased risk
Renal dysfunction
Associated with higher mortality
COPD
Stage 1 (FEV1 >50% predicted)
Stage 2 (FEV1 35-50% predicted)
Stage 3 (FEV1 <35% predicted
Ex tol
Anaes Hx - prev difficulty with intubation
Surgery - Proposed resection: post op preservation of resp function proportional to amount of lung parenchyma preserved
Investigations
Baseline spirometry
Absolute values: FEV1 >2l pneumonectomy, >1.5l for lobectomy
Estimated predicted postop FEV1% (PPO FEV1 = preop FEV1 x (1 - % functional lung removed/100))
If PPO FEV1 <40% - increased risk, then assess lung function
PPO FEV1 > 30% - high risk
Examine flow-volume loop to assess for airway compression (req if dyspnoea/coughing when supine)
Lung parenchymal function tests
DLCO
Correlates with total functioning surface area
Predictor periop mortality
PPO DLCO <40% - increased resp and cardiac complications
DLCO <20% - unacceptably high periop mortality rate
VO2 max
20ml/kg/min low risk complication
<15ml/kg/min unacceptably high morbidity/mortality
PPO VO2max <10ml/kg/min absolute contraindication
6 min walk test
Distance <610m - high risk
Fall in oximetry> 4% during exercise = high risk
V/Q scan - assess the contribution of each section: if region for resection is non/minimal fx then modify PPO parameters
3 legged stool (prethoractomy resp asessment)
Resp mechanics - FEV1 (PPO> 40%)
Cardiopulmonary reserve - VO2 max (>15ml/kg/min), Stair climb (2 flights), 6 min walk test (sats drop <4%)
Lung parenchymal function - DLCO (PPO> 40%)
Optimisation
Discuss post op analgesia
Optimise underlying lung disease: bronchodilators, physiotherapy
Smoking cessation
Optimise other medical conditions: cardiac, DM, cease nephrotoxics
Medications: consider PPI, consider antisialagogue if FOBT
Discuss with MDT: resp, CTh, ID, nutrition, physio ? ICU post op
Post op (?extubate)
Dependent on PPO FEV1 and other resp factors...