Thoracotomy

Patient Considerations

• Disease Specific Considerations

  • Thoracotomy may be performed for many reasons:

    • Tumor

      • Location?

        • Symptomatic Mediastinal Mass should be evaluated

    • Persistent pneumothorax

    • Trauma

    • Cyst resection

  • Appropriate workup and optimization of co-morbid conditions should occur prior to surgery whenever possible.

  • If available, Chest CT studies should be reviewed to evaluate for any airway compromise

Case Planning

• Specific or Unique Room Set-Up Requirements

  • Airway

    • Oral endotracheal tube

      • Double-lumen ETT/Bronchial Blocker rarely utilized in Peds

  • Drugs/Infusions

    • Consider epidural infusion

  • Monitors

    • Standard ASA monitors

    • Consider arterial access if significant blood loss is possible (i.e. Proximity to large vessels, tumors, etc)

      • The attending anesthesiologist should discuss blood loss concerns with surgeon

  • Blood Availability (if indicated)

    • T+S

    • Consider T+C if significant blood loss suspected

  • PICU Bed Availability (if indicated)

    • Discuss with surgeons on a case-by-case basis

Anesthetic Considerations

• Induction

  • Inhalational induction v. IV induction

  • Oral Single Lumen ETT unless otherwise discussed with surgeon

  • PIV x2

• Positioning

  • Usually lateral with operative side up

  • Take special care to pad down arm

  • Axillary roll

• Maintenance

  • Maintenance of Anesthesia

    • Hemodynamic/Physiologic goals

  • Surgical Considerations (such as neuromonitoring, muscle relaxation, anticipated blood loss)

    • Pediatric surgeons rarely require lung isolation for thoracoscopy/thoracotomy

      • They will pack the lung down out of their field

    • Surgeon may leave chest tube post-operatively

• Emergence/Disposition

  • Extubate awake v. deep then monitor in PACU

• Post-Op Pain Management

  • Appropriate patients may benefit from continuous caudal/epidural analgesia

• Case-Specific Complications

  • Hemorrhage

  • Pneumothorax

  • Difficult post-op pain management

  • Bronchopleural fistula

    • May impair ventilation