2.1 ETS Flashcards
a) List the indications for endoscopic thoracic sympathectomy (ETS). (25%)
> > Palmar, axillary or craniofacial hyperhidrosis.
> > Chronic regional pain syndromes.
> > Facial blushing.
> > Chronic angina pectoris,
unmanageable by pharmacological or cardiac
intervention (very unusual indication now).
b) Outline the general (30%) implications of managing a patient for ETS under general anaesthesia.
> > Patients are predominantly young and fit,
but may be older with comorbidities
especially if the indication is for refractory angina pectoris: consider need for additional assessment
and investigation preoperatively.
> > Complications are rare but can be catastrophic: ensure the patient has full understanding of
risks versus benefits.
> > Occasionally, conversion from
laparoscopic to open surgery is necessary:
prep and drape ready for thoracotomy.
> > Risk of major haemorrhage:
ensure large-bore intravenous access and
two group and save samples
for rapid blood issue.
> > Periods of hypoxia common:
shunt due to one-lung ventilation,
atelectasis and failure to fully inflate
the first lung before proceeding with
surgery on the second side.
> > Periods of hypotension due to
capnothorax likely: consider invasive blood
pressure monitoring or more frequent noninvasive monitoring.
> > Consider the complications of positioning:
• Usually supine, reverse Trendelenberg, arms abducted, with risk of brachial plexus injury.
• Sometimes prone, with risk of facial or eye damage, dislodgement of airway, difficulty with ventilation, nerve traction and injury.
• Sometimes lateral positioning with potential difficulty with ventilation, dislodgement of injury, damage to pressure points such as common peroneal nerve.
Outline the airway (15%) implications of managing a patient for ETS under general anaesthesia.
Need to achieve collapse of one lung followed by the other for bilateral
surgery. Options include the following:
» One-lung ventilation via double lumen tube.
» One-lung ventilation via endotracheal tube with bronchial blocker.
» Endotracheal tube with intrathoracic carbon dioxide insufflation.
» Laryngeal mask airway with intrathoracic carbon dioxide insufflation.
c) What are the most likely problems to be encountered in the intraoperative (15%) a
Intraoperative:
Airway:
» Malposition of double lumen tube or bronchial blocker may cause hypoxia.
Respiratory:
» One-lung ventilation causes shunt and, therefore, hypoxia.
Efforts to improve this may actually worsen hypoxia (oxygen insufflation or CPAP to the deflated
lung may reduce hypoxic pulmonary vasoconstriction;
PEEP to the ventilated lung may increase resistance to blood flow to the ventilated side).
> > With bilateral surgery, atelectasis of the reinflated lung may cause significant hypoxia when operating on the second side. Consider reinflation under direct vision.
Cardiovascular:
» Hypotension due to capnothorax, rarely cardiac arrest due to rapid insufflation.
> > Cardiac arrhythmia induced by intrathoracic diathermy.
> > Rarely, bleeding due to inadvertent damage to blood vessels on port insertion. May be catastrophic.
What are the most likely problems to be encountered in postoperative (15%) period?
Postoperative:
» Ongoing hypoxia due to atelectasis and residual pneumothorax.
> > Risk of acute lung injury in the days following operation if protective one lung ventilation not used.
> > Chest pain during the immediate postoperative period requiring intravenous morphine – may necessitate overnight stay.
