UBP 5.5 (Long Form): Pulmonary – Pneumonectomy

Question 1

Intra-Operative Management:

What monitoring would you require for this case?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoD_LCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV₁ = 37%)*

Answer 1

In addition to the ASA standard monitors, I would place –

• a 5 lead EKG to monitor for ischemia;
• an arterial line for continuous measurement of blood pressure and frequent measurement of arterial blood gases;
• a central venous pressure monitor (CVP) to allow the central infusion of vasoactive drugs and to provide access for a transvenous pacemaker or pulmonary artery catheter, should they be required; and
• a fiberoptic bronchoscope to assist in the accurate placement of a double lumen endotracheal tube.

Question 2

Intra-Operative Management:

After several attempts, you are unable to place the CVP in the right internal jugular vein.

What are your options?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 2

Other options for CVP catheter placement would include –

the left internal jugular vein, the external jugular veins, the subclavian veins, or one of the arm veins.

The right internal jugular vein is the preferred route due to a high success rate and optimum access for subsequent pacemaker or pulmonary artery catheter placement.

The left internal jugular and both subclavian veins provide a less direct route to the heart.

The external jugular and both subclavian veins are more prone to kinking/obstruction when placing the patient in the lateral decubitus position.

Finally, accessing the central circulation through the subclavian vein increases the risk of pneumothorax, a potentially catastrophic event if occurring in the dependent lung during one lung ventilation.

Therefore, when using the subclavian vein, it would be prudent to access the vein on the surgical side.

Question 3

Intra-Operative Management:

Do you plan to place a right or left double lumen endotracheal tube (DLT) for one lung ventilation?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 3

My preference would be to place a left-sided DLT,

because the right upper lobe bronchus’ close proximity to the carina (1-2.5 cm) increases the risk of right upper lobe obstruction.

The distance from the carina to the left upper lobe is about 5 cm, providing a greater margin of safety for upper lobe occlusion.

In placing a left-sided DLT, I would be careful to withdraw the bronchial lumen of the DLT into the tracheal position at the time of left bronchus resection, to avoid unintentional suturing of the tube to the bronchus.

Additionally, I would be vigilant to avoid inadvertent advancement of the DLT following closure of the bronchus, which could result in bronchial stump disruption.

Given the left bronchial involvement of the tumor seen on CT, there is the possibility that I would be unable to adequately advance the left bronchial lumen into the left main bronchus.

In this case, I could choose to use a right-sided DLT or a bronchial blocker.

Question 4

Intra-Operative Management:

How are you going to induce this patient?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 4

After ensuring the presence of appropriate airway equipment, placement of an epidural for post-operative pain control, adequate intravenous access, and appropriate monitoring – including an arterial line and central venous pressure monitor –

I would preoxygenate with 100% oxygen, and induce the patient with titrated doses of propofol and fentanyl.

Once I had demonstrated the ability to mask ventilate, I would administer a neuromuscular blocking agent and ventilate with a volatile agent.

Given his hypertension and COPD, my goal is to achieve an adequate plane of anesthesia to prevent bronchospasm and a sympathetic response to laryngoscopy, while avoiding significant hypotension.

Once this was accomplished, I would place the left-sided DLT, and confirm correct positioning with fiberoptic visualization.

Question 5

Intra-Operative Management:

After induction, you perform laryngoscopy and have a grade 3 view.

You are unable to pass the DLT.

What would you do?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 5

If I were unable to pass a DLT and mask ventilation was adequate,

I would attempt to intubate with a standard single lumen ETT using a fiberoptic bronchoscope.

Once the single lumen ETT was in place, I would use a tube exchanger to trade the single lumen ETT for a left-sided DLT.

If I were unable to pass a DLT and mask ventilation was inadequate, I would – reverse any reversible medications and follow the difficult airway algorithm, including calling for help, considering alternative airways such as a LMA, and making preparations for surgical intervention if I continued to be unsuccessful and the patient did not resume spontaneous respiration.

In either case, I would be prepared for even worse airway conditions upon extubation, secondary to airway edema and laryngeal trauma from initial intubation attempts.

Question 6

Intra-Operative Management:

You successfully place a single lumen ETT and exchange it for a left-sided DLT.

Following initiation of one lung ventilation, the SpO2 drops to 91%.

What would you do?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 6

• (Note – 91% is tolerable. If 88% – concerned & intervene.)*
• (DLT size? – if > 165 cm = 41 Fr DLT; if < 165 cm = 39 Fr DLT;*
• Dr. Gallen uses larger bore DLT)*
• –*

I would verify that 100% oxygen was being delivered and confirm proper DLT placement by checking the capnogram, auscultating the chest, watching for chest excursion, and using a fiberoptic bronchoscope for direct visualization.

I would then check the ECG and arterial line to ensure adequate perfusion.

–

If I believed right-to-left shunting from the collapsed lung was the problem,

I would apply CPAP (10 cm H2O) to the nondependent lung after slightly expanding that lung with a small tidal volume.

If this was not surgically acceptable, or the PaO2 did not improve, I would add PEEP (5-10 cm H2O) to the ventilated lung, recognizing that in patients with healthy lungs, this may result in pressure-induced shunting of blood to the nondependent lung and worsening PaO2.

If none of these maneuvers proved to be successful, I would reinflate the nondependent lung and discuss with the surgeon the possibility of ligating the pulmonary artery to completely eliminate the shunt.

Question 7

Intra-Operative Management:

You notice that you have been hyperventilating the patient and he is hypocapnic.

How might this be contributing to the decreased PaO2?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 7

Hypocapnia could contribute to increased shunt and worsening hypoxia by increasing vascular resistance in the dependent lung and inhibiting hypoxic pulmonary vasoconstriction (HPV) in the nondependent lung.

The hyperventilation of the dependent lung that would be necessary to cause hypocapnia, results in increased mean intra-alveolar pressure and subsequent increased vascular resistance in the dependent lung.

Additionally, hypocarbia-induced vasodilation results in inhibition of HPV in the nondependent lung.

The combination of these two effects leads to increased shunting of blood to the non-ventilated operative lung with subsequent decreased PaO2.

(Dr. Gallen – not sure about this answer)

Question 8

Intra-Operative Management:

The patient is returned to the supine position, and his blood pressure drops from 143/88 mmHg to 94/66 mmHg.

What will you do?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 8

Since this precipitous drop in blood pressure may be the result of cardiac herniation into the evacuated hemithorax,

I would immediately return the patient to the lateral decubitus position.

I would then auscultate the chest, verify proper DLT placement, ensure proper placement of the arterial line transducer, look at the EKG and CVP, and evaluate the patient for signs of mediastinal shift.

If mediastinal shift were suspected, a chest radiograph could be ordered to guide the therapeutic addition or removal of air via the chest drain to medialize the mediastinum.

Question 9

Post-Operative Management:

What are your options for post-operative pain control?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 9

(Not the best answer for oral boards. You have to pick one and defend it.)

There are several methods available to control post-operative pain in the post-thoracotomy patient, including –

• patient-controlled analgesia (PCA) with opioids,
• neuraxial blockade,
• intrapleural analgesia,
• intercostal nerve blocks,
• paravertebral nerve blocks,
• cryoneurolysis, and
• NSAIDs.

The goal is to provide adequate analgesia while avoiding significant respiratory depression in patients with marginal pulmonary function.

Epidural analgesia is the only method of pain control shown to consistently reduce post-thoracotomy respiratory complications.

Additionally, in patients with coronary artery disease, thoracic epidural local anesthetics have been shown to reduce myocardial oxygen demand in proportion to supply (this is not true of lumbar epidural local anesthetics).

Question 10

Post-Operative Management:

Would you extubate this patient in the operating room?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 10

Although his ppoFEV₁% is greater than 30%,

I would NOT attempt to extubate him in the operating room due to his reduced lung parenchymal function (VO2 max = 14 mL/kg/min) and cardiopulmonary reserve (ppoDLco = 40%).

Rather, he should be placed on mechanical ventilation and undergo a staged weaning process in order to evaluate the patient’s tolerance of the increased oxygen consumption associated with spontaneous ventilation.

Clinical Notes:

• Utilizing pre-thoracotomy respiratory function testing to plan extubation:
  
  • If the ppoFEV₁ is > 40%, you can extubate in the operating room, assuming the patient is alert, warm, and comfortable “A WaC”).
  • If the ppoFEV₁ is 30% - 40%, you can extubate in the operating room, as long as the patient’s measurements of lung parenchymal function and cardiopulmonary reserve exceed the increased risk thresholds. Consideration should also be given to the status of the patient’s associated medical conditions (i.e. COPD, asthma, hypertension, etc.).
  • If the ppoFEV₁ is 20% - 30%, you can extubate in the operating room if:
    
    1. the patient’s measurements of lung parenchymal function and cardiopulmonary reserve exceed the increased risk thresholds; and
    2. if the resection is performed with video-assisted thoracoscopic surgery (VATS) and/or thoracic epidural analgesia is being utilized.

Question 11

Post-Operative Management:

The patient does not meet your extubation criteria and requires postoperative ventilation.

Would you take the patient to the ICU with a DLT?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 11

Given the increased risk of mucosal ischemia and/or tracheal stenosis with prolonged use of the relatively large diameter DLT, and

considering the lack of experience that ICU personnel have with this type of airway,

I would prefer to change the DLT to a standard ETT prior to leaving the operating room.

However, given the difficulty of intubating this patient prior to surgery,

I would either utilize an ETT exchanger or leave the DLT in place with plans to educate the ICU team in the proper management of this specialized airway.

In the case of long-term mechanical ventilation,

I would discuss the possibility of performing a tracheostomy with the surgical team and immediate family.

Question 12

Post-Operative Management:

Two hours later, you are called to evaluate the patient.

The nurse reports that his blood pressure has trended down to 94/70 mmHg over the last several minutes.

What do you think?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 12

There are a number of complications that could lead to a drop in blood pressure in this post-thoracotomy patient with chronic hypertension and COPD, including –

• monitor error,
• hemorrhage,
• cardiac herniation,
• cardiac tamponade,
• right heart failure,
• arrhythmia,
• cardiac ischemia,
• pulmonary embolism, and
• decreased venous return with mechanical ventilation and PEEP.

While some of these potential complications could be easily investigated, others may require more intensive evaluation such as – echocardiography, radiographic imaging, or even surgical exploration, to make the diagnosis.

Xtra Q – Decreased ETCO2 & Decreased Peak airway pressures – what happened? ==> Bronchial rupture = new suture line compromised (you can see ribs at the end of fiberoptic scope).

Question 13

Post-Operative Management:

You look at the CVP and notice it is elevated.

What do you think?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 13

An elevated CVP is consistent with right heart failure,

which would be one of my top concerns, since this patient’s COPD and ppoFEV₁ < 40% place him at increased risk for this complication following pneumonectomy.

However, there are other complications that could lead to this clinical picture, such as –

• pulmonary embolism,
• cardiac ischemia,
• cardiac tamponade,
• arrhythmia, and
• cardiac herniation.

A focused physical exam, ECG, chest x-ray, and echocardiography would be helpful in making a definitive diagnosis.

Question 14

Post-Operative Management:

The patient is in atrial fibrillation.

Why are post-pneumonectomy patients at increased risk of developing supraventricular tachycardia?

• (A 68-year-old male is scheduled for a left pneumonectomy for small cell carcinoma of the lung. He complains of dyspnea on exertion and uses supplemental oxygen at night. He states that he has stopped smoking since his pre-anesthetic assessment 2 weeks ago.*
• PMHx: His past medical history includes COPD, HTN, peripheral vascular disease, and a 50 pack year smoking history.*
• Meds: HCTZ, Theophylline, Advair, ASA, O2, Albuterol prn*
• Allergies: PCN, Codeine*
• PE: Vital Signs: HR = 70, BP = 172/88, SpO2 = 90%, Temp 36.4 °C*
• Airway: Mallampati II*
• Lungs: Moderate expiratory wheezing*
• CV: RRR*
• Extremities: Digital clubbing*
• Chest CT: Multiple left lung nodules involving the left main-stem bronchus*
• ECG: Normal*
• Echo: Ejection fraction = 70%*
• Labs: Hct = 58; platelets = 214; K+ = 3.6 mEq/L*
• ABG: pH 7.38, PaCO2 50, PaO2 61 on 2 liters oxygen*
• PFTs: ppoDLCO = 40%; Vo2 max = 14 mL/kg/min; ppoFEV1 = 37%)*

Answer 14

There are multiple factors that contribute to an increased risk of developing dysrhythmias, including –

• underlying cardiopulmonary disease,
• increased right heart afterload due to pulmonary vascular bed reduction,
• pain-induced stimulation of the sympathetic nervous system,
• intraoperative cardiac manipulation, and
• metabolic abnormalities.

Atrial fibrillation is the most common type of supraventricular arrhythmia that occurs in these patients, and may be best controlled post-operatively with esmolol, due to its short duration of action and B1-cardioselectivity.