Pneumonectomy

Airway: Lung isolation required
Access: 2× Large IV; arterial line on lower arm
Pain: High, risk of CPSP, strongly consider regional
Position: Lateral
Time: 1.5-3 hours
Blood loss: ⩽500ml unless great vessels injured. G+H
Special: Lung isolation

Intro and technique

Considerations

  • B
    • Lung function
      Underlying and predicted post-operative pulmonary reserve.
    • Lung isolation
  • C
    • Concomitant cardiac disease
      In particular:
      • Pulmonary hypertension or RV dysfunction
        Relative contraindication due to the ↑ in RV afterload.
  • D
    • Analgesia
      Regional techniques recommended:
      • Epidural
      • Paravertebral
      • Extrapleural catheter

Preparation

Ensure preoperative lung function testing testing has been performed.

Induction

Intraoperative

Fluid management:

  • Aim <10ml/kg intraoperatively

Surgical Stages

  • Lung isolation
  • Chest entered
  • Lung allowed to passively deflate
  • Vascular structures usually divided first
    Division of hilar structures may compress the heart and great vessels, leading to:
    • Hypotension
    • Arrhythmia
  • Clamps applied
  • Lung resected
  • Leak test
    Chest filled with saline and Valsalva performed to identify bubbles.
  • ICC placed

Emergence

Postoperative

Key considerations:

  • Disposition
    • ICU
  • Analgesia
    Often regional techniques.
  • Chest drain
    Risk of cardiac herniation if drain is on suction due to mediastinal shift.
  • Empty hemithorax
    • Initally air-filled with volume loss
    • Usually fills at ~2 ribs/day with fluid, and concominant loss of air
      • More rapid ↑ in fluid volume suggests haemothorax
      • ↑ in air volume suggests bronchopleural fistula

Complications:

  • Arrhythmia
  • Pulmonary oedema
    Limit fluids to 20ml/kg in first postoperative day
  • Cardiac herniation
    • Keep drains off suction
    • Nurse operative site up

References