ANEASHTETIC CONSIDERATIONS

PRE-OP

• Pulmonary Function Test

• Cardiovascular: EKG, Chest X-ray & Scan

• Hematologic type and cross

• Administer Robaxin with Tylenol when leaving to OR (Tylenol can be given PO)

• Verify bean bag placement

 

INTRA-OP

• ANES technique: A inhalation, B inhalation with paravertebral block (20 min heads up to call pre-op for block cart) C inhalation with Exparel

• INDUCTION: Standard induction with DL/ETT with Bronchial blocker

• MAINTENANCE: keep narcotics to minimum if paravertebral block, local infiltration anticipated

• EMERGENCE: Pt rotated from lateral to supine position (HOB 40o), Extubation when indicated, Non rebreather recommended for transfer to PACU. (Monitor BP/HR/SaO2)

• FLUID REQUIREMENTS: Two large bore PIV or PIV plus 8F2L (ask PA). Minimum fluid during robotic lung surgery.

• MONITORING: Standard

  • A-LINE

  • Urinary catheter

  • CVP & FloTrac Optional

• POSITIONING:

  • METHOD A:

    • Axillary roll bean bag

    • Arm Board

    • Sequence of Pt positioning

      1. Illiac crust at table break point

      2. Rotate Pt to lateral

      3. Axillary roll

      4. Flex table

      5. Reverse Trendelenburg

      6. Feet up (watch at all times)

      7. Ideal position for procedure:

         • Pt horizontal between shoulders & hip

      8. Bottom arm sandwiched in pink foam on arm-board

      9. Upper arm restrained on arm-board & sandwiched in pink foam

      10. CAUTION

          • ENSURE PROPER HEAD/NECK ALIGNMENT

          • ULNAL NERVE AREAS CRADLED IN PINK FOAM

    • Confirm placement right after lateral positioning.

• LUNG ISOLATION

  • Commence initial one lung ventilation as surgeon enters OR.

  • Lungs completely down and disconnected for Trochar insertion

​

POSTOPERATIVE

• • Airway trauma from intubation

  • Trachial-bronchial rupture

  • Injuries related to lateral positioning

  • Structural injuries

  • Surgical complications

  • Cardiopulmonary complications

• EMERGENCY CHEST OPENING

  • Call ANES Attending, ANES Tech and Surgical Assistants

  • Notify Perfusion for possibility of CPB

  • Open fluids

  • Robot retracted from surgical site

  • Release Pt arms from armboards to facilitate supine position

  • If no CVL, anticipate and prep for CVL

  • Blood products in the room

• PAIN MANAGEMENT

  • Local infiltration by Surgeon/PA - Exparel