Approaches: Ivor Lewis (laparotomy and right thoracotomy, transhiatal (abdominal and neck incisions), left thoraco abdominal approach
Concerns:
Preoperative Chemotherapy
1. Less distinct tissue planes and increased bleeding
2. Bleomycin : pulmonary toxicity ; worsened by high oxygen concentrations
3. Doxorubicin: acute dysrhythmia, chronic cardiomyopathy
Incomplete Obstruction
1. Recurrent aspiration pneumonitis- decreased pulmonary reserve
2. Retained food products @ induction - increased risk of aspiration
History of smoking, alcoholism
1. Associated COPD
2. Alcoholic cardiomyopathy
3. If on antiplatelets for CAD, use of epidural may be contraindicated
Evaluation
1. CBC: check for infections
2. PFT-ABG-FLOW VOLUME LOOPS
3. CT/MRI- bronchoscopy; if required, to evaluate for presence of tracheal or bronchial compression
4. ECG, ECHO
Special points on Anesthetic technique
1. In thoracic or thoraco abdominal approach, placement of a DLT is indicated to provide OLV. If difficult airway, single lumen can be inserted first and then changed using a tube exchange catheter.
2. Surgeries involving only cervical or endoscopic approach don't require epidural
3. If epidural is planned placement and testing before induction is recommended
4. Significant third space loss : close monitoring of BP and Urine output
5. Transient compression of myocardium can produce dysrhythmia and hypotension : IBP will be helpful
6. PEEP- low tidal volume - low ventilator pressures can be lung protective strategies in OLV
7. Avoid excess fluids: anastamotic edema, pulmonary edema
8. Patients with significant intraoperative fluid shifts may develop airway edema- avoid premature extubation
8. If patient requires prolonged postoperative ventilation, DLT can be exchanged with single lumen tube, before shifting to icu.
9. Arrange platelets, ffp, cryoprecipitate etc.
10. CVP cannulation site should be determined by surgical approach
11. Prevent hypothermia
12. Take necessary precautions to avoid position related injuries; check radial pulse after placement of axillary roll. Can place pulseoximeter probe on down arm to check perfusion
13. Ensure normal potassium ( dysrhythmias)
14. Hypoxia during OLV : PEEP to ventilated lung, CPAP to non ventilated lung, return to double lung ventilation
15. Adequate BP is necessary for maintaining integrity of the anastamosis
16. POSTOPERATIVE
a. Recovery in head up position, ig risk of aspiration high
b. High index of suspicion for pneumothorax
c. Hoarseness = RLN injury
d. SVT: adenosine. 6 mg iv push and repeat if needed to 12 mg ; AF - DC cardioversion, beta blockers, Amiodarone, CCBs, pacing
e. DVT prophylaxis
