Anesthesia for Non-intubated Thoracic Surgery

Abstract

Initial attempts at anesthesia for thoracic surgery in the late 1800s were all made with non-intubated patients breathing air-ether spontaneously through a mask. The lung collapse and pendelluft effect (see Chap. 1) when the surgeon opened the chest led to hypoxemia, hypercapnia, and hemodynamic instability [1]. The first major advance in thoracic anesthesia came in the first decade of 1900 when Sauerbruch developed the negative pressure chamber for thoracic anesthesia (see Fig. 25.1) [2]. Non-intubated patients continued to breathe air-ether spontaneously, but the negative pressure in the chamber (which excluded the patients head) prevented the lung in the open hemithorax from collapsing. However, this technique did not deal well with the problem of secretions. This was a major drawback since most of the chest surgery in the early part of the past century was for infectious causes.

Clinical Case Discussion

A 72-year-old male has developed a bronchopleural fistula 5 days postoperatively after an uncomplicated right pneumonectomy (see Fig. 25.3). The patient has been started on antibiotics and a chest drain inserted which drained 250 ml of fluid and showed a persistent air leak. The patient is not septic. The patient is scheduled to undergo thoracoscopy, rib resection, and insertion of a large-caliber drainage tube. The surgeon has requested that the airway not be instrumented due to the possibility of injury to the precarious bronchial stump.

• How would you manage the anesthetic for this surgical procedure?

Fig. 25.3

Chest X-ray of a 72-year-old patient who developed a bronchopleural fistula after a right pneumonectomy

After placement of standard ASA monitors and an arterial line, a thoracic epidural catheter was placed by a paramedian technique at the T5-6 level. After a test dose of 3 ml lidocaine 2%, a mixture of bupivacaine 0.2% and fentanyl 10ug/ml was titrated in 2 ml aliquots (total dose 8 ml) until a sensory block developed from T2-10. The patient was then started on an intravenous infusion of dexmedetomidine 0.7ug/kg/h and supplemental oxygen via a facemask and turned to the left lateral positon for surgery.

• How would you manage this case if the patient was septic?

Because of the concern of the development of an epidural abscess in a septic patient, other types of nerve block may be optimal for this patient. Ultrasound-guided serratus anterior or erector spinae plane blocks may be considered in place of an epidural (see Chap. 59).