Anaesthesia For Thoracic Surgery in Children - Particularities

ANAESTHESIA FOR THORACIC
SURGERY IN CHILDREN
-PARTICULARITIES-
Cristian Tănase,
“Grigore Alexandrescu” Clinical Emergency Hospital for Children, Bucharest
NEONATAL SURGERY
Most common thoracic non-cardiac surgical conditions:
 Oesophageal atresia, with or without tracheo-oesophageal fistula
 Congenital diaphragmatic hernia
Anesthetic techniques must be tailored to child and surgery, but the key
principles of management are similar
Differencies in anatomy, physiology, pharmachology in neonates
 Oxigen consumption is twice that of an adult 7 ml/kg/ hour

 Hypoxia develops quickly
 Diaphragmatic breathing is important. Abdominal distension may
compromise
 Thermolability – warming fluids and active warming strategies
 Response to hypoxemia is temperature dependent
Differencies in anatomy, physiology, pharmachology in neonates
 Haemoglobin 20 g/dl but fetal Hb, poor tissue oxygen delivery.

 Postoperative apnea, mostly in prems and anaemia
 Vitamin K dependent clotting factors are low at birth. Vitamin K 1 mg IM
 Adequate analgesia! nociceptive pathways develop and vulnerable
long term consequences
 Hypoglycemia
 Congenital heart disease
 Echocardiography preoperatively
 Prostacyclin infusion for patency of ductus arteriosus. Low pulmonary

lung perfusion may need systemic to pulmonary artery shunt
ANESTHESIA
 Fasting 6 hours (formulas), 3-4 hours (breast- fed), 2 hours (clear fluids)
 Tracheal intubation. Laringeal mask size 1 <
 MAC higher
 Myocardium sensitive to depression and vagotonic action of volatile agents – Atropine
0.02 mg/kg
 Sevo for induction, Sevo, Iso or Desflurane for maintenance
 Opioid- based techniques when postop ventilation
 Venous capacitance is relatively low
 Maintaining normothermia
OESOPHAGEAL ATRESIA AND TRACHEO-OESOPHAGEAL
FISTULA
 Several variants
 5 types classification; with or without fistula
 Type C distal tracheao-oesophageal fistula
 Polyhydramnios, malformations, anomalies
 First feed – no passage of a nasogastric tube
 Chest X ray - coiled tube
 Aspiration
 Chronic lung disease
 continuous low level suction
 gastrointestinal ventilation, distension, respiratory compromise
 Gentle gas induction
OESOPHAGEAL ATRESIA
No nitrous oxide
Gentle epigastric pressure by the assistant
Intubate deep and withdraw to block the fistula
Rigid bronchoscopy
If gastric distension – disconnect and decompress the stomach via the tracheal
tube. Urgent gastrostomy is not useful
Fogarty catheter to block the fistula
Right thoracotomy, right lung retracted, gentle hand ventilation
Unstable, desaturations, re-ventilation of the compressed lung
Ligation, anastomosis, labeled transanastomotic tube.
OESOPHAGEAL ATRESIA
 Oesosophagostomy
 Gastrostomy
 Extubate vs postop ventilation (curare)
 Gastrooesophageal reflux
 Tracheomalacia – aortopexy
 Strictures. Dilations of oesophagus

CONGENITAL DIAPHRAGMATIC HERNIA
 1 / 5000 live births

 Left hand side
 Antenatal diagnosis
 Lung underdeveloped, abdominal viscera cranial migration, pushed mediastinum
 Respiratory distress
 HFOV or ECMO
 Pulmonary hypertension
 Nitric oxide
CONGENITAL DIAPHRAGMATIC HERNIA
 Surgical closure – stable, conventional ventilation, off inotropic support

 CHD 98% left posterolateral (Bochdalek), 2% retrosternal
 Primary closure/ patch (anterior abdominal wall scaphoid)
 Derotation and fixation of the abdominal content
 Elective appendicectomy
 Postoperatively - hypoxia ongoing – pulmonary hypertension, right to left shunting

through ductus arteriosus
CONGENITAL ABNORMALITIES OF THE LUNG
CONGENITAL LOBAR EMPHYSEMA
 Due to bronchial cartilaginous dysplasia

 Valve effect, emphysematous accumulation of air, poor deflation of the lobe
 Left upper lobe
 Incidental X ray finding, to acute distress
 Lobectomy
CONGENITAL CYSTIC ABNORMALITIES OF THE LUNG
 Cystic adenomatous malformation
 Pulmonary sequestration
 Bronchogenic cysts
Symptoms caused by mass effect or secondary infection

 Congenital cystic adenomatous malformation
 Local arrest of maturation of fetal lung

 Filled cysts non communicating
 Resection to relieve compression / infection, malignant change
 Pulmonary sequestration
 Separate bronchopulmonary mass or cyst disconnected from the bronchial tree

 but separate blood supply from the aorta
 From a supernumerary lung bud

 Bronchogenic cysts
 Solitary, unilocular, mucus filled
 May become infected

ACQUIRED PATHOLOGY
THORACIC TUMOURS IN CHILDREN
 Primary lung
 Thoracic – neuroblastoma
 Metastases
 Anterior mediastinal mass

 Hematological malignancy ex lymphoma, or primary malignancy
 Compression, airway obstruction, venous return
 Risc with relaxation and changing position
 Rigid bronchoscope, or prone position.
 Cardiopulmonary bypass
PLEURAL COLLECTIONS
EMPYEMA
 Bacterial pneumonia – pneumococcal

 Purulent pleural effusion
 Broncho pleural fistula
 Surgical decortication, on a small thoracotomy incision
 Bacteriemia and haemodinamical compromise
 Treat anaemia. Blood loss!
 Stabilise. Possible postoperative ventilation
LUNG ABCESSES
 Primary infection
 Foreign body
 Lung resection
 Bronchopleural fistula
 Protective one lung ventilation

BRONCHIECTASIS
 Damaged and dilated bronchi

 Cystic fibrosis
 Associated with immune compromise
 Surgical resection with single lung ventilation

CHEST WALL DEFORMITY
 Pectus escavatum. Pectus carinatum

 Ravitch, Nuss procedure
 Thoracoscopy with CO2
 Pain; epidural
ANAESTHESIA FOR THORACIC SURGERY
SPECIFIC CONSIDERATIONS
Hypoxic pulmonary vasoconstriction
 Limites blood flow through unventilated or hypoxic areas of lung
 Inhibitory effects of inhalational anaesthetic agents on HTP – debatable

LATERAL DECUBITUS POSITION
 Ventilation/perfusion mismatch may result in hypoxaemia
 More marked in infants
 FRC increases when moved from supine to lateral
 Opening pleura, than retracting the lung decrease FRC with 50 %
 FRC returns to baseline on completion of surgery

LUNG RETRACTION
 When single lung ventilation is not possible

 Low compliance
 Saturation 85 – 90 %
 Avoid lung contusion and mediastinal compression – occlude venous return to the
hearth.
 Use PEEP during thoracotomy
SINGLE LUNG VENTILATION
Single lumen tube

 The mainstem bronchus of the nonoperative side is intubated with a tube 0.5 mm smaller
than normal; usually the right main bronchus
 For left, raise the right shoulder and turn the head towards the right
 Fiber-optic bronchoscope passed through the tube, than advancing the tube over the
bronchoscope
 Movement tolerance in small children is 2-3 mm, ! upper lobe ventilated
 The upper right bronchus can arise from the carina , or directly from the trachea
 Auscultation, when moving the child.
 Sealing the bronchus with an uncuffed tube
 Cuff can occlude the upper lobe bronchus
Baloon-tipped bronchial blockers

 Baloon, central lumen which the lung deflates
 End hole balloon wedge catheter
 Fogarty embolectomy catheter
 Wire guided endobronchial blockers WEB; 5 Fr, outher diameter 1.7 mm; passed
through bronchoscopy
 2.2 bronchoscope admit a 4.5 mm internal diameter tracheal tube. 9.7 kg child
 Univent tube
 Conventional tracheal tube with a second lumen through which a bronchus blocker is
advanced
 3.5 mm internal, same as a 5 mm tracheal tube; children > 2 years.
 Double lumen tubes

 Two inequal length tubes moulded together. Left / right sided
 Adolescence
INDICATIONS FOR SLV IN CHILDREN
Strong indication
 major gas trapping in one lung or pleural space
 lobectomy to prevent airway soiling by blood or pus
 minimally invasive thoracic surgery
Moderate indication
 lobectomy or pneumectomy for cystic malformations and tumour
 anterior spine surgery
 oesophageal or aortic surgery
Contraindication SLV
 unacceptable hypoxia after institution of SLV
 safe isolation of the lung impossible
BRONCHOSCOPY
 Rigid and flexible

 Prior to intubation
 Lung isolation, variants, microbiological tests
 Stridor, infections, trauma, tracheomalacia, stenosis, extrinsic compression …
 Smallest flexible 2.8 mm; without succion 2.2 mm
 Through laryngeal mask or transnasally
 Rigid; can ventilate if attaching a open circuit to the side arm of a Storz bronchoscope
 Inhalational agents, or I.V.
VIDEO ASSISTED THORACOSCOPIC SURGERY
 Minimally invasive surgery

 Intrapeural insufflation of carbon dioxide; venous return !
Pleural drains
 Tube + one way valve + collecting chamber
 Different suction sources for different tubes
 Not clamped or occluded in IPPV – tension pneumothorax!
PRINCIPLES OF ANAESTHESIA FOR THORACIC SURGERY
 Topical local anaesthetic

 Nitrous oxide - contraindicated
Vascular access
 Bleeding, plasma losses
 Peripheral and central venous access
 CVP monitoring can be misleading in lateral decubitus
 Invasive arterial pressure monitoring
VENTILATION STRATEGIES
 No spontaneous ventilation
 Muscle relaxation and IPPV
 Sever congenital lobar emphysema; spontaneous vent until the chest wall is opened,
or slow respiratory rate without PEEP, SLV when possible
 Tailoring the ventilation
 Spirometry
 Manual ventilation
 Permissive hypercapnia
 Compliance monitoring
 End tidal capnography may underestimate PaCO2, in SLV
POSTOPERATIVE MANAGEMENT AND ANALGESIA
Postop analgesia in neonates

 IV nurse controlled morphine
 Boluses 10 mcg/ with 20-30 min lockout, no background infusion.
 Paracetamol
 Prems 45 mg/kg/ day
 32 weeks postmenstrual age to 3 months 60 mg/kg
 Ibuprofen – not licenced below 3 months
 Epidurals
 Levobupivacaine plain 0.125 %, up to 0.3 ml/kg/h
POSTOPERATIVE ANALGESIA IN CHILDREN
 Intensive therapy
 Pain management, physiotherapy, CPAP
 Most intense pains

 Combination of regional + systemic analgesia (opioid and non steroid).
 Regional anaesthesia
 Intercostal nerve blocks
 Subpleural space catheter, blocking also the paravertebral space
 Epidural analgesia - catheter at the op level , or caudally inserted
 Intrapleural instillation of LA; toxicity!
 Systemic analgesia
 Opioid infusion, NCA or PCA boluses, 48 hours after thoracothomy, in addition to RA
 Paracetamol
 NSAID
THANK YOU!

Anaesthesia For Thoracic Surgery in Children - Particularities

Uploaded by

Copyright:

Available Formats

Anaesthesia For Thoracic Surgery in Children - Particularities

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Anaesthesia For Thoracic Surgery in Children - Particularities

Uploaded by

Copyright:

Available Formats

ANAESTHESIA FOR THORACIC

Most common thoracic non-cardiac surgical conditions:

 Oesophageal atresia, with or without tracheo-oesophageal fistula

 Congenital diaphragmatic hernia

 Oxigen consumption is twice that of an adult 7 ml/kg/ hour

 Haemoglobin 20 g/dl but fetal Hb, poor tissue oxygen delivery.

 Prostacyclin infusion for patency of ductus arteriosus. Low pulmonary

 Extubate vs postop ventilation (curare)

 Strictures. Dilations of oesophagus

 1 / 5000 live births

 Surgical closure – stable, conventional ventilation, off inotropic support

 Postoperatively - hypoxia ongoing – pulmonary hypertension, right to left shunting

 Due to bronchial cartilaginous dysplasia

 Cystic adenomatous malformation

Symptoms caused by mass effect or secondary infection

 Local arrest of maturation of fetal lung

 Separate bronchopulmonary mass or cyst disconnected from the bronchial tree

 From a supernumerary lung bud

 Solitary, unilocular, mucus filled

 May become infected

 Anterior mediastinal mass

 Bacterial pneumonia – pneumococcal

 Protective one lung ventilation

 Damaged and dilated bronchi

 Surgical resection with single lung ventilation

 Pectus escavatum. Pectus carinatum

 Thoracoscopy with CO2

Hypoxic pulmonary vasoconstriction

 Limites blood flow through unventilated or hypoxic areas of lung

 Inhibitory effects of inhalational anaesthetic agents on HTP – debatable

 Ventilation/perfusion mismatch may result in hypoxaemia

 More marked in infants

 FRC increases when moved from supine to lateral

 Opening pleura, than retracting the lung decrease FRC with 50 %

 FRC returns to baseline on completion of surgery

 When single lung ventilation is not possible

Single lumen tube

Baloon-tipped bronchial blockers

 Double lumen tubes

 Rigid and flexible

 Minimally invasive surgery

 Topical local anaesthetic

Postop analgesia in neonates

 Pain management, physiotherapy, CPAP

 Most intense pains

You might also like