Guidelines for Flexible Bronchoscopy, Esophagoscopy, Esophageal Dilation and
Photodynamic/Laser Therapy
Equipment:
1.
2.
3.
4.
5.
Dental Guard (supplied by OR staff)
Portex Adapter (for flexible bronchoscopy)
Bard infusion pump with Propofol plate
Standard anesthesia set-up
8.0 endotracheal tube (need this for bronchoscopy/EGD performed using
GETA)
IV Access:
Preferably at least a 20 or 18 gauge intravenous line, however, many patients
arrive to the holding area with a 22 gauge already in place. If the intravenous line
is functional, you may proceed. Use you judgement.
Drugs:
1.
2.
3.
4.
5.
In the holding area, midazolam may be administered if appropriate.
Fentanyl may be added if appropriate.
Topical airway anesthetics (i.e., cetacaine spray, nebulized lidocaine
and/or pontocaine, 4% viscous lidocaine, 4% lidocaine ointment
administered individually or in combination). Consult with MD* for their
preference as this will vary.
Propofol
Odansetron, reglan, dexamethasone as needed
Bronchodilators, lidocaine, ephedrine, phenylephrine, epinephrine and
glycopyrrolate should be available in addition to the standard anesthetic
agents.
Perioperative Management:
Induction and maintenance: (assumes procedure is performed via MAC)
1.
Following placement of standard monitors, oxygen should be administered
via face mask or nasal cannula.
2.
Patients having flexible bronchoscopy should be placed in the supine
position. Patients for esophagoscopy should be placed in the left lateral
decubitus position.
3.
The majority of these procedures may be performed using monitored
anesthesia care (MAC) with intravenous sedation. However, some
patients (particularly those with esophageal obstruction, nausea and
vomiting prior to the procedure) will require general anesthesia. Consult
MD for their preference.
4.
For flexible bronchoscopy during MAC, please remember to topicalize the
patient’s nares, as the scope will be passed via the nose.
Erin A Sullivan, MD
Page 1
4/27/2016
*MD within the text of these guidelines refers to the attending anesthesiologist responsible for the case.
Guidelines for Flexible Bronchoscopy, Esophagoscopy, Esophageal Dilation and
Photodynamic/Laser Therapy
(continued)
Perioperative Management:
Induction and maintenance: (assumes procedure is performed via MAC)
5.
6.
7.
In addition to intravenous midazolam, propofol may be administered as
needed either by continuous infusion or intravenous bolus in order to
provide adequate sedation during the procedure.
If photodynamic therapy or laser therapy will be performed, please ensure
that the patient is wearing the appropriate eye protection.
Always be prepared to manage an airway fire, particularly when laser
therapy is being performed. In order to reduce the possibility of an airway
fire, use an FiO2 of < 35%.
Emergence and recovery:
1.
At the conclusion of the procedure, the patient should be awake and
functioning at their neurologic baseline with intact airway reflexes.
2.
Most of these patients may be sent to the PACU as a backthrough
(Holding/Phase II). Please place the patient on oxygen (if necessary) and
a pulse oximeter while they are waiting for the escort service to transport
them to their destination.
3.
Some patients require a generous amount of sedation for their procedure.
Please admit these patients to the PACU for recovery (PACU/Phase I) if
they do not meet appropriate discharge criteria.
Erin A Sullivan, MD
Page 2
4/27/2016
*MD within the text of these guidelines refers to the attending anesthesiologist responsible for the case.
Guidelines for Rigid Bronchoscopy
Equipment:
1. See Guidelines for flexible bronchoscopy
2. Jet ventilator
3. Arterial and central venous line transducers if appropriate
4. BIS or PSA 4000 monitor
IV Access:
18 or 16 gauge intravenous access if possible.
Drugs:
1.
2.
3.
4.
See Guidelines for flexible bronchoscopy (consult with MD)
Induction agent of choice; propofol works best since you will not be able
to use a volatile agent during the rigid bronchoscopy/jet ventilation
Muscle relaxant: a nondepolarizing neuromuscular blocking agent such as
rocuronium usually works well.
Cefazolin is the most frequently administered antibiotic for patients who
are not allergic to penicillin or other cephalosporins.
Perioperative Management:
Induction and maintenance:
1.
Following the placement of standard monitors + any appropriate invasive
monitors, preoxygenate the patient and administer the appropriate general
anesthetic agents.
2.
Secure the patient’s airway using at least an 8.0 endotracheal tube.
3.
During rigid bronchoscopy, the surgeon will extubate the patient prior to
insertion of the rigid scope. Be prepared to jet ventilate the patient!
4.
The trachea will be reintubated at the conclusion of the rigid
bronchoscopy.
Emergence and recovery:
1.
Proceed in the standard fashion for patients receiving general anesthesia.
2.
Patients should be recovered in the PACU prior to discharge to the floor.
Erin A Sullivan, MD
Page 3
4/27/2016
*MD within the text of these guidelines refers to the attending anesthesiologist responsible for the case.
Guidelines for Mediastinoscopy
Equipment:
1.
2.
3.
4.
Standard equipment
Arterial line transducer if appropriate
Central venous line transducer if appropriate
BIS or PSA 4000 monitor
IV Access:
18 or 16 gauge intravenous access is preferred. Consult with MD regarding the
need for central venous access.
Drugs:
1.
2.
3.
In the holding area, midazolam may be administered if appropriate.
Fentanyl may be added if appropriate.
Standard anesthetic medications, muscle relaxants and emergency drugs
Cefazolin is most often administered to patients who are not penicillin or
cephalosporin allergic.
Blood/Blood Products:
Consult with MD regarding the need for type and screen or type and crossmatch.
Perioperative Management:
Induction and maintenance:
1.
The endotracheal tube should be secured to the patient’s left side. This
will keep the tube out of the surgical field.
2.
Consider placing the blood pressure cuff and arterial lines on opposite
arms. If an arterial line is not used, consider placing a pulse oximeter
probe on each side. These monitors may assist with early detection of
innominate artery compression.
3.
General anesthesia is required for mediastinoscopy. Discuss plan with
MD.
4.
Patients with Eaton-Lambert Syndrome (resulting from oat cell
carcinoma) are sensitive to succinylcholine and nondepolarizing muscle
relaxants. Reduced doses are necessary.
Emergence:
1.
Extubate the patient when they are appropriately responsive and exhibit
the full return of protective airway reflexes.
2.
Patients should be admitted to the PACU.
Erin A Sullivan, MD
Page 4
4/27/2016
*MD within the text of these guidelines refers to the attending anesthesiologist responsible for the case.
Guidelines for Open Lung Biopsy (Wedge Resection of Lung Lesion)
Equipment:
1.
2.
3.
4.
5.
6.
7.
Fiberoptic bronchoscope with light source
Single lumen (8.0) and double lumen endotracheal tubes
Large clamp for the double lumen endotracheal tube
Lower body Bair Hugger
CPAP connectors and PEEP valve (usually 5 cm of H2O is sufficient)
Arterial and central venous line transducers if needed
BIS or PSA 4000 monitor
IV Line Access:
18 or 16 gauge intravenous line is preferred. Consult with MD regarding the need
for arterial line and/or central venous access.
Drugs:
1.
2.
3.
4.
5.
Standard anesthetic medications, muscle relaxants and emergency drugs
In the holding area, midazolam may be administered if appropriate.
Fentanyl may be added if appropriate.
Odansetron, reglan, dexamethasone as needed
Bronchodilators with adapter for the anesthesia circuit
Cefazolin is most often administered to patients who are not penicillin or
cephalosporin allergic.
Blood/Blood Products:
Check for the availability of type and screen/type and crossmatch. Consult with
MD regarding the need for blood/blood products.
Perioperative Management:
Induction and maintenance:
1.
Following the placement of standard monitors + any appropriate invasive
monitors (which may be placed after the induction of anesthesia; consult
MD), preoxygenate the patient and administer the appropriate general
anesthetic agents.
2.
First, secure the patient’s airway using at least an 8.0 endotracheal tube if
flexible bronchoscopy is going to be performed. Drs. Ferson and
Buenaventura usually prefer securing the patient’s airway with a doublelumen endotracheal tube from the very beginning. They will usually
instruct otherwise if this is not his plan.
3.
The single lumen endotracheal tube will be changed to a double lumen
endotracheal tube in order to perform the thoracoscopic open lung biopsy.
Confirm the correct placement of the double lumen endotracheal tube with
fiberoptic bronchoscopy.
4.
The patient will be placed in the lateral decubitus position with the
operative (nondependent) lung facing up.
Erin A Sullivan, MD
Page 5
4/27/2016
*MD within the text of these guidelines refers to the attending anesthesiologist responsible for the case.
Guidelines for Open Lung Biopsy (Wedge Resection of Lung Lesion)
(continued)
Perioperative Management:
Induction and maintenance:
5.
Maintenance of anesthesia may be achieved with a balanced general
anesthetic technique of choice.
6.
Most patients will require the use of either oxygen alone or an oxygen/air
combination during single lung ventilation. You will achieve better lung
deflation if you use 100% oxygen prior to isolating the operative lung. If
hypoxemia occurs or persists during single lung ventilation on 100%
oxygen, verify endobronchial tube placement and position; consider
adding 5 cm H2O CPAP to the nondependent lung (the collapsed lung); if
this does not correct hypoxemia consider adding PEEP to the dependent
lung (the “down” or ventilated lung); if none of the above maneuvers
corrects the hypoxemia, convert back to double lung ventilation (reinflate
the operative lung). Caution: you may not be able to utilize CPAP during
thoracoscopic procedures since this will impede the surgeon’s operative
field due to re-expansion of the operative lung. Consult with the MD.
Emergence and recovery:
1.
Extubate the patient in the OR when/if they meet the appropriate criteria.
If the patient does not meet extubation criteria, consider changing the
double lumen endotracheal tube to a single lumen endotracheal tube and
mechanically ventilate the patient until he/she meets the appropriate
extubation criteria.
2.
Transfer the patient to the PACU or ICU with oxygen delivered either by
facemask or endotracheal tube.
Notes about patient positioning:
Positioning of the “up” arm varies according to the surgeon’s preference:
1.
Drs. Luketich, Christie, and Fernando place their patients on a beanbag
with the operative arm in a Velcro sling that is suspended from a bar.
2.
Drs. Ferson and Buenaventura position the “up” arm on an overhead arm
board.
3.
Make sure that the axillary roll is placed in the proper position in order to
minimize the chance of a brachial plexus injury.
4.
Make judicious use of eggcrate to pad all pressure points!
5.
Make sure that the patient’s head is maintained in the neutral position.
Erin A Sullivan, MD
Page 6
4/27/2016
*MD within the text of these guidelines refers to the attending anesthesiologist responsible for the case.
Guidelines for Thoracoscopy (Wedge Resection, Lobectomy, Bullectomy,
Laparoscopic Esophagectomy, Pericardial Window)
Equipment:
1.
2.
3.
4.
5.
6.
7.
8.
Fiberoptic bronchoscope with light source
Single lumen (8.0) and double lumen endotracheal tubes
Large clamp for the double lumen endotracheal tube
Lower body Bair Hugger
CPAP connectors and PEEP valve (usually 5 cm of H2O is sufficient)
Arterial and central venous line and pulmonary artery transducers if
needed (Consult with MD)
Epidural kit (Consult with MD)
BIS or PSA 4000 monitors
IV Line Access:
18 or 16 gauge intravenous line is preferred. Consult with MD regarding the need
for central venous access. If the patient is scheduled for laparoscopic
esophagectomy and you desire central venous access, please place the CVP line
on the right side, as the surgeons will perform their esophageal pull-through on
the left side of the neck.
Drugs:
1.
2.
3.
4.
5.
Standard anesthetic medications, muscle relaxants and emergency drugs
In the holding area, midazolam may be administered if appropriate.
Fentanyl may be added if appropriate.
Odansetron, reglan, dexamethasone as needed
Bronchodilators with adapter for the anesthesia circuit
0.25%-0.5% bupivacaine or 2% lidocaine for epidural injection (if TEA
will be used;consult with MD regarding the use of epidural narcotics
intraoperatively)
Blood/Blood Products:
Check on availability of type and screen/type and crossmatch. Consult with MD
regarding the need for blood/blood products.
Perioperative Management:
Induction and maintenance:
1.
Following the placement of standard monitors + any appropriate invasive
monitors (which may be placed after induction of anesthesia; consult
MD)and TEA if desired, preoxygenate the patient and administer the
appropriate general anesthetic agents.
2. First, secure the patient’s airway using at least an 8.0 endotracheal tube if
flexible bronchoscopy or laparoscopic esophagectomy is going to be
performed. Drs. Ferson and Buenaventura prefer to secure the patient’s
airway with a double-lumen endotracheal tube from the very beginning
Erin A Sullivan, MD
Page 7
4/27/2016
*MD within the text of these guidelines refers to the attending anesthesiologist responsible for the case.
Guidelines for Thoracoscopy (Wedge Resection, Lobectomy, Bullectomy,
Laparoscopic Esophagectomy, Pericardial Window)
(continued)
(except during esophagectomy). They will usually instruct otherwise if
this is not the plan.
Perioperative Management:
Induction and maintenance:
1.
The single lumen endotracheal tube will be changed to a double lumen
endobronchial tube in order to perform the thoracoscopic procedure.
Confirm the correct placement of the double lumen endobronchial tube
with fiberoptic bronchoscopy.
2.
The patient will be placed in the lateral decubitus position with the
operative lung facing up (non-dependent lung).
3.
Maintenance of anesthesia may be achieved with a balanced general
anesthetic technique of choice + thoracic epidural anesthesia.
4.
Most patients will require the use of either oxygen alone or an oxygen/air
combination during single lung ventilation. You will achieve better lung
deflation by administering 100% oxygen prior to isolating the lung. If
hypoxemia occurs or persists during single lung ventilation on 100%
oxygen, verify endotracheal tube placement and position; consider adding
5 cm H2O CPAP to the non-dependent lung (the collapsed lung); if this
does not correct hypoxemia consider adding PEEP to the dependent lung
(the “down” or ventilated lung); if none of the above maneuvers corrects
the hypoxemia, convert back to double lung ventilation (reinflate the
operative lung). During thoracoscopy, CPAP may interfere with the
operative field. Consult with the MD.
5.
The MD may elect to insert a thoracic epidural catheter either
preoperatively or immediately postoperatively in order to provide
analgesia. Alternatively, the surgeon may perform intercostal nerve
blocks or insert an intrapleural catheter at the conclusion of the operation.
Any of these procedures may be helpful for the patient if it is necessary to
convert the thoracoscopic procedure to an open thoracotomy, but a
functioning thoracic epidural catheter is often best.
Emergence and recovery:
1.
Extubate the patient in the OR when/if they meet the appropriate criteria.
If the patient does not meet appropriate extubation criteria, consider
changing the double lumen endobronchial tube to a single lumen
endotracheal tube and mechanically ventilating the patient in the PACU or
ICU until they meet appropriate extubation criteria.
2.
Transfer the patient to the PACU or ICU with oxygen delivered either by
facemask or endotracheal tube.
3.
See Guidelines for TEA if a thoracic epidural catheter is used for pain
management.
Erin A Sullivan, MD
Page 8
4/27/2016
*MD within the text of these guidelines refers to the attending anesthesiologist responsible for the case.
Guidelines for Thoracoscopy (Wedge Resection, Lobectomy, Bullectomy,
Laparoscopic Esophagectomy, Pericardial Window)
(continued)
Notes about patient positioning:
Positioning of the “up” arm varies according to the surgeon’s preference:
1.
Drs. Luketich, Christie, and Fernando place their patients on a beanbag
with the operative arm in a Velcro sling that is suspended from a bar.
2.
Drs. Ferson and Buenaventura position the “up” arm on an overhead arm
board.
3.
Make sure that the axillary roll is placed in the proper position in order to
minimize the chance of a brachial plexus injury.
4.
Make judicious use of eggcrate to pad all pressure points!
5.
Make sure that the patient’s head is maintained in the neutral position.
Erin A Sullivan, MD
Page 9
4/27/2016
*MD within the text of these guidelines refers to the attending anesthesiologist responsible for the case.
Guidelines for Thoracotomy
Equipment:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Fiberoptic bronchoscope with light source
Single lumen (8.0) and double lumen endotracheal tubes
Large clamp for the double lumen endotracheal tube
Lower body Bair Hugger
CPAP connectors and PEEP valve (usually 5 cm of H2O is sufficient)
Arterial and central venous line and pulmonary artery transducers if
needed (Consult with MD)
Blood warmer, not primed
Epidural catheter insertion kit, local anesthetic for nerve block
(preservative-free), and infusion pump (may use Bard pump with generic
faceplate). Consult with MD regarding the use of epidural narcotics.
BIS or PSA 4000 monitor
IV Line Access:
18 or 16 gauge intravenous line is preferred. Consult with MD regarding the need
for central venous access.
Drugs:
1.
2.
3.
4.
Standard anesthetic medications, muscle relaxants and emergency drugs
In the holding area, midazolam may be administered if appropriate.
Fentanyl may be added if appropriate.
Odansetron, reglan, dexamethasone as needed
Bronchodilators with adapter for the anesthesia circuit
Blood/Blood Products:
Check the availability of type and screen/type and crossmatch. Consult with MD
regarding the need for blood/blood products.
Perioperative Management:
Induction and maintenance:
1.
Following the placement of standard monitors + any appropriate invasive
monitors (which may be placed after induction of anesthesia; consult MD)
and thoracic epidural catheter (if desired), preoxygenate the patient and
administer the appropriate general anesthetic agents.
2.
First, secure the patient’s airway using at least an 8.0 endotracheal tube if
flexible bronchoscopy is going to be performed. Drs. Ferson and
Buenaventura prefer to secure the patient’s airway with a double-lumen
endobronchial tube from the very beginning. They will usually instruct
otherwise if this is not the plan.
3.
The single lumen endotracheal tube will be changed to a double lumen
endobronchial tube in order to perform the thoracotomy. Confirm the
Erin A Sullivan, MD
Page 10
4/27/2016
*MD within the text of these guidelines refers to the attending anesthesiologist responsible for the case.
Guidelines for Thoracotomy
(continued)
correct placement of the double lumen endotracheal tube with fiberoptic
bronchoscopy.
Perioperative Management:
Induction and maintenance:
1.
The patient will be placed in the lateral decubitus position with the
operative lung facing up.
2.
Maintenance of anesthesia may be achieved with a balanced general
anesthetic technique of choice + thoracic epidural anesthesia.
3.
Most patients will require the use of either oxygen alone or an oxygen/air
combination during single lung ventilation. If hypoxemia occurs or
persists during single lung ventilation on 100% oxygen, verify
endotracheal placement and position; consider adding 5 cm H2O CPAP to
the non-dependent lung (the “up” or collapsed lung); if this does not
correct hypoxemia consider adding PEEP to the dependent lung (the
“down” or ventilated lung); if none of the above maneuvers corrects the
hypoxemia, convert back to double lung ventilation (reinflate the operative
lung). Consult with the MD.
4.
The MD may elect to insert a thoracic epidural catheter either
preoperatively or immediately postoperatively in order to provide
analgesia. Alternatively, the surgeon may perform intercostal nerve
blocks or insert an intrapleural catheter at the conclusion of the operation.
Emergence and recovery:
1.
Extubate the patient in the OR when/if they meet the appropriate criteria.
If the patient does not meet appropriate extubation criteria, consider
changing the double lumen endobronchial tube to a single lumen
endotracheal tube.
2.
Transfer the patient to the PACU or ICU with oxygen delivered either by
facemask or endotracheal tube.
3.
Follow the Guidelines for TEA if a thoracic epidural catheter is used.
Notes about patient positioning:
Positioning of the “up” arm varies according to the surgeon’s preference:
1.
Drs. Luketich, Christie, and Fernando place their patients on a beanbag
with the operative arm in a Velcro sling that is suspended from a bar.
2.
Drs. Ferson and Buenaventura position the “up” arm on an overhead arm
board.
3.
Make sure that the axillary roll is placed in the proper position in order to
minimize the chance of a brachial plexus injury.
4.
Make judicious use of eggcrate to pad all pressure points!
5.
Make sure that the patient’s head is maintained in the neutral position.
Erin A Sullivan, MD
Page 11
4/27/2016
*MD within the text of these guidelines refers to the attending anesthesiologist responsible for the case.