Esophagectomy

The case is booked as an Ivor-Lewis esophagectomy.  Let’s learn a couple of things here from what the surgery will be, to the type of anesthesia, to post-op pain management.

What’s an Ivor-Lewis esophagectomy?

Esophagectomy

Anesthetic monitors:

  • Central line (Cordis for volume in emergency)
  • Vigileo/FloTrac – SVI, SVV, SVR, CO great markers for fluid management
  • BIS
  • UOP

Anesthetic technique:

  • Induction: lidocaine, Propofol, rocuronium/sux (dependent upon if blockage from tumor necessitating RSI or not)
  • Maintenance: sevoflurane
  • Extubation: attempt in OR
  • Fluid management
    • Colloid vs. crystalloid
    • CVP vs. Esophageal doppler vs. pulse pressure vs. stroke volume variation
      • Keep SVI >35 mL/m2 to decrease risk of AKI
  • OLV
    • To reduce lung damage and ARDS
    • 4-6 cc/kg ventilation strategy (lung-protective)
    • Pressure-controlled
    • Optimization of PEEP
    • PIPs <35mmHg, Plateau pressure <25mmHg
  • Pain Management
    • Pre-op adjuvant pain meds:
      • Oxycodone XR 20mg PO if <70y/o or 10mg if >70yo
      • Celecoxib 400mg PO if <70y/o or 200mg if >70yo
      • Pregabalin 150mg PO if <70y/o or 75mg if >70yo
    • Thoracic Epidural: Improved blood flow to anastomotic site, earlier extubation times, reduced pneumonia rates.
  • Vasopressors: phenylephrine. Consider norepinephrine (improved CO), vasopressin if needed.

Case:

40-something year old female who was newly diagnosed with squamous cell cancer of her distal esophagus about 2 months prior.  Presented to ED with N/V, epigastric pain, malnourishment.  Had underone chemo and radiation.  PMH achalasia, endometriosis.  NKDA. Scheduled for Ivor-Lewis esophagectomy.  Pt appeared cachectic, on TPN, 45kg, 5’5″.  L chest port-a-cath in place.

In OR, pt received T7 epidural.  RSI w cricoid pressure throughout.  37Fr L DLT placed gently without resistance.  31cm at teeth noted after fiberoptic bronch check.  20g L radial a-line placed.  Surgeon stated no cervical approach needed, therefore, I placed a R IJ cordis and CVP.  FloTrac for SVI, SVR, SVV, CO.

Albumin for IVF.  Goal SVI >35, CVP 5-10. Phenylephrine for SBP >90.  OGT (resistance met prior to first dark marking on tube that was expected with 6 cm tumor).  BIS goal 40-60.  Epidural initially dosed with 5ml 2% lido with epi.  Another dose given roughly 30 minutes later.  Remaining dosing throughout case with 4ml 0.25% bupi.  Acetaminophen IV 1000mg prior to incision.  Fentanyl IV for abdominal laparoscopy.

Abdominal laparoscopy –> tumor unable to be freed/resected via laparoscopy.  Converted to laparotomy.  Tumor adhered to pericardium.

R thoracotomy: OLV at 200ml TV, RR 21 (volume-restrictive ventilation strategy 4-6ml/kg).  Good lung isolation.  Good anastamosis of tissues.  Two lung ventilation according to surgeon.  Recruit lungs to decrease atelectasis.

Emergence: + Pressure support through DLT.  Extubate in OR.

Lessons learned:

  1. Early communication with surgeon(s).
  2. Lung-protective strategies
  3. Volume restriction for IVF
  4. Appropriate pressor choice
  5. Pain control: thoracic epidural (0.125% bupiv + hydromorphone 10mg/ml), IV low dose ketamine (0.1-1mg/kg/hr), precedex if tolerated, if PO then preop pain meds above.  If not PO, then IV acetaminophen RTC, IV ketorolac RTC (if ok with surgeon).  Continue baseline pain regimen if patient is a chronic pain patient.
  6. Setup is key.  Discuss which side for the cervical approach (if doing) prior to doing neck lines so not in the surgical field.

Resources:

 

OB Anesthesia

Today, I’m on call covering OB.

MGH: OB anesthesia Q&A for patients

BWH: OB anesthesia Q&A for patients

IARS 2010: OB anesthesia in the 21st century

IARS 2011: OB anesthesia update

A&A 2013: A Randomized Controlled Comparison of Epidural Analgesia and Combined Spinal-Epidural Analgesia in a Private Practice Setting: Pain Scores During First and Second Stages of Labor and at Delivery

Indian J Anesthesia 2006: Acute Pain – Labour Analgesia

Presentation on mobile epidural

2014: CONTINUOUS VERSUS PATIENT-CONTROLLED EPIDURAL ANALGESIA FOR LABOUR ANALGESIA AND THEIR EFFECTS ON MATERNAL MOTOR FUNCTION AND AMBULATION

June 2011: Update on rural OB anesthesia

Oct 2013: Presentation on Labor analgesia. Epidural vs CSE, bolus v infusions

To epidural or not to epidural. That is the question.

My Reddit Comment

A great YouTube video on what an epidural is and what it will feel like.

YouTube vid of a real epidural placement ** Needles are involved in this one**

Lately, I’ve been changing my regimen for pain control with PCEA.  It seems most of my partners use a 10ml/hr basal rate, 5ml bolus dose, 10 minute lockout, and 30 ml/hr max.

My current strategy for PCEA (0.0625% bupi + 2mcg/ml fentanyl):

  • 5ml/hr basal rate
  • 10ml bolus
  • 20 minute lockout
  • 35 ml/hr max

Anesth Analges 2007: A Comparison of a Basal Infusion with Automated Mandatory Boluses in Parturient-Controlled Epidural Analgesia During Labor.

ASA Nov 2001: PCEA during labor

Br J Anaesth 2010:Labour analgesia and obstetric outcomes.

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial

Neuraxial anesthesia in the non-pregnant patient

Anesthesiology Research and Practice 2012: Recent advances in epidural analgesia.

Br J Anaesth 2012: Failed epidural: causes and management.

From my blog:

OB Anesthesia

Today, I’m on call covering OB.

MGH: OB anesthesia Q&A for patients

BWH: OB anesthesia Q&A for patients

IARS 2010: OB anesthesia in the 21st century

IARS 2011: OB anesthesia update

A&A 2013: A Randomized Controlled Comparison of Epidural Analgesia and Combined Spinal-Epidural Analgesia in a Private Practice Setting: Pain Scores During First and Second Stages of Labor and at Delivery

Indian J Anesthesia 2006: Acute Pain – Labour Analgesia

Presentation on mobile epidural

2014: CONTINUOUS VERSUS PATIENT-CONTROLLED EPIDURAL ANALGESIA FOR LABOUR ANALGESIA AND THEIR EFFECTS ON MATERNAL MOTOR FUNCTION AND AMBULATION

June 2011: Update on rural OB anesthesia

Oct 2013: Presentation on Labor analgesia. Epidural vs CSE, bolus v infusions

To epidural or not to epidural. That is the question.

My Reddit Comment

A great YouTube video on what an epidural is and what it will feel like.

YouTube vid of a real epidural placement ** Needles are involved in this one**

Lately, I’ve been changing my regimen for pain control with PCEA.  It seems most of my partners use a 10ml/hr basal rate, 5ml bolus dose, 10 minute lockout, and 30 ml/hr max.

My current strategy for PCEA (0.0625% bupi + 2mcg/ml fentanyl):

  • 5ml/hr basal rate
  • 10ml bolus
  • 20 minute lockout
  • 35 ml/hr max

Anesth Analges 2007: A Comparison of a Basal Infusion with Automated Mandatory Boluses in Parturient-Controlled Epidural Analgesia During Labor.

ASA Nov 2001: PCEA during labor

Br J Anaesth 2010:Labour analgesia and obstetric outcomes.

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial

Neuraxial anesthesia in the non-pregnant patient

Anesthesiology Research and Practice 2012: Recent advances in epidural analgesia.

Br J Anaesth 2012: Failed epidural: causes and management.

From my blog: