Hensley's Practical Approach to Cardiothoracic Anesthesia

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IV. Thoracic Anesthesia

H. Foreign Body Removal 1. Compatible with flexible bronchoscopy (with basket forceps) or rigid bronchoscopy 2. Indications: Endotracheal or proximal bronchial foreign body 3. Complications: Tracheal injury, esophageal injury, airway bleeding, aspiration 4. Additional anesthetic considerations: Maintenance of spontaneous ventilation until for eign body is retrieved, to avoid distal dislocation with positive pressure. VI. Preoperative Assessment for Interventional Pulmonology Procedures A. Most IP procedures are done on an outpatient basis, and patients are seen by the anesthesiolo gist on the same day, in the presurgical area, unless severe comorbidities are present and the patient needs to be optimized. Therefore, a thorough preoperative evaluation that is tailored to the needs of the IP procedure and the most relevant patient-related factors is necessary to plan a safe anesthetic. 1. Patients with reactive airway disease should continue their inhalers and steroids on the day of surgery. Additional bronchodilators may be needed throughout the perioperative period. 2. Patients with cardiac disease should be optimized before elective procedures. For patients with a pacemaker or automatic implantable cardioverter defibrillator (AICD), basic infor mation about the device (eg, indication for placement, last battery check, dependency, and underlying rhythm) should be available on the day of the procedure. 3. Additional comorbidities and medications should be reviewed, and the plan custom ized accordingly. B. The need for transfusion is fairly rare during IP procedures. However, in the presence of ane mia or known antibodies, a type and screen should be available on the day of the procedure. C. Hemodynamic Instability may occur in patients with severe COPD (due to high intratho racic pressure secondary to increased lung volumes, causing a decrease in venous return and cardiac output), or as a consequence of the ventilator settings or pneumothorax, requiring continuous blood pressure monitoring either via arterial line or noninvasive devices. D. A detailed conversation with the interventional pulmonologist should take place before the start of the case about the specific procedure and the possible complications, including the potential for loss of the airway. A plan for airway rescue should be developed that is tailored to patient and procedural factors. Any additional equipment that may be needed for rescue should be collected before the procedure starts. VII. Management of Interventional Pulmonology–Specific Intraprocedural Complications While complications are uncommon during IP procedures, when they do occur, they may be life-threatening, since the airway is being manipulated and patients undergoing these procedures may have limited reserve. A. Airway Irritability: Cough, bronchospasm, and laryngospasm are the most common compli cations. Nebulized lidocaine is usually effective in suppressing cough. Bronchospasm responds well to nebulized β-agonists (albuterol), anticholinergics (ipratropium), and racemic epineph rine. Laryngospasm can be managed by deepening the anesthetic, positive pressure, and/or administration of paralytics. B. Airway Loss: IP procedures involve sharing the airway, and loss of airway control can result in respiratory arrest and death. Communication with the interventional pulmonologist and de tailed planning are instrumental in preventing this potentially fatal complication. Specifically, different ETT and SGA sizes, an airway exchange catheter, jet ventilation, or ECMO may be needed and should be set up ahead of time, if necessary. C. Airway Bleeding: Certain procedures (eg, cryobiopsy, stent placement) can cause significant airway bleeding, and this risk is exacerbated by certain patient-specific factors (eg, history of chest irradiation, renal cell, or sarcoma metastasis to the airway). Bronchial blockers can be used to tamponade the source of bleeding and are placed at the hemorrhagic source until bleeding stops, which may take only minutes or may take longer to abate. Ongoing airway bleeding may require arterial embolization by an interventional radiologist, postprocedural mechanical ventilation, and intensive care unit (ICU) care. When transferring patients on

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