What the Anesthesiologist Should Know before the Operative Procedure
The resection of the chest wall are a range of surgeries that goes from a small incision of less than 5 centimeters to complex reconstructions that include muscle flaps and synthetic mesh. Chest wall tumors are rare, less that 1% of the total of tumors in general. Half of chest wall tumors are malignant, and of those half are metastasis of other tumors or local invasion from an adjacent organ.
Benign chest wall tumors include, desmoid tumors, chondromas, osteochondromas, fibrous dysplasia and others. Malignant tumors are myelomas, lymphomas, chondrosarcomas, osteosarcomas, ewing sarcoma and others soft tissue sarcomas.
Because in some cases it is very difficult to determine the malignancy of the tumor, the majority of them are treated as malignant. This implies that the resection will have at least 4 cm of margins, leaving potentially a very large defect.
Chest wall defects less than 5 cms can be close primarily, while larger defects often require reconstruction that can include different types of mesh or if rigidity is needed acrilic materials can be used.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
This kind of surgery is not usually performed in a urgent setting. However, in some occasions tumors may invade or compress intrathoracic structures, including respiratory and vascular and in these cases urgent of emergent surgery may be undertaken.
A clear understanding of the anatomy and relations of the tumor are fundamental for the surgical management and the anesthetic technique.
2. Preoperative evaluation
Chest walls tumors are a pathology that cross a wide segment of the population from children to adults. The benign tumors generally appear at a younger age (median of 25) than the malignant tumors (median of 40). This implies that the preoperative evaluation will depend on the age group and the specific comorbidities of the patient.
The risks for the adult population of respiratory complications are in the range of 15 % to 20% and cardiovascular between 10 % to 15 %. The mortality depends on the etiology of the tumor.
The tumor itself must also be taken in to consideration. Lymphomas and other unique tumors can generate other comorbidities by themselves.
Medically unstable conditions warranting further evaluation include:
– Cardiac disease, ischemia
– Infectious processes
Delaying surgery may be indicated if any of the pathologies mentioned above are not under control and well managed. Delays may also occur if there is a coagulation problem.
3. What are the implications of co-existing disease on perioperative care?
Perioperative evaluation- The preoperative evaluation for chest wall tumors should include the standard evaluation for any thoracic surgery. (Blood test, coagulation, platelet count), EKG, respiratory function tests, Imaging (Thoracic XRay, Thoracic Scanner).
Perioperative risk reduction strategies- Chronic medication such as antihypertensives and beta blockers should not be discontinued in the preoperative period. Anticoagulants and antiplatelet medication should be discontinued or overlapped with unfractionated heparin to allow good hemostasis and eventually the use of regional anesthesia.
b. Cardiovascular system
Acute/unstable conditions: Ischemia or arrhythmias.
Perioperative Evaluation: ECG, coronary angiography, or stress test according to the clinical symptoms/ state of the patient.
Perioperative risk reduction strategies: Maintain chronic medication, specifically beta blockers. Avoid volume overload. Consider invasive monitoring with arterial line and CVP.
Baseline coronary artery disease or cardiac dysfunction – Goals of management: Systemic pressures similar to the hemodynamics of the awake patient. Heart rate between 60 and 70 beats per minute. Avoid volume overload.
Perioperative Evaluation: Pulmonary function tests, with and without bronchodilators. Arterial Blood gases and DLCO.
Perioperative risk reduction strategies: Optimize bronchodilatory therapy, consider steroids.
Reactive airway disease (Asthma):
Perioperative Evaluation: Pulmonary Function tests, with and without bronchodilators.
Perioperative risk reduction strategies: Optimize bronchodilatory therapy, consider steroids.
Perioperative Evaluation: Creatinine, BUN. Consider Creatinine clearance if the function is diminished.
Perioperative risk reduction strategies: Adequate volume replacement therapy during surgery.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
Perioperative Evaluation: Blood count, platelet count. Coagulation exams (INR, PTT)
Perioperative risk reduction strategies: Consider perioperative transfusion if needed.
4. What are the patient's medications and how should they be managed in the perioperative period?
Anticoagulant drugs and antiplatelets drugs should be discontinued before the surgery. In case that the patient needs mandatory anticoagulation for any medical reason, such as a mechanical prosthetic valve, the anticoagulation should be overlapped with unfractionated heparin and discontinued 12 hrs before the surgery.
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
i. What should be recommended with regard to continuation of medications taken chronically?
Cardiac: Continue with antihypertensives and beta blockers.
Pulmonary : Continue with any broncodilatory medicine.
Anti-platelet: Discontinue and manage according with the primary indication.
j. How To modify care for patients with known allergies –
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
l. Does the patient have any antibiotic allergies- [Tier 2- Common antibiotic allergies and alternative antibiotics]
In case of allergy to Penicillin or Cephalosporins, consider Gentamicin for surgery without implants or Vancomycin for surgery with implants.
m. Does the patient have a history of allergy to anesthesia?
Documented- avoid all trigger agents such as succinylcholine and inhalational agents:
Proposed general anesthetic plan:
Insure MH cart available:
[- MH protocol]
Family history or risk factors for MH:
Local anesthetics/ muscle relaxants:
5. What laboratory tests should be obtained and has everything been reviewed?
Common laboratory normal values will be same for all procedures, with a difference by age and gender
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
The optimal anesthetic management for this kind of patients are the combined techniques of general anesthesia and epidural. This techniques generate the optimal balance of good intraoperative management with good post anesthetic pain control.
a. Regional anesthesia – Multiple techniques has been used, such as spinal with opioids and epidural anesthesia. Regional techniques such as intercostal blocks have also been used but are less common.
Benefits: Generally good pain control, during the surgery and after if a catheter is used. Usually easy placement. Can be used only with local anesthetics or add opioids for a better coverage.
Drawbacks: In case of the spinal, even with opioids, the postoperative pain control can be insufficient and may need IV analgesics. Local anesthetic infusion or PCA can cause some degree of hypotension.
Issues: Lateralization of epidural catheters to the non surgical side can generate an unexpected situation that may lead to deeper general anesthesia and or side effects.
Peripheral Nerve Block
Benefits: Depending on the technique can generate lasting effects that can provide analgesia for the postoperative period. Lack of hypotensive response as the neuroaxial techniques. The techniqueis only performed in the side that will be operated. Intercostal nerve block, can be performed by the surgeon under direct vision.
Drawbacks: Complex techniques (root block), that need special training and equipment. Simple techniques (intercostal nerve block), usually have as short half life.
Issues: Bigger doses of local anesthetic can cause secondary effects and even toxicity. The placement of lateralized catheters as needed in a continuous root block can interfere with the surgical site if a muscle flap is needed.
b. General Anesthesia
Benefits: In this kind of surgery the general anesthesia is mandatory, because usually lung isolation is needed. Combined with a thoracic epidural anesthesia can give the most stable management for the intra and post operative periods.
Drawbacks: General anesthesia as a single technique needs to be very deep to give a proper level of analgesia. This patients usually perform better if they are soon extubated after the surgery. so very large doses of opioids are not generally recommended.
Airway concerns: Patients usually need lung isolation so the usage of a double lumen tube or a bronchial blocker are needed.
c. Monitored Anesthesia Care
6. What is the author's preferred method of anesthesia technique and why?
What prophylactic antibiotics should be administered? – First generation cephalosporins such as cefazolin are indicated for this surgery.
What do I need to know about the surgical technique to optimize my anesthetic care? – The surgical technique differ greatly between patients due to the location of the tumor. In general the tumors are removed with a wide margin, so usually the defects after the surgery are of considerable size from removal of several partial ribs. If the lesion compromise the sternum, a sternotomy with resection of the adjacent costal arches are performed. If a muscle flap is performed the eventual placement of catheters in the back for analgesia should be discussed with the surgeon to avoid the surgical site.
What can I do intraoperatively to assist the surgeon and optimize patient care? Usually cell saver are not indicated in this kind of surgery because of the neoplasic nature of the lesions.
What are the most common intraoperative complications and how can they be avoided/treated? Prioritize them by urgency. Bleeding is some times a complication depending on the extension of the tumor, the type and its proximity to vascular extructures.
Cardiac complications-Ischemia in susceptible patients and arrhythmias. Ischemic episodes occur more commonly in patient with coronary artery disease. To avoid these situations, a proper perfusion pressure and heart rate should be mantained through the duration of surgery. Arrhythmias (usually atrial fibrillation) are treated with amiodarone or cardioversion depending on the hemodynamic impact in the patient.
Pulmonary-Failure in the ventilation secondary to movement of the DLT. Desaturation due to the single lung ventilation are common. Should be treated with repositioning of the DLT and optimization of the ventilation. Use of PEEP in the non dependent lung is an alternative if does not interfere with the surgery, if the desaturation persists surgical lung CPAP implemented sequentially is often helpful for oxygenation and tolerable to the surgeon.
b. If the patient is intubated, are there any special criteria for extubation?
no special criteria
c. Postoperative management
What analgesic modalities can I implement?
The options are IV analgesics, continuous nerve block or epidural analgesia. The last one is the preferred over the first two for the simplicity in the installment and management and the possibility of continue after the surgery for at least three days.
What level bed acuity is appropriate?
The level of bed acuity depends on the extension of the resection and the comorbidities of the patient. In case of a big resection with an extensive reconstruction of the chest wall, an ICU bed will be necessary to ensure mechanical ventilation for at least a couple of hours until the patient can reacquire proper ventilatory mechanics.
What are common postoperative complications, and ways to prevent and treat them?
Common postoperative complications are prolonged mechanical ventilation, that can be prevented with optimization of the pulmonary function and proper anesthesia technique. Reoperation for bleeding, depends on the surgical technique and the experience of the surgeon. Postoperative delirium depends on the general conditions of the patient. Influence by the anesthesiologist may be limited.
What's the Evidence?
Slinger, P. “Principles and Practice of Anesthesia for Thoracic Surgery”. 2011. (Very good text that summarizes general aspects of the anesthetic management of patients undergoing thoracic surgery.)
Shah, AA, D’Amico, TA. “Primary chest wall tumors”. J Am Coll Surg. vol. 210. 2010. pp. 360-6. (Very good paper that summarizes the clinical presentation, diagnosis, and treatment of the primary chest wall tumors.)
Kim, JY, Hofstetter, WL. “Tumors of the mediastinum and chest wall”. Surg Clin North Am. vol. 90. 2010. pp. 1019-40. (Good text that refers in some extents to different histological types of chest wall tumors.)
Campo-Cañaveral De La Cruz, JL, Herrero Collantes, J, Sánchez Lorente, D, Torres Lanzas, J. “Cirugia de la pared toracica”. Arch Bronconeumol. vol. 47. 2011. pp. 15-24. (Text in Spanish. Very good text that summarizes the treatment and types of surgeries and results of the reconstruction of the chest wall.)
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- b. Cardiovascular system
- c. Pulmonary
- d. Renal-GI:
- e. Neurologic:
- f. Endocrine:
- g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How To modify care for patients with known allergies -
- k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
- l. Does the patient have any antibiotic allergies- [Tier 2- Common antibiotic allergies and alternative antibiotics]
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 6. What is the author's preferred method of anesthesia technique and why?
- a. Neurologic
- b. If the patient is intubated, are there any special criteria for extubation?
- c. Postoperative management