Position: Lateral
Time: 2-4 hours (long)
Blood Loss: Moderate (50 – 200 ml)
Post-op Pain: High (7-10)
Maintenance Paralytic: Yes

Preoperative Preparation – A list of things to have/do prior to the surgery:
1. place 2 large bore IVs or central line.
2. Arterial line recommended.
3. Obtain CBC and ABG for preop values.
4. Have type and cross completed.
5. Place thoracic Epidural for intra-op and post-op pain control.
6. Have bronchoscope and large hemostat or clamp at bedside.
7. Warming – Fluid warmer and Lower body bair hugger.
8. Have a properly sized Left Double Lumen Tube (DLT). Males- Usually 39 or (41 if they’re tall). Women – usually 37.

Induction – Place DLT with the aid of a glidescope if needed, then ensure placement of the left sided tube with a bronchoscope. Tape very securely before you turn the patient. Turn patient laterally with the affected lung up – (see general lateral positioning implications below).

Lung Deflation – The surgeon will notify you when they are ready to deflate the affected lung. Turn off ventilation and clamp the tube. Once you are sure that the lung is deflated restart ventilator at a lower tidal volume (TV). Most will drop the TV by half of the original volume. Using Pressure Control Ventilation (PVC) is also acceptable for one lung ventilation. Keep your Positive Inspiratory Pressure (PIP) below 40 cm H2O.

SaO2 drops – If SaO2 drops attempt to add PEEP (usually no more than 7), or hand ventilate until oxygenation is increased. If these methods fail, inform the surgeon and ask if it is feasible to reinflate the affected lung for a short time.

Lung Inflation – When surgeon is finished they will let you know to reinflate the lung. Usually it is best to hand ventilate until lung is completely reinflated, then place back on original vent settings.

Extubation – Extubating these patients in a head up position is best. Make sure to lower both balloons on the DLT and make sure the airway is not compromised (active bleeding, extreme swelling) before extubation. It is best to extubate awake.

Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape.  Unhook anesthesia circuit while turning lateral and be especially careful to keep patient’s head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient’s head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn’t being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.

High blood loss RISK (general considerations): Though most of these cases don’t result in a high blood loss, there is a high blood loss RISK. Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra IV push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

VATS are performed as a minimally invasive procedure, compared to an open chest or thoracotomy. Advantages of VATS include a smaller incision, less postoperative pain, less risk of complications, and shorter hospital stay. A Disadvantage of VATS could include incomplete lymph node removal/dissection due to less surgical space and visualization for the surgeon.

Indications for VATS include: lymph node dissection or biopsy, lung decortication for infection or fluid accumulation, lung resection due to cancer or trauma, mediastinal mass resection.