A day of thoracic anesthesia
The thoracic anesthesia rotation at UVA is often performed after residents have completed their cardiac rotation and usually lasts for 2 weeks. During this time, the resident gets a chance to revisit important respiratory physiology concepts, since many of the cases performed require delivering anesthesia under one lung isolation. There is a great deal of variety in the types of cases that we are exposed to and as such, we get the chance to perform a good number of procedures in any given day. Here is a glimpse into one of my days on the thoracic rotation.
Taking it one lung at a time
0610 Arrived at the hospital a little earlier than usual to set up my room for the day. Today is Wednesday, and every Wednesday starting at 0700 our department has mandatory lectures for both faculty and residents. I ensure that my anesthesia machine is operating correctly, draw up my drugs, and make sure that I have all my airway equipment available and arranged appropriately.
0655 Made a pit stop at Higher Grounds for my regular Caramel Latte with soy before heading to lecture. It’s like our own version of Starbucks in the hospital – only better.
0850 Lectures are over and I, along with the rest of the Anesthesiology department, walk back to the ORs to get our cases started for the day. I find my attending and we briefly review the plan for our first patient that we had discussed the night before. He is a 51 year old man who has laryngomalacia and is scheduled to have a tracheobronchoplasty performed via a right thoracotomy incision. Since this is a type of procedure that is highly variable in its approach, we find the attending surgeon so that we can understand his approach and organize our anesthetic plan accordingly. Flexibility and communication with the surgeon is critical to optimal patient care.
0902 Just finished introducing myself to the patient and his family and discussed the anesthetic plan, which included offering the patient an epidural to help with his post-operative pain. After going over the risks and the benefits, the patient consented but only after telling me that he has a history of spondylolithesis. This might affect the ease of epidural placement, but we will do our best as always!
0935 After multiple attempts to put in the epidural, I am finally successful! He was a bit harder than expected, but at least I was forewarned! I make a mental note to call the Acute Pain Service once we’re at a steady point in the case to make sure the patient gets his epidural infusion so he will wake up comfortably and pain free.
0951 Just finished inducing the patient with propofol, fentanyl, rocuronium, and lidocaine and intubating him on the first attempt with my trusty miller blade. The left-sided 39 French double lumen tube was inserted without any difficulty and I confirmed placement with a fiberoptic bronchoscope. I then went and placed an additional peripheral IV and arterial line before getting ready to position the patient.
1016 Rechecked the position of my double lumen tube now that the patient has been properly positioned on his side. After some mild adjustments I’m satisfied with its position and begin ventilating one lung in preparation for his ensuing thoracotomy.
1026 Surgical incision. No changes in the patient’s heart rate or blood pressure. He seemed to tolerate that well. Now time to catch up on charting. Thank goodness we have the electronic medical record that automatically charts vital signs!
1133 The attending comes in to do some intraoperative teaching on ventilator settings and his preferences for one-lung ventilation. After a quick discussion and some ventilator management tweaking, I leave for my 30 minute lunch break.
1215 Trying to facilitate the flow of the OR schedule. Our next patient is scheduled to receive a pre-operative epidural. I contact the Acute Pain Service and inform them that the patient has been called for early to allot additional time for epidural placement.
1340 Revisited the plan for extubation with my attending. Our patient has had documented repeat episodes of laryngospasm following emergence. Anything but a smooth emergence might disrupt the integrity of the surgical repair and lead to additional post-operative complications. We confirm the plan to extubate our patient deep while running a lidocaine infusion.
1458 At last, after more than 6 hours, the long surgical repair is complete. The patient tolerated one-lung ventilation without any problems. Now, since they’re closing up, I can resume two-lung ventilation.
1521 It’s showtime! The procedure has just ended so I ensure that the patient has been adequately reversed from his paralytic, suctioned his posterior oropharynx and placed both a nasal and oral airway. I had an LMA ready in case we needed to establish emergency airway access. Had sevoflurane running at 1.2 MAC and the lidocaine infusion going. Pulled the tube and… whew! Patient tolerated the extubation well with no signs of laryngospasm. Transported him to the PACU and was there to see him as he woke up and rated his pain as… a 2/10. I’ll take that!
1608 Ready to start the next case. The patient is in her 20s and has a paraesophageal mass that needs to be removed under one lung isolation. Since she’s so healthy and fairly thin, we opt to go with a bronchial blocker as opposed to a double lumen tube so that I can get more experience.
1615 Just finished the IV induction which went smoothly. The bronchial blocker was finally placed, but not without some difficulty as we tried to maneuver the blocker down the correct mainstem. Nonetheless, I’m grateful that my attending was willing to let me try something new.
1652 Now for the real test as one lung ventilation is initiated. Surgeons report good lung isolation! That was like music to my ears given that this was the first bronchial blocker I had ever placed. Getting ready to settle in and catch up on charting.
1656 Before I could get too settled in, the colleague who was on call for the night came in to relieve me for the day. I gave him a complete sign out on the patient and left to see my postops from the day before and my preops for the day after. If I finish them fast enough I should be able to get out of the hospital by 6pm.
1758 Walking home. It may be dark outside already, but I still have my whole evening ahead of me. I call my attending to discuss the cases for the next day and settle into an evening of reading and relaxation.