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Author Spotlight: A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia
Published on: May 26, 2023
When to abandon single-lung anesthesia during video-assisted thoracoscopic surgery (VATS) in infants and young
Chulananda Goonasekera1, Malcolm Mathew1, Meera Kurup1
1Department of Anesthetics, King's College Hospital NHS Trust, Denmark Hill, London, United Kingdom.
Insights
Maintaining normal gas exchange during one-lung anesthesia in infants undergoing video-assisted thoracoscopic surgery (VATS) is challenging. Severe hypoxemia or hypercapnia necessitates conversion to open thoracotomy to ensure patient safety.
Area of Science:
- Pediatric Anesthesiology
- Thoracic Surgery
- Respiratory Physiology
Background:
- Video-assisted thoracoscopic surgery (VATS) in pediatric patients often requires one-lung anesthesia.
- Maintaining adequate gas exchange during one-lung anesthesia in infants presents significant challenges.
Purpose of the Study:
- To highlight the difficulties in maintaining gas exchange during one-lung anesthesia in infants undergoing VATS.
- To discuss management strategies and indications for conversion to open thoracotomy.
Main Methods:
- Case report of two infants experiencing respiratory compromise during one-lung anesthesia for VATS.
- Review of factors contributing to impaired gas exchange, including dead space, CO2 pressure, airway resistance, and blood contamination.
Main Results:
- One infant developed hypoxemia, while the other experienced hypercapnia.
- Existing guidelines for permissive hypoxemia/hypercapnia in this setting are insufficient.
Conclusions:
- Irreversible hypoxemia or hypercapnia, with associated acid-base disturbances, are critical indications for immediate conversion to open thoracotomy.
- Abandoning one-lung ventilation is crucial for patient safety in severe cases.
Abstract:
Video-assisted thoracoscopic surgery (VATS) in infants and young children increasingly require one-lung anesthesia. However, the maintenance of norms of gas exchange is difficult during one-lung anesthesia in some infants. A combination of factors including added dead space of HME and the circle Y piece, intrathoracic inflation of CO2 and its pressure, airway resistance and bilateral lung disease contribute. Seeping blood from the operating lung soiling the endobronchial tube causes airway narrowing and obstruction adding to this difficulty especially during prolonged thoracoscopy. We report two cases: hypoxemia in one and hypercapnia in the other. Guidance on safe limits of permissive hypoxemia or hypercarbia in this scenario is vague. Therefore, irreversible hypoxemia and hypercarbia with changes in acid-base status should be considered as indications for swift conversion to open thoracotomy and abandon one-lung ventilation.
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