The overall population is aging (44-45% of the US population is > 65 yo)
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- Lucinda Walton
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2 The overall population is aging (44-45% of the US population is > 65 yo) 50,000,000 40,000,000 30,000,000 20,000,000 10,000,000 male female 0 male
3 ,000, ,000 0 males males females Population age in the Czech Republic Eurostat data 2015
4 Age = risk factor for lung Ca Peak incidence = age 70 Average life expectancy = 78.6 yr >75 Men Women J Thorac Cardiovasc Surg 2012; 144:33 J Thorac Oncol 2012; 7: 57
5 PRE operative Testing Invasive Consults INTRA operative Invasive monitors Medication & complications POST operative Analgesia iv vs regional Adjuvants Complications Delirium/confusion Are elderly patients candidates for thoracic procedures?
6 90 yo Male 164 cm, 81 Kg (BMI= 29.8) PMHX: HTN, A Fib, CAD post CABG (1985), 3 AVB, post PM placement COPD, OSA, B pleural effusion + RML carcinoid NIDDM prostate CA? dementia PSHX: TURBt, R rotator cuff, BCC excision
7 FVC = 53% FEV 1 = 62 % DLCO = 46% Labs = Hb= 12.5; BUN/cr= 19/1.2 BNP = 111 Echo = EF 63%, mild MR, mod TR. Paradox septal motion, PAP= 36-40mmHg
8 Because Do And and you it s we is have a MINIMALLY great other day INVASIVE!!!. for robot!!!!!! plans??? this case! Why Right are we doing this??????
9 Minimally Invasive Surgery 55-67% Open approach (quite invasive) VATS 35% Ann Surg 2012; 256: 487 Robotic surgery 3.4%
10 77 yo Robotic lobe
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12 RATS RATS cases by age (875) < > MSKCC Robotics Overall volume N=8,
13 PROs CONs LOS surgical times pain Skilled personnel EBL Consistent OR team scarring ± Costs Better LN dissection ± Conversion to open Sublobar resection Open lobe = $ VATS lobe = $ RATS lobe= $ 1 Robot = million Maintenance/yr = $ Instruments = $ NEJM 2010; 363: 701 J Thorac Cardiovasc Surg 2010; 139: 366 BJS 2012; 99: 1025 Ann Cardiothorac Surg 2012; 1: 56 Anesthesiol Clin 2012; 30:699 Ann Thorac Surg 2014; 97: 1000 J Thorac Cardiovasc Surg 2014; 147: 929
14 VATS ROBOT TECHNOLOGY Tactile feedback 3D visual Wristed instruments PROCEDURE Relying on an assistant for the camera Surgeon in the field Stable platform Surgeon away from the field OUTCOMES Similar Similar/? Slightly better COSTS -? higher LONG TERM OUTCOME Maybe upstaging N1 ds Similar N1 to open J Thorac Cardiovasc Surg 2012; 143: 383 Ann Thorac Surg 2014; 97: 236
15 1. Preoperative a.asa status et al b. Frailty assessment c. Comprehensive Geriatric Assessment d. Baseline cognitive function 2. Logistics Positioning Bed placement 3. Monitoring lines 4. Physiology CO 2 insufflation hemodynamics OLV 5. Emergency planning Bleeding arrhythmias Anesthesiol Clin 2012; 30: 699 J Clin Oncol 2014; 32: 2647
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17 Surgery = best treatment for solid tumors AGE ALONE should NOT be a determinant for treatment Preop assessment = risk stratification = post op outcome a. Frailty assessment b. Comprehensive Geriatric Assessment c. Baseline cognitive function d. Identify hazards of hospitalization Surgical treatment & anesthesia risks Chemo XRT
18 J Thorac Cardiovasc Surg 2012; 143:1314
19 MSKCC data 2014 Total procedures = Total thoracic cases = 2139 Lobectomy = 467 MIS lobe = 230 (35% pt>70) Esophagectomy = 95 MIS goose = 38 (18% pt>70) >80 tot VATS Robotic Open tot >80 tot VATS Robotic Open tot Age = ASA status Cardiac ds + stress test fresh cardiac stent Respiratory ds Abnormal PFTs (including DLCO) Other organ ds renal, DM, CVA Poly-pharmacology Post operative Cognitive Dysfunction
20 1. Preoperative a.asa status et al b. Frailty assessment c. Comprehensive Geriatric Assessment d. Baseline cognitive function 2. Logistics Positioning Bed placement 3. Monitoring lines Physiology CO 2 insufflation hemodynamics OLV 5. Emergency planning Bleeding Arrhythmias Anesthesiol Clin 2012; 30: 699 J Clin Oncol 2014; 32: 2647
21 Full semi Lateral decubitus positional neuropathy Direct (compression of PP) Indirect (robotic arms) Reverse Trendelenburg Sliding off the bed
22 Away from the anesthesia equipment Extension for line + circuit Access to the pt may be difficult Easier for all the lines to be in place prior to this stage Isolation device of choice needs to be in final position Once the robot is docked, the patient position cannot be changed
23 supine lateral prone Part 2: R thoracoscopy = hypotension 1. CO 2 insufflation of the chest Part 1: Laparoscopy = hypotension 1. Reverse T-berg hypotension 2. Pneumoperitoneum hypotension 3. L PNX hypotension Trying to minimize fluid Use of pressors
24 Positioning Eur J Anaesth 2010; 27: 473 Eur J Anaesthesiol 2010; 27: 473 Sloppy left lateral decubitus L UE extended back Brachial plexus injury from stretching From the robotic arms Burns Need for OLV Difficult access to the DLT Intraoperative events: Arrhythmias + hypotension Nerve injury RLN, vagus, phrenic Vascular injury Innominate, brachiohephalic, azygous,subclavian, SVC Possible right sided PNX
25 1. Preoperative a.asa status et al b. Frailty assessment c. Comprehensive Geriatric Assessment d. Baseline cognitive function 2. Logistics Positioning Bed placement 3. Monitoring lines 4. Physiology CO 2 insufflation hemodynamics OLV 5. Emergency planning Bleeding Arrhythmias Anesthesiol Clin 2012; 30: 699 J Clin Oncol 2014; 32: 2647
26 Monitoring Standard ASA Yes Invasive monitoring Yes/No A Line Central line PA catheters TEE Epidural analgesia Yes/No PRO : ASA status PFTs CONS : small incisions quick discharge Patient Surgical Role of adjuvants
27 Analgesia options 1. Iv route 2. Regional 1. Epidural 2. Paravertebral catheters 3. Intercostal blocks (Exparel ) 3. Adjuvants 1. Ketamine 2. Dexmedetomidine 3. NSAIDs / Acetaminophen 4. Preop analgesia (ERAS) 1. COX 2 inhibitors 2. Gabapentin PRO REGIONAL Patient factors Old age Comorbidities Any reason to avoid CO 2 and O 2 Surgical factors Major lung resection Esophagectomy Thymectomy Thorac surg clin 2008: 18; 249 Ann Thorac Surg 2008; 85: S719 Regioanl Anaetsh Pain Med 2011; 36: 63
28 1. Preoperative a.asa status et al b. Frailty assessment c. Comprehensive Geriatric Assessment d. Baseline cognitive function 2. Logistics Positioning Bed placement 3. Monitoring lines 4. Physiology CO 2 insufflation hemodynamics OLV 5. Emergency planning Bleeding Arrhythmias Anesthesiol Clin 2012; 30: 699 J Clin Oncol 2014; 32: 2647
29 PNX Physiology Cardiac effects CO 2 CO 2 Better+faster Lung collapse Intra Thoracic Pressure Venous return Stroke Volume Vagal activity ( pulm stretch receptors) Cardiac Output Respiratory effects PIP C L Anesthesiol Clin 2012; 30: 699 Anesthesiol Clin North Am 2001; 19: 141 Best Practice Res Anaethseiol 2002; 1: 53 Venous air embolism Cardiac tamponade Recommendations: sec after incision 2. Slow insufflation ( <1L/min) 3. Keep Pressures < mmhg BP HR SatO 2
30 The surgical requirement for thoracoscopy is a good view of the contents of the thorax. 1. Lung collapse 2. CO 2 insufflation (More popular with robot) DLT Blockers PROs Faster collapse + expansion Easier to suction Easy use of CPAP+ PEEP Choice of Side (R vs L) and several sizes (28-41F) Higher margin of safety Sequential lung isolation No need to change the ETT in case of post op PPV Great for diff aw cases (awake FOB ETT, tracheostomy) CONs Bulky (aw trauma) Always in the surgical side Slow lung collapse (passive absorption) Difficult to use CPAP/PEEP Dislodge often with hilar manipulation Problem for R lung isolation (take off RUL) Best Practice & Research Clin Anesthesiol 2002: 16: 53
31 DLT L ETT + blocker
32 1. Preoperative ASA status et al Frailty assessment Comprehensive Geriatric Assessment Baseline cognitive function 2. Logistics Positioning Bed placement 3. Monitoring lines 4. Physiology CO 2 insufflation hemodynamics OLV 5. Emergency planning Bleeding Arrhythmias Anesthesiol Clin 2012; 30: 699 J Clin Oncol 2014; 32: 2647
33 Bleeding Call for help CO 2 pressure tamponade bleeding apnea Mechanical compression of the source Rapid undocking Arrhythmias / cardiac arrest Rapid undocking Supine Defibrillation + CPR are difficult in the lat decubitus
34 90 YO MALE R RATS WEDGE/PLEURAL EFFUSION DRAINAGE
35 A line 2 big Iv Epidural DLT Positioned Surg time = 4 hrs Intraop events 1. Hepatic injury while placing the port 2. Venous tear during wedge 3. PM malfunction when turned supine
36 MIS is gaining more popularity Be prepared to face emergencies in an unfavorable ground Communication among all team members is key
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