Download PRE OP PREPARATION

PNEUMONECTOMY
It is a surgical procedure to remove a lung.
INDICATIONS:
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Bronchietasis
Resistant pneumonia
Broncho pleural fistula
Lung abscess or hemorraghe
TB
Malignancy
COPD
ARDS
Interstitial lung disease
PRE OP PREPARATION:
Assessment:
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Detailed history
Baseline spirometry
Respiratory mechanics
Lung parenchymal function
Cardiopulmonary reserve assessment
History:
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Age
Functional status
Dyspnoea , cough
Smoking
Drug use , radiation exposure
Chest pain , recent infections
Metastatic disease
Immobility / venous insufficiency
Physical examination:
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Appearance , anthropometry
Cyanosis , clubbing
Tracheal position
Chest wall abnormality
Oropharyngeal crowding and dentition
Respiration
Auscultation
Cardiac assessment
Abdomen
Investigation:
ECG,Echo
Chest Xray
CBC
Sputum culture , gram stain
LFT,PFT,RFT
Coagulation profile
Assess for co morbidities:
Pre op optimization:
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Stop smoking
Pre op exercise – weight management
Medication – antibiotics , mucolytics, antacids
Chest physio
Pre op education
Psychological preparation
Pulmonary care training – spirometry
Nursing care - pre op:
1. Nursing assessment
2. Informed consent
3. NPO – 8hrs, bowel and bladder preparation
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Premedications ,stop antiplatelets , anticoagulants as ordered
Skin preparation
Removal of jewellery , dentures , contact lens , spectacles
Site marking
Betadine baths
Blood products – arrange as ordered
TYPES:
simple
Removal of affected lung
extrapleural
Removal of affected lung , part of
diaphragm , the parietal pleura, and
pericardium on that side , lining are
replaced by gortex, usually done for
mesothilioma
OPERATIVE STEPS - EXTRA PLEURAL TYPE:
1. After induction of GA , a double lumen ET tube is placed and
positioned
2. An NG tube is inserted to facilitate palpitation of esophagus , during
posterior extra pleural dissection
3. Patients are monitored with arterial line , CVP, foley catheter
4. A thoracic epipleural catheter is placed preop for post op pain
management
5. Lateral decubitus position
6. A standard posterior lateral throacotomy
7. Serratus muscle is saved and retracted medially
8. Chest is entered over the unressected 6th rib
9. After division of intercostals muscle , an extrapleural plane is
developed superior and inferior to the throacotomy incision.Superior
component of dissection is carried out first. Medially the dissection is
carried out from apex down to azygos vein.
Medial pleura is dissected free from SVC and azygos vein.The
pericardium at the level of azygos vein is opened to determine
myocardial involvement, if no involvement pericardiotomy is
extended anteriorly and inferiorly to encompass the tumor.
1. The dissection of pericardium is completed at the pericardiopleural
attachment
2. The diaphragm is excised starting at anterior margin in the
circumferential fashion
3. Diaphragm is divided over IVC and dissection is carried posteriorly
leaving a line of tissue.
4. Lung is retracted medially and complete and complete mediastinal
lymphadenectomy done and thoracic duct is ligated to prevent post
op chylothorax
5. Pulmonary artery and veins are ligated and divided.After vessels are
divided , pericardium is opened posteriorly to hilum which completes
pericardial resection
6. Main stem bronchus is dissected free from peribronchial tissue and
stapled.En bloc specimen – lungs, parietal pleura , pericardium and
diaphragm is sent for HPE
7. After hemostasis is obtained , a tissue flap to cover bronchial
stump.Azygos vein ligated and divided at SVC.
8. Pericardium is reconstructed with a patch to prevent cardiac
herniations(bovine patch).
9. Diaphragmatic defect is closed with PTFE patch
CONVENTIONAL PNEUMONECTOMY:
 GA is given, posteriolateral throacotomy incision.
 Extends from the point below the shoulder blade around the side of
body along the curvature of the ribs at the front of the chest.
 Surgeon removes part of 5th rib in order to have a clearer view , then
deflates collapsed lung, ties off the major blood vessel, clamps the
main bronchus , cuts through the bronchus , removes the lung ,
staples the end of the bronchus that has been cut.
 Chest drains are inserted and chest is closed
COMPLICATIONS:
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Bleeding
Mediastinal shift
Pulmonary edema
Bronchopleural stump rupture
POST OP NURSING CARE:
Vital parameter setting
Contionus cardiac monitoring
Respiratory status and neuro status
NPM till extubation
Fluid restriction, I/O chart , U/O ,drains
Chesrt xray , CBC,RFT
Adequate analgesia
ABG
Antibiotics as per policy
Dressing
Chest physio
Hygiene