One-lung ventilation during video-assisted thoracoscopic ligation of a thoracic duct in a three-year-old child

Abstract

A 3-year-old 15kg child with a history of episodic cyanosis and a diagnosis of tetralogy of Fallot presented to Children’s Hospital for a complete primary repair. The patient underwent ventricular septal defect closure, transannular right ventricular outflow tract patch plasty, and partial closure of the patent foramen ovale. The residual atria1 septal defect was created to serve as a “pop off’ for the dysfunctional right ventricle in the early postoperative period. Postoperatively the child had no evidence of residual right ventricular outflow tract obstruction or ventricular septal defect; however, the patient developed a right chylothorax that did not respond to nonoperative management. She was scheduled for video-assisted ligation of the thoracic duct. Preoperative evaluation included a chest radiograph that was remarkable for a right aortic arch, normal heart size, normal pulmonary vascularity, and a chest tube in the right pleural cavity. Echocardiogram demonstrated good left ventricular function, a widely patent right ventricular outflow tract with mild pulmonic insufficiency, a small posterior pericardial effusion, and a small right-to-left atria1 shunt. A residual right-to-left shunt remained in this patient due to right ventricular dysfunction from the ventriculotomy. On the morning of surgery, the patient was given oral lipids to enhance visualization of the thoracic duct. The surgeon requested a left endobronchial intubation to maximize exposure of the aortic hiatus. The patient was taken to the operating room without premedication. Prior to induction of anesthesia the patient was monitored with a five-lead electrocardiogram, noninvasive arterial blood pressure, and pulse oximetry that demonstrated a baseline SpOa of 95%. A functioning peripheral intravenous catheter was in place. Following preoxygenation a rapid-sequence induction with cricoid pressure was performed. The trachea was intubated easily with a 5.5 mmID uncuffed endotracheal tube. Position of the endotracheat tube was confirmed by the presence of bilateral breath sounds and end-tidal CO2 waveform on capnography. A leak was present at 18 cmHs0. The patient tolerated induction and intubation without hemodynamic change. An orogastric tube was placed to evacuate the stomach. A 5.5 mmID endotracheal tube was then placed through the right nostril and exchanged for the prior endotracheal tube under direct vision using Magi11 forceps. Position of the endotracheal tube was confirmed as before, and a 3.5 mmOD pediatric fiberoptic bronchoscope was used to position the endotracheal tube into the left mainstem bronchus, taking care not to obstruct the orifice of the left upper lobe bronchus. Breath sounds confirmed the absence of air exchange in the right chest. A 24-gauge arterial catheter was placed in the right radial artery. The patient was positioned in the left lateral decubitus position and prepped for surgery; SpOa remained at 95%. Anesthesia was maintained with oxygen, fentanyl, pancuronium, and midazolam. Surgical exposure was excellent, with total collapse of the right lung, facilitating identification of the thoracic duct at the level of the diaphragm, which was interrupted with vascular clips (Fig 1). Three brief episodes of desaturation (lowest SpOz 88%) were associated with manipulation of mediastinal structures. Desaturations were treated with volume expansion (5% albumin intravenously, 5 mL/kg), a deeper level of anesthesia, and the application of positive end-expiratory pressure to the dependent lung. Desaturations resolved within 2 to 3 minutes to the baseline of 95% with the maneuvers described. Following the completion of surgery the patient was positioned supine and the endotracheal tube was withdrawn into the trachea. The patient was taken to the cardiac intensive care unit intubated, sedated, and in stable condition. Chest radiograph postoperatively showed good lung expansion bilaterally and good endotracheal tube position. The patient’s trachea was extubated within 4 hours. Postoperatively the patient received minimal doses of systemic narcotics as needed for pain. DISCUSSION