Bahirathan Krishnadasan, MD
Double Lumen Tubes
Dr. K is NOT particular about having a DLT on the opposite side of the lung mass even for pneumonectomy (Can always use a Left Sided DLT). For difficult intubations, a bronchial blocker works as well. He does not routinely ask for the lung to be deflated and reinflated during the case. In addition, the CO2 insufflation during robotic VATS helps with lung collapse and does not require a lot of suctioning during the case.
Lines, Blood Availability
Generally one IV is fine for non-anatomic resection- wedge, pleurodesis, decortication. If there is a plan for a segment or a lobe, please have two peripheral IVs.
Always discuss with him before transfusing blood product.
Place a pre-induction a-line in cases with large mediastinal masses or any other conditions which could impair cardiac filling on induction. Unless there is a large mediastinal mass or possibility collapse upon induction, please place all a-lines after patient is asleep (Dr. K prefers the patient not experience the pain of a-line insertion, when possible)
Type and screen all anatomic lung resections, but not necessarily for pleural work- decorts, pleural bx, chylothorax
Is unfamiliar with the diltiazem for lobes. Would prefer patients use their beta blocker if they are on one.
Does not usually require a type and screen for mediastinoscopies.
For pneumonectomies- give 150mg of solumedrol about a 1 min before ligating the relevant pulmonary artery
Does not anticipate doing tracheal resections
Esophagectomies are done completely robot assist- type and screen- ok for more volume, try to avoid pressors but not critical, about a 4-5 hour operation, DLT, NGT foley. a-line for all these cases.
Does a lot of paraesophageal work: single lumen ETT, no a-line, two IV’s, EGD scope will be left in the esophagus and will be in your way, no bougies at all, usually about 2 hours console time.
Foley Catheter/Bladder Scan
Per Dr. K: "I reviewed the POUR study that led to the institution of this protocol at St John's. My sense is that this workflow is more relevant to joint and spine surgery- use of regional blocks, large volume shifts and longer operations. In general I prefer not to have a foley for cases shorter than 2 hours, and I am not enthusiastic about bladder scans and reflexive straight caths. There are some elderly men with prostatic pathology that should get foleys for the case regardless of length. I am happy to discuss on case by case basis- but i don’t think everyone needs a bladder scan at the end of the case."
Please contact Dr. Krishnadasan prior to removing thoracic epidural catheters.