C.6. Intraoperatively, the surgeon must dissect the tumor in the anterior mediastinum and needs to have a quiet surgical field. How would you accomplish this?
Answer:
Double-lumen tubes are not used in the neonatal age group because of the exceedingly small lumen and the technical difficulties of securing both lungs. Instead, a single-lumen endotracheal tube can be advanced into the right or left mainstem bronchus or an extraluminal bronchial blocker placed to allow for one-lung ventilation. This can be fraught with consequences in this infant with an IAA, but it can still be attempted. Keep in mind that hypoxic pulmonary vasoconstriction might not occur readily in the neonate and excessive shunting can occur. In addition, having an infant on one-lung ventilation can lead to excessive hypercarbia or hypoxemia. During one-lung ventilation in infants, V̇/Q̇ mismatch occurs due to compression of the dependent lung as a result of a less rigid cartilaginous rib cage and abdominal pressure, causing reduced compliance and ventilation. In addition, there is a decrease in shunting of blood away from the nondependent lung to the dependent lung, which also worsens V̇/Q̇ mismatch.
References
- Lazar A, Chatterjee D, Templeton TW. Error traps in pediatric one-lung ventilation. Paediatr Anaesth. 2022;32:346-353.
- Templeton TW, Piccioni F, Chatterjee D. An update on one-lung ventilation in children. Anesth Analg. 2021;132:1389-1399.