DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Pulmonary alveolar proteinosis.
POSTOPERATIVE DIAGNOSIS: Pulmonary alveolar proteinosis.
PROCEDURE PERFORMED: Left total lung lavage.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old woman who has had a few years of slowly progressive dyspnea. A chest CT revealed a diffuse heterogeneous infiltrative process with increased septal markings. Pulmonary function testing indicated an intact DLCO and volumes. She underwent a lung biopsy via mini right thoracotomy, which demonstrated pulmonary alveolar proteinosis. She was referred to Dr. John Doe for ongoing evaluation and management. After his evaluation, he felt that lung lavage would be appropriate. He met with the patient who concurred. She was therefore booked for left lavage today and right lavage 48 hours from that.
DESCRIPTION OF PROCEDURE: After the induction of general anesthesia, a double lumen endotracheal tube was inserted. She had some difficulty with prior double lumen placement, but this seemed to progress without undue difficulty. It was mildly tight at the cords. We then positioned the tube in the left main stem bronchus under bronchoscopic visualization without difficulty. Heparin had been given subcutaneously, and boots were placed for DVT prophylaxis. A percussion vest was placed on the patient. She was then switched from the anesthesia ventilator to the ICU ventilator on pressure point ventilation maintaining 5 PEEP. Lung isolation was performed, breathing only to the right lung, with minimal desaturation over five minutes. We therefore felt it was safe to proceed with the procedure.
After pre-oxygenation of both lungs, lung isolation was then achieved and lavage of the left lung using warm saline proceeded. One liter would be instilled via the bronchial lumen of the double lumen tube and then drained by gravity. The first bag was quite cloudy. Specimens were sent for microbiologic studies. The remainder of the specimens obtained during the procedure was sent to Dr. John Doe’s lab according to the patient’s consent. A total of 18 L of warm saline was instilled to lavage the left lung.
At the completion of the procedure, the effluent was reasonably clear. There were no significant desaturations during the operation. Her lowest oxygen saturation was 89% during drainage of the final few liters. After completing the lavage, the patient was returned to two-lung ventilation. We performed bronchoscopy briefly through the bronchial lumen to suction any remaining fluid from the left lung. The patient was then extubated and brought to the postanesthesia care unit hemodynamically stable and breathing spontaneously. There were no intraoperative complications.
