What should be included in a comprehensive checklist for thoracoscopy?

Comprehensive Checklist for Thoracoscopy

A thoracoscopy checklist must address pre-procedure preparation, intra-procedural monitoring, post-procedure care, and equipment decontamination to minimize morbidity and mortality. While the provided evidence primarily addresses bronchoscopy, the principles of airway procedures and general anesthesia preparation apply directly to thoracoscopy, which requires general anesthesia and carries risks of pneumothorax, bleeding, and respiratory complications 1, 2, 3.

Pre-Procedure Assessment and Preparation

Patient Evaluation

• Respiratory function testing: Patients with suspected COPD should undergo spirometry; if FEV1 <40% predicted and/or SaO2 <93%, arterial blood gas measurement is mandatory 4, 1
• Cardiac risk stratification: Avoid thoracoscopy within 6 weeks of myocardial infarction when possible 4
• Asthma optimization: Premedicate asthmatic patients with bronchodilators 4, 1

Laboratory Testing

• Coagulation studies: Check platelet count, prothrombin time, and partial thromboplastin time before any biopsy procedure 4, 1
• Routine testing: Only required for patients with known bleeding risk factors 4, 1

Anticoagulation Management

• Oral anticoagulants: Stop at least 3 days before thoracoscopy or reverse with low-dose vitamin K 4, 1
• Continued anticoagulation: If absolutely necessary, reduce INR to <2.5 and bridge with heparin 4, 1

Infection Prophylaxis

• Prophylactic antibiotics: Administer to patients who are asplenic, have heart valve prostheses, or have previous endocarditis history 4, 1

Fasting and IV Access

• NPO status: No solid food for 4 hours; clear fluids permitted up to 2 hours before procedure 4
• Intravenous access: Establish before procedure commences and maintain until end of recovery period 4, 1

Anesthesia Considerations

• General anesthesia: Required for thoracoscopy, with or without double-lumen intubation 2, 5
• Sedation caution: Avoid sedation if pre-procedure arterial CO2 is elevated; use oxygen supplementation with extreme caution in these patients 4
• Atropine: Not routinely required 4

Equipment and Staffing Requirements

Essential Equipment

• Thoracoscopy instruments: Rigid telescopes, forceps, scissors, staplers, and video recording equipment 2, 5
• Resuscitation equipment: Must be readily available 4

Personnel

• Minimum staffing: At least two endoscopy assistants, with at least one qualified nurse 4

Intra-Procedure Monitoring

Physiologic Monitoring

• Pulse oximetry: Mandatory continuous monitoring 4, 1
• Oxygen supplementation: Maintain oxygen saturation ≥90% to reduce arrhythmia risk 4, 1
• ECG monitoring: Consider for patients with severe cardiac disease or hypoxia despite oxygen supplementation 4, 1

Anesthetic Management

• Local anesthetic dosing: Limit lignocaine to 8.2 mg/kg (approximately 29 ml of 2% solution for 70 kg patient); exercise extra caution in elderly or those with hepatic/cardiac impairment 4
• Sedative administration: Use incremental doses to achieve adequate sedation and amnesia 4

Procedural Considerations

• Artificial pneumothorax: Induced to facilitate visualization 2, 5
• Chest tube placement: Always insert at procedure end, even briefly until lung re-expands 2, 5

Post-Procedure Care

Immediate Recovery

• Oxygen supplementation: May be required, particularly for patients with impaired lung function or who received sedation 4, 1
• Chest radiograph: Obtain at least 1 hour post-procedure to exclude pneumothorax 4

Patient Instructions

• Pneumothorax warning: Provide verbal and written advice about delayed pneumothorax development 4
• Post-sedation restrictions: Advise patients not to drive, sign legal documents, or operate machinery for 24 hours 4, 1
• Discharge planning: Day-case patients should be accompanied home; high-risk patients (elderly, post-biopsy) should have overnight supervision 4, 1

Equipment Decontamination

Cleaning Protocol

• Timing: Decontaminate at beginning and end of list, and between patients 4
• Initial cleaning: Thorough cleaning with detergent is the most critical step 4
• Dedicated facility: Perform cleaning in dedicated room by trained staff 4

Disinfection Standards

• Standard immersion: 20 minutes in 2% glutaraldehyde for routine cases 4
• Extended immersion: 60 minutes for atypical mycobacterial infections or HIV-positive patients with respiratory symptoms 4
• Tuberculosis cases: Schedule at end of list 4

Water Quality and Rinsing

• Sterile water: Use autoclaved or filtered water (0.2 μm filters) for rinsing 4
• Water pathway maintenance: Regular cleaning and disinfection of tanks, filters, and pipework 4
• Resistant organisms: Use chlorine-releasing agent or peracetic acid for Mycobacterium chelonae 4
• Final step: If water quality uncertain, wipe external surfaces and flush lumen with 70% alcohol 4

Documentation

• Equipment tracking: Record which thoracoscope and reusable equipment used on each patient, plus decontamination procedure details 4

Critical Pitfalls to Avoid

• Inadequate coagulation assessment: Even short procedures requiring biopsy demand proper anticoagulation management 1
• Respiratory optimization failure: Uncontrolled asthma or unassessed severe COPD significantly increases complications 4, 1
• Conversion readiness: Maintain low threshold for conversion to thoracotomy (27% conversion rate in community practice) for poor visualization, bleeding, or extensive adhesions 3, 6
• Delayed pneumothorax recognition: Post-procedure chest radiograph is non-negotiable 4