Principles and Practice of Anesthesia for Thoracic Surgery (eBook)

Peter Slinger, MD, FRCPCProfessor of Anesthesiology, Faculty of Medicine, University of TorontoStaff Anesthesiologist, Toronto General HospitalToronto, OntarioCanada

Preface 6
Contents 8
Contributors 12
Part I: Introduction 18
1: History of Thoracic Anesthesiology 19
Introduction 19
Ages of Thoracic Surgery 20
Surgery for Infective Lung Disease 20
Surgery for Lung Cancer 21
Surgery for Respiratory Failure 22
Lung Separators 22
The Blocker Story 22
The Endobronchial Tube Story 22
The Double-Lumen Tube Story 23
Origins of Thoracic Endoscopy 23
Tracheobronchial Stenosis 25
Esophageal Surgery 25
Pain Relief 25
Conclusion 25
Further Reading 26
Part II: Preoperative Evaluation 27
2: Preanesthetic Assessment for Thoracic Surgery 28
Introduction 28
Assessment of Respiratory Function 29
Lung Mechanical Function 30
Pulmonary Parenchymal Function 32
Cardiopulmonary Interaction 33
Regional Lung Function 35
Split-Lung Function Studies 36
Combination of Tests 36
Concomitant Medical Conditions 37
Cardiac Disease 37
Ischemia 38
Arrhythmias 39
Age 40
Renal Dysfunction 41
Chronic Obstructive Pulmonary Disease 41
Carbon Dioxide Retention 41
Preoperative Therapy of COPD 41
Physiotherapy 42
Restrictive Lung Diseases 42
Pulmonary Hypertension 43
Smoking 43
Type of Surgical Procedure 43
Combined Strategies for Preoperative Assessment 43
Perioperative Considerations in Thoracic Malignancies 44
Non-Small Cell Lung Cancer (NSCLC) 46
Adenocarcinoma 46
Squamous Cell Carcinoma 48
Large Cell Undifferentiated Carcinoma 48
Small-Cell Lung Cancer 49
Carcinoid Tumors 49
Pleural Tumors 49
Preoperative Assessment of the Patient with Lung Cancer 50
Postoperative Analgesia 50
Premedication 51
Summary of The Initial Preoperative Assessment 51
Final Preoperative Assessment. 51
Difficult Endobronchial Intubation 52
Prediction of Desaturation During One-Lung Ventilation 52
Assessment for Repeat Thoracic Surgery 53
Clinical Case Discussion 53
Questions 53
References 54
3: Thoracic Imaging 57
Introduction 57
Normal Tracheobronchial Anatomy 57
Chest Radiographs 58
Chest Radiographs and Pulmonary Disease 58
Lung Mass and Chest X-Rays 59
Mediastinal Mass and Chest X-Rays 59
Bullae 61
Pneumothorax 62
Pleural Effusion 64
Chest Tube Placement 64
Previous Lobectomy 65
Pneumonectomy 65
Double-Lumen Endotracheal Tubes 67
Postoperative Acute Lung Injury 68
Computed Tomography Scan and Pulmonary Disease 69
Computed Tomography Scan and Lung Mass, Mediastinal Mass, Pleural Effusion, and Pericardial Effusion 69
Multidetector Computer Tomography Scan of the Chest 71
Magnetic Resonance Imaging and Pulmonary Disease 71
Summary 74
References 74
Part III: Thoracic Anatomy, Physiology, and Pharmacology 76
4: Essential Anatomy and Physiology of the Respiratory System and the Pulmonary Circulation 77
Introduction 77
Functional Anatomy 77
Upper Airway Anatomy 77
Oropharynx and Nasopharynx 77
Larynx 78
Pharyngeal Innervation 79
Upper Airway Function 79
Homeostatic Mechanisms 79
The Cough Reflex 80
Clinical Issues 80
Airway Obstruction 80
Nebulized Medications 80
Tracheobronchial and Respiratory Anatomy 81
Tracheal and Bronchial Structure 81
Tracheobronchial Circulation and Lymphatic System 81
Respiratory Airways and Alveolar Histology 82
Innervation 83
Neural Control of Respiration 83
Respiratory Centers 83
Chemoreception and Respiratory Control 84
Neural Control of the Airways 85
Respiratory Muscles 86
Inspiration 86
Expiration 87
The Respiratory “System” 87
The Pleural Pressure 87
Lung Volumes 87
Dynamic Mechanical Aspects of the Respiratory System 89
The Pressure-Volume Relationship 89
Lung Compliance, Lung Volume, and Dynamic Modifiers 90
Distribution of Ventilation 91
The Physiology of the Pulmonary Circulation 91
Anatomical Considerations 91
Pulmonary Hemodynamics 91
Cardiopulmonary Interactions 92
Factors Affecting Right Ventricular Performance 92
Pulmonary Vascular Resistance 92
Changes in Intrathoracic Pressure 93
Systemic Venous Return 93
Factors Affecting Left Ventricular Performance 93
LV Preload and Ventricular Interdependence 93
LV Afterload 93
Impact of Weaning from Mechanical Ventilation 94
Distribution of Lung Perfusion 94
Gravity and Pulmonary Blood Flow 94
Architecture and Pulmonary Blood Flow 94
Regional “Zones of Blood Flow” 95
Ventilation to Perfusion Matching (The VA/Q Ratio) 96
Hypoxic Pulmonary Vasoconstriction 97
Clinical Applications 98
Anesthesia and Atelectasis 98
Anesthesia and VA/Q Matching 99
Non-anesthetic Drugs and HPV 99
References 100
5: Physiology of the Lateral Decubitus Position, Open Chest, and One-Lung Ventilation 105
Introduction 105
Perfusion 105
Hypoxic Pulmonary Vasoconstriction (HPV) 108
Anesthetic Modifiers 109
Other Modifiers of HPV 110
Cardiac Output and Arterial Oxygenation 111
Ventilation 111
Ventilation–Perfusion Matching 112
V/Q Matching in the Lateral Position 112
Awake 112
Anesthetized 112
Paralyzed/Ventilated 113
Open Chest 113
Positions Other Than Lateral 114
Supine 114
Prone 114
Alternative Approaches 114
Capnothorax 114
Awake Non-intubated Lung Surgery 114
Summary 114
References 115
6: Clinical Management of One-Lung Ventilation 118
Introduction 118
Acute Lung Injury 118
Individual Ventilator Settings 120
Tidal Volume 120
PEEP 123
FiO2 125
Minute Ventilation/Permissive Hypercapnia 126
I:E Ratio and Respiratory Rate 127
Peak/Plateau Pressure 127
Driving Pressure 127
Ventilatory Mode 128
Recruitment/Re-expansion 129
OLV Duration 131
Combined Ventilator Strategy 131
Hypoxemia 132
Prediction 132
Treatment 133
Systemic Effects 134
Alternatives to One-Lung Ventilation 135
Conclusion 135
References 136
7: Nonrespiratory Functions of the Lung 141
Introduction 141
Uptake and Metabolism Within the Lung 141
Drugs 143
Opioids 143
Muscle Relaxants 144
Local Anesthetics 144
Hypnotics 145
Inhaled Medications 145
Pulmonary Handling of Endogenous Substances 146
Angiotensin-Converting Enzyme 146
Biogenic Amines 147
Arachidonic Acid Metabolites 148
Natriuretic Peptides 149
Other Endogenous Substances 149
The Lung as Vascular Reservoir and Filter 150
The Respiratory Epithelium 150
The Cells of the Respiratory Epithelium 150
Ciliated Columnar Cells 150
Goblet Cells 151
Submucosal Secretory Cells 151
Clara Cells 152
Mast Cells 152
Macrophages and Monocytes 152
Alveolar Epithelial Cells 153
Functions of the Respiratory Epithelium 153
Airway Surface Film 153
Humidification 153
Removal of Inhaled Particles 154
Response to Inhaled Organisms 154
Summary 154
References 155
8: Pharmacology of the Airways 160
Introduction 160
Influence of the Autonomic Nervous System on the Airway and Modulation of the Response 161
Inhaled Adrenergic Agonists 161
Mechanism of Action 161
Clinical Applications 161
Side Effects 162
Safety Concerns 162
Systemic Adrenergic Agonists 163
Mechanism of Action 163
Clinical Applications 163
Side Effects 163
Inhaled Cholinergic Antagonists 163
Mechanism of Action 163
Clinical Applications 163
Side Effects 164
Systemic Cholinergic Antagonists 164
Influence of Inflammation on the Airway and Modulation of the Response 164
Inhaled Corticosteroids 165
Mechanism of Action 165
Clinical Applications 165
Side Effects and Safety Concerns 165
Systemic Corticosteroids 166
Leukotriene Modifiers 166
Mechanism of Action 166
Clinical Applications 166
Side Effects 166
Mast Cell Stabilizers 166
Mechanism of Action 167
Clinical Applications 167
Side Effects 167
Methylxanthines 167
Mechanism of Action 168
Clinical Applications 168
Side Effects 168
Phosphodiesterase 4 Inhibitors 168
Mechanism of Action 168
Clinical Applications 168
Side Effects 168
Influence of Anesthetics on the Airway 168
Volatile Anesthetics 168
Mechanism of Action 168
Clinical Applications 169
Side Effects 169
Intravenous Anesthetics 169
Mechanism of Action 169
Clinical Applications 169
Side Effects 169
Local Anesthetics 169
Influence of Adjunctive Agents on the Airway 169
Heliox 169
Antihistamines 170
Magnesium Sulfate 170
Summary 170
Clinical Case 170
Questions 170
Answers 170
References 171
9: Pharmacology of the Pulmonary Circulation 174
Introduction 174
Anesthetic Drugs 175
Introduction 175
Ketamine 175
Propofol 175
Etomidate 176
Dexemedetomidine 176
Opioids 176
Neuromuscular Blockers 177
Vasopressors and Inotropes 177
Magnesium 177
Volatile Anesthetics 177
Perioperative Analgesia 178
Conclusion 178
Support of the Right Ventricle 178
Pulmonary Vasodilators (PO/IV/Inhaled) 179
Nitric Oxide/Cyclic-GMP Pathway 179
Nitric Oxide 179
cGMP/cAMP Pathway 180
Endothelin Antagonists 180
Prostaglandins 181
Pulmonary Vasodilators in Thoracic Surgery 182
Clinical Case Study 182
References 183
10: Perioperative Lung Injury 189
Introduction 189
Acute Lung Injury in Patients with Healthy Lungs 189
Pulmonary Resection 191
The Role of the Glycocalyx in Lung Injury 195
Transfusion-Related Acute Lung Injury (TRALI) 196
Prevention and Therapy for Acute Lung Injury 196
Outcomes 197
Avoiding One-Lung Ventilation 198
Clinical Case Discussion 199
References 200
Part IV: Diagnostic and Therapeutic Procedures of the Trachea and Airways 202
11: Bronchoscopic Procedures 203
Introduction 203
Anesthetic Considerations 204
Central Airway Obstruction 205
Airway Stents 207
Other Modalities 209
Laser 209
Endobronchial Electrosurgery 209
Argon Plasma Cautery 210
Balloon Bronchoplasty 210
Delayed Resection Techniques 210
Foreign Body Extraction and Emerging Techniques 211
Endobronchial Valves 212
Bronchial Thermoplasty 212
Diagnostic Bronchoscopy 213
Noninvasive Techniques 214
Invasive Techniques 216
Awake Fiber-Optic Intubation 216
Clinical Case Discussion 218
Questions 218
Authors’ Management 218
References 220
12: Intravenous Anesthesia for Thoracic Procedures 224
Introduction 224
Rationale for Total Intravenous Anesthesia 224
TIVA in Special Thoracic Surgical Conditions 226
Scenarios that Benefit from TIVA 227
Intravenous Anesthetic Agents 227
Propofol 227
Dexmedetomidine 228
Remifentanil 228
Ketamine 228
Lidocaine 229
Infusion Systems 229
Anesthetic Depth Monitors 231
Methodology 231
Premedication and Thoracic Epidural Placement 231
Induction 231
Maintenance 232
Emergence 232
Clinical Case Discussion: TIVA for Thoracic Procedures (Fig. 12.2) 232
Questions 232
References 233
13: Tracheal Resection and Reconstruction 236
Historical Note 236
Etiology of Tracheal Lesions 237
Planning Tracheal Surgery 238
Tracheal Anatomy and Surgical Management 239
The Subglottis and Upper Trachea 239
Mid-Trachea 239
Carinal Resection 240
Patient Characteristics 240
Preoperative Assessment 241
Patient Monitoring 242
Ventilation Strategies 242
Distal Tracheal Intubation, Intermittent Positive Pressure Ventilation (IPPV) 242
Low-Frequency Jet Ventilation (LFJV) 245
High-Frequency Jet Ventilation 245
High-Frequency Positive Pressure Ventilation (HFPPV) 246
Extraordinary Ventilation Strategies 247
Cardiopulmonary Bypass (CPB) and Extracorporeal Oxygenation (ECMO) 247
Spontaneous Ventilation 247
Hyperbaric Oxygenation 247
Anesthesia Induction and Maintenance 247
Reconstruction of the Airway 248
Emergence After Airway Surgery 249
Immediate Postoperative Complications Specific to Airway Surgery 249
Tracheal Procedures with Specific Considerations 250
Airway Trauma 250
Tracheoesophageal Fistula 251
Pediatrics 251
Management of the Patient with a T-Tube 251
References 252
Part V: Diagnostic and Therapeutic Procedures of the Mediastinum 254
14: Anesthesia for Patients with Mediastinal Masses 255
Introduction 255
Anatomy and Pathophysiology 256
Preanesthetic Assessment 257
Clinical Signs and Symptoms 257
Investigations 257
Anesthetic Risks 258
Risk Stratification (Fig. 14.2) 258
Preoperative Treatment 258
Anesthetic Management 258
Sedation 258
Induction and Intubation 259
Maintenance of Anesthesia and Intraoperative Monitoring 260
Emergence and Postoperative Care 260
Complications 260
Airway Compression 260
Cardiovascular Compression 261
Extracorporeal Circulation (ECC) 261
Anesthesia for Mediastinoscopy 261
Summary 262
Clinical Case Discussion 262
Question 1 262
Answer 262
Question 2 263
Answer 263
Question 3 263
Answer 263
References 266
15: Thymic Surgery and Paraendocrine Syndromes 268
Introduction 269
Thymic Surgery 269
Myasthenia Gravis 269
Pathophysiology 270
Presentation 270
Diagnosis 270
Classification 270
Medical Management 270
Surgical Management 272
Myasthenic vs Cholinergic Crisis 272
Anesthetic Considerations 273
Paraendocrine and Paraneoplastic Syndromes 275
Carcinoid Tumors 275
Lambert-Eaton Myasthenic Syndrome (LEMS) 277
Case Discussion 278
References 279
Part VI: Anesthetic Management for Intra-Thoracic Surgery 283
16: Lung Isolation 284
Introduction 284
Double-Lumen Endotracheal Tubes 284
Size Selection 285
Methods of Insertion 286
Right-Sided Double-Lumen Endotracheal Tubes 289
Safety 289
Placement Technique 289
Left-Sided Double-Lumen Endotracheal Tubes 290
Placement Technique 290
VivaSight Double-Lumen Tube 291
Auscultation and Fiberoptic Bronchoscopy when Placing Double-Lumen Endotracheal Tubes 292
New Technology with Double-Lumen Endotracheal Tubes 294
Complications Associated with Double-Lumen Endotracheal Tube Placement 295
Bronchial Blockers 295
Torque Control Blocker Univent 295
Independent Bronchial Blockers During Lung Isolation 296
Arndt® Wire-Guided Endobronchial Blocker 296
Methods of Placement 297
Cohen® Flexitip Endobronchial Blocker 298
Methods of Placement 298
Fuji Uniblocker® 299
Methods of Placement 300
The EZ-Blocker 301
Methods of Placement 302
Complications with the Use of Bronchial Blockers 302
Lung Isolation in Patients with Tracheostomy in Place 303
Lung Collapse During Lung Isolation 303
Future Trends in Lung Isolation 304
Summary 305
Clinical Case Discussion 305
Questions 305
Focus on the Patient’s Gender, Size, Height, and Preoperative Chest Radiograph 307
Choice of Lung Isolation Device 307
Expected Intraoperative Problems During Lung Isolation 307
References 307
17: Fiberoptic Bronchoscopy for Positioning Double-Lumen Tubes and Bronchial Blockers 311
Introduction 311
Flexible Fiberoptic Bronchoscopy and Double–Lumen Endotracheal Tube Placement 312
Optimal Position of the Left-Sided Double-Lumen Tube with Flexible Bronchoscopy 312
Optimal Position of a Right-Sided Double-Lumen Tube with Flexible Bronchoscopy 314
Flexible Fiberoptic Bronchoscopy and Bronchial Blockers 314
Placement of the Arndt® Blocker with Fiberoptic Bronchoscopy 314
Placement of the Cohen® Blocker with Fiberoptic Bronchoscopy 315
Placement of the Fuji Uniblocker® with the Fiberoptic Bronchoscopy 316
Placement of the EZ-Blocker with Fiberoptic Bronchoscopy 316
Selective Lobar Blockade with Bronchial Blocker and Flexible Fiberoptic Bronchoscopy 317
Other Uses of Flexible Fiberoptic Bronchoscopy During Double-Lumen Tubes or Bronchial Blockers 320
Summary 320
References 321
18: Lung Isolation in Patients with Difficult Airways 323
Introduction 323
Preoperative Evaluation of the Difficult Airway and Lung Isolation Techniques 323
Difficult Airway and Lung Isolation: Securing the Airway First 324
Use of a Flexible Bronchoscope During Awake Intubation 325
Special Consideration for Patients with High Aspiration Risk 326
Use of Laryngeal Mask Airway and a Bronchial Blocker During Difficult Airways 326
Use of a Double-Lumen Endotracheal Tube in Patients with Difficult Airways 326
Lung Isolation Techniques in Patients with Tracheostomies 330
Lower Airway Abnormalities and Lung Isolation 330
Lung Isolation in Patients with Cervical Spine Abnormalities 333
Extubation or Mechanical Ventilation After Surgery 334
Summary 334
Clinical Case Discussion 334
Questions 334
Suggested Management 334
References 335
19: Intraoperative Patient Positioning and Neurological Injuries 337
Central Neurological Injuries 340
Clinical Case Discussion 341
References 342
20: Intraoperative Monitoring 343
Introduction 343
ECG 344
Pulse Oximetry 344
Capnography 345
Intraoperative Spirometry 346
Arterial Blood Pressure Monitoring 346
Central Venous Pressure 347
Pulmonary Artery Catheter Monitoring 348
Transesophageal Echocardiography 349
Minimally and Noninvasive Hemodynamic Monitoring Devices and Tissue Perfusion Monitoring 349
Esophageal Doppler Monitoring 350
Continuous Pulse Contour Analysis (PiCCO) 352
Lithium Dilution Cardiac Output 352
Arterial Pressure Cardiac Output Device (APCO, FloTrac/Vigileo) 353
BioReactance (Cheetah) 353
References 354
21: Fluid Management in Thoracic Surgery 356
Introduction 356
The Fluid Problem 356
Lung Injury After Thoracic Surgery 356
Incidence 356
Factors Contributing to Postoperative Lung Injury 357
Surgical Risk Factors 357
Patient-Related Risk Factors 357
Intraoperative Management 358
Perioperative Fluid Administration and Acute Lung Injury 358
Physiologic Basis of Fluid Overload 359
Role of the Glycocalyx 359
Hypervolemia and the Glycocalyx 361
Mechanical Ventilation and the Glycocalyx 361
Fluid Composition 362
Risks of Fluid Restriction in Thoracic Surgery 362
Methods of Targeting Fluid Management 363
Approach to Fluid Management in Thoracic Surgery 365
ERAS-Based Fluid Management 365
Managing Fluids in Lung Surgery 365
Managing Fluids in Esophagectomy 366
Conclusion 367
References 367
22: Intraoperative Ventilation Strategies for Thoracic Surgery 373
Introduction 373
Physiology of One-Lung Mechanical Ventilation (See Chap. 6 for a More Complete Discussion) 374
Modes of Mechanical Ventilation for OLV in the Operating Room 376
Pressure- Versus Volume-Controlled Ventilation 376
High Versus Low Tidal Volume 378
Positive End-Expiratory Pressure 379
Lung Opening Procedures 381
Conclusion 382
Clinical Case Discussion 382
References 383
23: Anesthesia for Open Pulmonary Resection: A Systems Approach 386
General Concepts 386
A Systems Approach 388
Patient Care Processes in Thoracic Anesthesia 388
Preoperative Care 391
Intraoperative Care 392
Postoperative Care 397
Lung Cancer 397
Intrathoracic Manifestations 397
Extrathoracic Metastatic Manifestations 397
Extrathoracic Nonmetastatic Manifestations 397
Treatment Options 398
Anesthesia and Long-Term Cancer Outcomes 399
Surgical Procedure 399
Pulmonary Resection 399
Lobectomy 400
Sleeve Lobectomy 401
Pneumonectomy 401
Sleeve Pneumonectomy 403
Limited Pulmonary Resections: Segmentectomy and Wedge Resection 403
Bronchopleural Fistula 403
Clinical Case Discussion 404
Questions 404
Discussion 404
References 405
24: Anesthesia for Video-Assisted Thoracoscopic Surgery (VATS) 410
Historical Considerations of Video-Assisted Thoracoscopy 410
Indications 411
Diagnostic Procedures 411
Therapeutic Procedures 412
Benefits 412
Surgical Technique 413
Anesthetic Management 413
Local/Regional Anesthesia 414
General Anesthesia 414
Management of OLV 417
Localization of Small Parenchymal Lesions 418
Uniportal VATS 418
Pain Management Techniques 418
Clinical Case Discussion 419
References 420
25: Anesthesia for Non-intubated Thoracic Surgery 422
Techniques of Non-intubated Thoracic Anesthesia 423
Conversion to General Anesthesia and Endotracheal Intubation 423
Clinical Case Discussion 423
References 424
26: Troubleshooting One-Lung Ventilation 425
Introduction 425
Hypoxia 425
Permissive Hypoxia 425
Management of Hypoxia 426
Ventilation of the Dependent Lung 426
Management of the Non-ventilated Lung 427
Regulation of Perfusion 428
Pharmacology 429
Lung Collapse 430
Case Discussion 430
References 431
27: Intraoperative Extracorporeal Life Support for Thoracic and Airway Surgery 433
Introduction 433
Brief History 434
Components of the ECMO Circuit 434
Oxygenator 434
Pump (When Applicable) 435
Reservoir, Circuit and Connectors 435
ECMO Configurations 436
Configurations of ECMO 436
Veno-venous ECMO 436
Veno-arterial ECMO 437
AV-ECMO (Pumpless) 437
PA-LA Novalung (Pumpless) 438
Applications in Thoracic Surgery 438
Lung Transplantation 438
Airway Surgery 439
Impossible One-Lung Ventilation 440
Mediastinal Masses 440
Advanced Surgical Resections 440
Thoracic Emergencies 441
Preoperative Planning of ECMO 441
Are the Proposed Vessels Big Enough? 441
Will the Patient Tolerate the Procedure? 442
Are the Cannulas Correctly Positioned? 442
What Are the Risks of Anticoagulation, and How Should It Be Managed? 442
Vascular Access 442
Ventilation Strategies for ECMO 443
Monitoring Patients on ECMO 443
Troubleshooting ECMO 443
Hypoxia 443
Flows Are Insufficient 443
Recirculation 443
Differential Hypoxia/Watershed Phenomenon 443
Hypotension 444
VA-ECMO Flows Are Insufficient 444
The Patient’s Afterload Is Too Low 444
Weaning ECMO 444
VA-ECMO 444
VV-ECMO 445
Complications of ECLS 445
Clinical Case Discussion 446
Summary 447
References 447
Part VII: Applications of Ultrasound in Thoracic Anesthesia 451
28: Pulmonary Ultrasound 452
Introduction 452
Ultrasound Physics 452
Transducers 453
Ultrasound Nomenclature 454
Clinical Environment 455
Image Acquisition 455
Machine Settings 456
Lung Sliding, Lung Pulse, and Lung Point 456
A-Lines, B-Lines, and Consolidation Patterns 457
Clinical Applications 459
Assessment of the Patient in Undifferentiated Respiratory Failure 459
Assessment of Pneumothorax 459
Assessment of Pulmonary Edema and Fluid Tolerance 460
Assessment for the Presence of Pneumonia and Atelectasis 460
Assessment of Acute Respiratory Distress Syndrome 460
Assessment of Pleural Effusions 461
Pleural Fluid Volume (Ml) = Maximal Subpulmonic Distance (Mm) * 20 461
Assessment of Respiratory Complications Post-brachial Plexus Blockade 462
Case Presentation 462
Case Resolution 462
References 463
29: Ultrasound for Vascular Access 465
Introduction 465
Why Use Ultrasound? 466
Which Ultrasound Probe Should I Use? 466
Before Placing the Probe: A Word About Aseptic Technique 466
Image Optimization 467
Distinguishing the Vein from the Artery 467
Limitations of Ultrasound Technique 467
Summary 468
Ultrasound for Internal Jugular Vein Cannulation 468
Anatomy 468
Short Axis Technique 469
Long Axis Technique 469
Wire Confirmation, Trouble Shooting, and Complications 470
Summary 470
Ultrasound for Subclavian Vein Cannulation 470
Anatomy 470
Infraclavicular Approach 471
Supraclavicular Approach 472
Wire Confirmation, Trouble Shooting, and Complications 472
Summary 472
Ultrasound for Femoral Vein Cannulation 473
Anatomy 473
Ultrasound Technique 473
Long Axis Technique 474
Wire Confirmation, Trouble Shooting, and Complications 474
Summary 474
Ultrasound for Radial Artery Cannulation 474
Anatomy 474
Ultrasound Technique 474
Summary 475
References 475
30: Intraoperative Transesophageal Echocardiography for Thoracic Surgery 477
Introduction 478
Indications for TEE in Thoracic Surgery 478
Safety and Complications of TEE Probe Insertion 478
Basic Hemodynamic Assessment 480
Assessment of Left Ventricular (LV) Function 480
Assessment of Right Ventricular (RV) Function 484
TEE Assessment of PFO 487
Specific Applications 489
Lung Transplant 489
Heart-Lung Transplant 493
Pulmonary Embolism 493
Lung and Mediastinal Masses 494
Clinical Case Discussion 495
References 496
Part VIII: Specific Patient Consideration 500
31: Anesthesia for Patients with End-Stage Lung Disease 501
Introduction 501
Preoperative Optimization 502
Smoking Cessation 502
Pulmonary Rehabilitation 503
Medical Optimization 504
Chest Physiotherapy 505
General Considerations 505
Preoperative Assessment 505
Nocturnal Hypoxemia 506
Pulmonary Hypertension and Right Ventricular Function 506
Intraoperative Monitoring 507
General Versus Regional Anesthesia 507
Ventilation and ESLD 509
Minimally Invasive Surgery 510
Optimizing Emergence 510
Postoperative Management 510
Chronic Obstructive Pulmonary Disease 511
Diagnosis and Staging of COPD 511
Etiology of COPD 511
Causes of Expiratory Flow Obstruction 512
Dynamic Hyperinflation 514
Respiratory Drive in COPD 515
Bullae 516
Ventilation Strategies in Patients with Obstructive Disease 516
Cystic Fibrosis 517
Pulmonary Manifestations of CF 517
Management of CF 518
Extrapulmonary Manifestations of CF 518
Pregnancy and CF 519
Interstitial Lung Diseases 519
Pulmonary Manifestations of ILDs 519
Medical Management of ILDs 520
Ventilation Strategy for Restrictive Lung Diseases 520
ILDs and Thoracic Surgery 520
Clinical Case Discussion 521
How Would You Optimize This Patient for Surgery? 521
What Investigations Would You Like Prior to Induction? 521
How Would You Provide an Anesthetic for This Case? 521
References 522
32: Thoracic Surgery in the Elderly 526
Introduction 526
Physiology of Aging 526
Cardiovascular 527
Pulmonary 527
Hepatorenal 528
Nervous System 528
Aging and the Thoracic Surgical Population 528
The Risk-Benefit Relationship of Surgical Intervention in the Elderly 529
Age-Related Perioperative Morbidity and Mortality 529
Risk and Oncological Outcome 529
The Emerging Role of Minimally Invasive Surgical (MIS) Techniques 531
Preoperative Evaluation and Postoperative Care 532
Preoperative Assessment 532
Postoperative Planning 532
Conclusion 532
Clinical Case Discussion 533
Questions 533
Discussion 533
References 534
33: Thoracic Anesthesia for Morbidly Obese Patients and Obese Patients with Obstructive Sleep Apnea 536
Introduction 536
Preoperative Considerations 537
Weight 537
Pulmonary Function 537
Obstructive Sleep Apnea 538
Obesity Hypoventilation Syndrome 539
Cardiovascular Function 539
Premedication 539
Intraoperative Management 539
Induction Dosing of Anesthetic Agents 539
Patient Position 540
Airway 540
Lung Separation 541
One-Lung Ventilation 542
Anesthetic Drugs/Maintenance of Anesthesia 543
Intravenous Fluid Management 543
Emergence and Extubation 543
Postoperative Pain Control 544
Complications 544
Surgical Issues 545
Conclusion 545
Clinical Case Discussion 545
Preoperative Management 546
Intraoperative Management 546
Postoperative Management 547
References 547
34: Pulmonary Resection in the Patient with Pulmonary Hypertension 551
Introduction 552
Perioperative Risk 552
Preoperative Assessment 553
History, Physical Exam, and Investigations 553
Treatment and Consultations 554
Intraoperative Management 555
Premedication 556
Intraoperative Monitoring 556
Anesthetic Management 557
Intravenous Agents 557
Volatile Anesthetics 558
Vasopressor Agents 558
Vasodilator Agents 558
Analgesia 559
Management of One-Lung Ventilation 560
Intraoperative Fluid Management 561
Use of Extracorporeal Support for Pulmonary Resection (See Also Chap. 27) 562
Postoperative Management 562
Conclusion 563
Clinical Case Discussion 564
References 566
Part IX: Complex Thoracic Surgical Procedures 571
35: Surgery of the Chest Wall and Diaphragm 572
Chest Wall Surgery 572
Tumors 572
Congenital Deformities 572
Thoracic Outlet Syndrome 573
Diaphragm Surgery 574
Hernia 574
Eventration 575
References 575
36: Extrapleural Pneumonectomy 576
Introduction 576
Malignant Pleural Mesothelioma and Pleural Dissemination of Malignancy 577
Intraoperative Intracavitary Heated Chemotherapy 577
Surgical Considerations 577
Technique of IOHC 578
Patient Selection 579
Preoperative Patient Preparation 579
Cardiopulmonary Risk Assessment 579
Radiologic Studies 579
Anesthetic Considerations 579
Specific Anesthetic Issues for EPP 579
Lines and Monitors 580
Choice of Anesthesia 580
Thoracic Epidural Analgesia 580
One-Lung Anesthesia 580
Lung Isolation Techniques 580
Optimizing Oxygenation During One-Lung Ventilation (OLV) 580
Hemodynamic Management 581
Hypertension 581
Hypotension 581
Induction 581
Dissection Phase 581
Repositioning and Emergence 581
Fluid Management 581
Postpneumonectomy Pulmonary Edema (PPE) 582
Cardiovascular Considerations 582
Dysrhythmias 582
Myocardial Ischemia 582
Perioperative Pain Management 583
Early Postoperative Considerations 583
Management of the Ipsilateral Thoracic Space 583
Other Issues Specific to EPP 583
Conclusion 583
Clinical Case Discussion 583
Questions 583
References 584
37: Pancoast Tumors and Combined Spinal Resections 586
Introduction 586
Anatomy of Pancoast Tumors 586
Initial Assessment 587
Multimodality Treatment 588
Surgical Approaches to Resection 590
Posterior Approach 590
Tumors Involving the Vertebral Bodies and Epidural Region 590
Anterior Approaches 592
Anesthetic Considerations 593
Postoperative Considerations 595
Clinical Case Discussion 595
Questions 595
Discussion 595
References 596
38: Anesthesia for Esophageal Surgery 597
Anatomy and Physiology of the Esophagus 598
Nonmalignant Disorders of the Esophagus and Surgical Therapies 599
Hiatal Hernia, Gastroesophageal Reflux Disease (GERD), and Esophageal Stricture 599
Esophageal Perforation and Rupture 601
Achalasia and Motility Disorders 602
Tracheoesophageal Fistula (TEF) 603
Esophageal Diverticula 603
Malignant Disease of the Esophagus and Esophagectomy 604
Esophageal Cancer 604
Esophagectomy 605
Esophageal Conduits 606
Anesthetic Management of Esophageal Surgery Patients 607
Preoperative Evaluation and Preparation 607
Intraoperative Monitoring 608
Pain Control 608
Induction and Airway Management 609
Intraoperative Management 611
Lung Isolation and One-Lung Ventilation 612
Fluid Management 612
Intraoperative Complications 614
Postoperative Management and Complications 615
Anesthetic Considerations for Specific Esophageal Procedures and Disorders 616
Esophagoscopy 616
Tracheoesophageal Fistula (TEF) 616
Transthoracic Nissen and Belsey Fundoplication, Collis Gastroplasty, and Paraesophageal Hernia Repair 617
Esophagectomy 618
Transhiatal Esophagectomy (THE) 618
Transthoracic Esophagectomy (Ivor Lewis TTE)
Minimally Invasive Esophagectomy (MIE) 620
Robotic Esophagectomy 620
Postoperative Care of the Esophagectomy Patient 620
Adverse Outcomes After Esophagectomy 621
Esophageal Anastomotic Leaks 621
Cardiovascular Complications 621
Pulmonary Complications 622
Improving Outcomes After Esophagectomy 622
Surgery for Esophageal Rupture and Perforation 624
Surgery for Achalasia 624
Surgery for Esophageal Diverticula 625
Zenker’s Diverticulum 625
Thoracic Diverticula 625
Esophageal Surgery Clinical Case Discussion 625
Questions 625
References 626
39: Anesthesia for Robotic Thoracic Surgery 638
Introduction 638
The da Vinci® Robot Surgical System 638
Anesthetic Implications in Robotic Thoracic Surgery 639
Robotic-Assisted Surgery and Anesthesia for Mediastinal Masses 640
Robotic-Assisted Pulmonary Lobectomy 641
Carbon Dioxide Insufflation During Robotic Surgery 642
Robotic-Assisted Esophageal Surgery and Anesthetic Implications 643
Summary 644
References 645
40: Anaesthesia for Combined Cardiac and Thoracic Procedures 647
Introduction 647
Structure of the Alveolar-Capillary Barrier 647
Lung Injury During Surgery with Use of Cardiopulmonary Bypass 650
Prevention of Lung Injury After Cardiac Procedures 652
Surgical Considerations 653
Anaesthetic Management for Combined Cardiac and Thoracic Procedures 653
Preoperative Assessment 654
Anaesthetic Management 654
Summary 656
Case Presentation 656
Questions 657
Questions 657
References 658
41: Open Thoracoabdominal Aortic Aneurysm Repair 660
Introduction 660
Anatomy and Physiology 661
Crawford Classification of TAAA Repair 661
Pathophysiology of Aortic Clamp 662
Pathophysiology of Spinal Cord Injury 662
Blood Supply of the Spinal Cord 662
A Physiological Approach to SCI 663
Surgical Technique 664
Preoperative Evaluation 665
Intraoperative Management 666
Monitoring 666
Five-Lead Electrocardiogram (ECG) and Defibrillation Pads 666
Invasive Blood Pressure 666
Pulmonary Artery Catheter (PAC) 666
Transesophageal Echocardiogram (TEE) 667
Spinal Cord Monitoring 667
Cerebral Monitoring 667
Temperature 667
Vascular Access 668
Other Tubes 668
Anesthetic Technique 668
Positioning 668
One-Lung Ventilation 668
Hemodynamic Management 669
Fluid Management with Massive Blood Loss 669
Spinal Cord Protection Strategies 670
Cerebrospinal Fluid Drainage (CSFD) 671
Supporting SCPP 671
Hypothermia 672
Drugs 672
Hyperbaric Oxygen 672
Technical Specifics of Cerebrospinal Fluid Drainage 672
Renal Protection Strategies 674
Postoperative Care 675
Summary 675
Clinical Case Discussion 675
References 675
Part X: Anesthetic Management of Uncommon Pulmonary Procedures 681
42: Thoracic Anesthesia in the Developing World 682
Introduction 682
Challenges Faced by Thoracic Anesthesiologist in the Developing World 682
Conduct of Thoracic Anesthesia in Developing World: Meeting the Challenge 683
Preoperative Care: Assessment and Optimization 684
Intraoperative Care 684
Selection of Lung Isolation Devices 685
Methods to Aid Insertion of Lung Isolation Devices 686
Methods to Monitor the Position of the Lung Isolation Device 686
Postoperative Care and Analgesia for Thoracic Patients 687
Anesthesia for Thoracic Surgeries in Patients with Infective Lung Diseases 688
Tuberculosis 688
Incidence and Prevalence 688
Pathophysiology 689
Surgery and TB 690
TB and Anesthesia Implications 691
Preventing Transmission of TB to Other Patients and Healthcare Workers (HCW) 691
Postoperative Care 692
Bronchiectasis 692
Pathophysiology and Causes 692
Anesthetic Considerations 694
Empyema 694
Bacteriology 695
Pathophysiology 695
Surgery for Empyema 696
Lung Abscess 696
Pneumatoceles 697
Hydatid Disease of the Lung or Pulmonary Echinococcosis 697
Cyst Composition 697
Surgical Options 697
Anesthesia Considerations 698
References 698
43: Bronchopleural Fistulae 700
Summary 700
Pathophysiology and Pathogenesis of Bronchopleural Fistulae 700
The Pathophysiological Consequences of Large Air Leaks 703
Bronchopleural Fistula, Intermittent Positive Pressure Ventilation, and Effective Fistula Size 703
Anesthesia and BPF 704
Interventional Pulmonology Management of Bronchopleural Fistula 708
Management of Bronchopleural Fistula in Ventilated Patients 709
References 710
44: Massive Hemoptysis 715
Introduction 715
Historical Considerations 716
Etiologies 716
Clinical Manifestation 717
Initial Management of MH 717
Life-Threatening Intervention 717
Diagnostic Tools and Therapeutic Approaches 719
Bronchoscopy 719
Timing 719
Type of Bronchoscopy 720
Rigid 720
Flexible 720
Endobronchial Therapy 720
Pharmacologic Adjuncts 720
Mechanical Therapy 720
Systemic Therapy 720
Bronchial Artery Embolization (BAE) 721
Surgery 721
Iatrogenic Pulmonary Artery Rupture (IPAR) 722
Intensive Care Unit Setting 722
Operating Room Setting 723
Radiological Setting 724
Pulmonary Artery False Aneurysm (PAFA) 724
Other Causes 724
Management Post Hemoptysis 724
Tracheostomy Hemorrhage 724
Conclusion 725
Clinical Case Discussion 725
Questions 726
References 726
45: Whole Lung Lavage 728
Introduction 728
Historical Consideration 728
Indications 728
Pulmonary Alveolar Proteinosis 728
Pathogenesis and Classification 729
Clinical Manifestations 729
Radiographic Findings 729
Physiological Testing 729
Laboratory Investigation 729
Therapy 730
Whole Lung Lavage 730
GM-CSF 730
Other Therapies 730
Whole-Lung Lavage Technique 730
Monitoring 730
General Anesthesia 731
Lung Separation 731
Lung Lavage 731
Bilateral WLL 732
Associated Bronchoalveolar Lavage (BAL) 732
Complications 733
Desaturation 733
Leakage 733
Ending 734
Post Whole-Lung Lavage Evolution 735
Pediatric Whole Lung Lavage 736
Conclusion 737
Clinical Case Discussion 737
References 737
Part XI: Anesthesia for Surgical Procedures for End-Stage Lung Diseases 739
46: Lung Volume Reduction 740
Introduction 740
History of Lung Volume Reduction Surgery (LVRS) 740
Clinical Features of Emphysema 741
Preoperative Medical Management of Emphysema Patients 741
Evaluation of Patients for LVRS and Selection Criteria 742
General Evaluation 742
Anatomic/Radiologic Evaluation 742
Physiologic Evaluation 743
Approach: Surgical vs. Bronchoscopic 744
Video-Assisted Thoracoscopic Surgery (VATS) 744
Bronchoscopic Placement of Endobronchial Valves and Blockers 744
Anesthetic Management 746
Preoperative Assessment 746
Pharmacologic Preparation 746
Pain Management 746
Thoracic Epidural Analgesia 746
Paravertebral Nerve Block 747
Intraoperative Management 747
Monitors 747
General Anesthesia 747
Mechanical Ventilation 747
Early Extubation 747
Postoperative Management 748
Summary 748
Clinical Case Discussion 748
Questions 748
References 749
47: Lung Transplantation 751
Introduction 751
Donor Organ Management 751
Recipient Candidates 753
Anesthesia for Lung Transplantation 755
Preoperative Assessment 755
Monitoring 755
Transesophageal Echocardiography 755
Induction of Anesthesia 756
Maintenance of Anesthesia 757
Management of RV Dysfunction 757
Extracorporeal Support 758
Organ Reperfusion 758
Analgesia 758
Postoperative care 758
Clinical Case Discussion 759
Case Presentation 759
Questions 759
Case Continuation 760
Questions 760
Case Continuation 760
Questions 760
Case Continuation 760
Questions 760
Discussion 760
References 763
48: Anesthesia for the Patient with a Previous Lung Transplant 768
Introduction 768
Common Procedures After Lung Transplantation 768
Pulmonary Physiology Post Lung Transplantation 768
Anesthetic Considerations 769
Intraoperative Airway and Ventilation Management 770
Intraoperative Management 771
Postoperative Care 771
Clinical Case Discussion 771
Questions 771
Transplant-Related History 771
Intraoperative Concerns 771
Postoperative Analgesia 772
References 772
49: Anesthesia for Pulmonary Thromboendarterectomy 773
Introduction 773
Classification of Pulmonary Hypertension 774
Chronic Thromboembolic Pulmonary Hypertension (CTEPH) 774
Incidence 774
Etiologic Factors 774
Pathology and Pathogenesis 774
Clinical Presentation 775
The Surgical Procedure 776
Surgical Approach and Technique 776
Surgical Subtypes 777
Anesthetic Management 778
Setup and Preparation 778
Anesthetic Induction and Pre-CPB Management 778
Management of Deep Hypothermic Circulatory Arrest (DHCA) 780
Post-DHCA Rewarming 781
Separation from CPB 781
Post-CPB Management 781
Postoperative Management 782
Outcome After PTE 784
Future 785
Clinical Case Discussion 785
Questions 785
References 785
Part XII: Anesthesia for Pediatric Thoracic Surgical Procedures 788
50: Anesthesia for Pediatric Thoracic Surgery 789
Introduction 789
Pediatric Growth and Development 790
Special Considerations 791
Prematurity 791
Pulmonary Hypertension 791
Cardiac Disease 792
Preoperative Evaluation 792
Strategies for Lung Isolation 793
Anesthetic Management of Specific Procedures and Diseases 796
Bronchoscopy 796
Thoracotomy and Video-Assisted Thoracoscopic Surgery (VATS) 798
Empyema 799
Patent Ductus Arteriosus (PDA) 799
Tracheoesophageal Fistula (TEF) 800
Mediastinal Mass 801
Diagnosis and Risk Stratification 802
Congenital Diaphragmatic Hernia (CDH) 804
Lung Biopsy 806
Cystic Fibrosis (CF) 806
Pulmonary Alveolar Proteinosis 807
Trauma, Pneumothorax, and Hemothorax 808
Lung Transplantation 809
Postoperative and Pain Management 810
Clinical Case Discussion 811
References 811
Part XIII: Trauma 816
51: Anesthetic Management of Thoracic Trauma 817
Introduction 817
Anatomy 818
Initial Approach to the Patient with Thoracic Trauma 818
Echocardiography in Thoracic Trauma 819
Image Acquisition 820
Blunt Cardiac Injury (Myocardial Contusion, Valvular Insufficiency, Pericardial Effusion, and Tamponade) 821
Aortic Injury 822
Hypovolemia 823
Training and Certification 824
Traumatic Airway Management 824
Lung Isolation 826
Tracheobronchial Injury 826
Aortic Injury 827
Pulmonary Contusion 829
Blunt Cardiac Injury 829
Chest Wall Injury 831
Flail Chest 831
Pleural Space 832
Pain Management for Blunt Thoracic Trauma 833
Clinical Case Discussion 837
Questions 837
Questions 837
Questions 838
References 838
Part XIV: Post-operative Management 843
52: Enhanced Recovery After Surgery (ERAS) for Thoracic Surgery 844
Background 844
ERAS General Overview 845
ERAS for Thoracic Surgery: Rationale 846
ERAS Thoracic Surgery: Pre-operative Components 846
Optimization of Comorbid Conditions 847
Nutrition 847
Anemia Screening 848
Tobacco 848
ERAS Thoracic Surgery: Intraoperative Components 848
Analgesia 848
Mechanical Ventilation Strategy 849
Maintenance of Anesthesia 849
Fluid Management 849
ERAS Thoracic Surgery: Post-operative Components 850
Removal of Lines and Drains 850
Chest Drains 850
Early Mobilization 851
Incentive Spirometry 851
Multimodal Analgesia 851
Barriers to Implementation and Sustainability 852
Current State, Future Directions, and Applicability 852
References 852
53: Anesthetic Management of Post-thoracotomy Complications 856
Introduction 856
Mechanical Ventilation and Extubation 857
Classification of Respiratory Failure 857
Criteria for Extubation 857
Complications of Prolonged Intubation and Mechanical Ventilation 857
Independent Lung Ventilation 858
Airway Complications 858
Endotracheal Intubation and Airway Injury 858
Airway Bleeding and Secretions 859
Vocal Cord Injuries 859
Intrathoracic Complications 859
Air Leak, Pneumothorax, and Bronchopleural Fistula 859
Mediastinal Emphysema 860
Deep Vein Thrombosis and Pulmonary Embolism 860
Postpneumonectomy Syndrome 860
Post Lung Resection Pulmonary Edema 861
Phrenic Nerve Injury 861
Cardiac Complications 861
Cardiac Failure and Arrhythmias 861
Cardiac Herniation 862
Interatrial Shunting 862
Clinical Case Discussion 863
Questions 863
References 863
54: Postoperative Respiratory Failure and Treatment 866
Definition 867
Preoperative Predictors of Postoperative Respiratory Failure 868
History 868
Procedure and Extent of Resection 869
Thoracotomy for Lung Resection 869
Video-Assisted Thoracic Surgery for Lung Resection 869
Robot Video-Assisted Thoracic Surgery for Lung Resection 869
Lung Volume Reduction Surgery 869
Trans-sternal Thymectomy 869
Esophagogastrectomy 870
Lung Transplantation 870
Thoracoabdominal Aortic Aneurysm (TAAA) Repair 870
Specific Etiologies of Respiratory Failure: Their Prevention and Treatment 870
Atelectasis 870
Bronchospasm 873
Retained Secretions 874
Pneumonia 874
Pulmonary Embolism 875
Pulmonary Edema 875
Pneumothorax 876
Persistent Air Leaks and Bronchopleural Fistula 876
Aspiration of Gastric Contents 876
Torsion of Residual Lobe 877
Neurologic Injuries 877
Mechanical Ventilation After Thoracic Surgery 877
Preoperative Indications for Postoperative Mechanical Ventilation 878
Intraoperative Indications for Postoperative Mechanical Ventilation 878
Immediate Postoperative Indications for Mechanical Ventilation 879
Ventilatory Modes 879
Noninvasive Ventilation 879
Lung-Protective Ventilation 881
Acute Respiratory Distress Syndrome 882
Therapy of ARDS 882
Mechanical Ventilation with PEEP 883
Prone Position 885
Alternate Modes of Ventilation 885
Inhaled Pulmonary Vasodilators 885
Extracorporeal Membrane Oxygenation (ECMO) 885
Complications of Mechanical Ventilation 886
Trauma to the Lungs or Tracheobronchial Tree 886
Ventilator-Associated Pneumonia 886
Diagnosis 886
Prevention 886
Withdrawal of Mechanical Ventilation 887
Extubation 888
Tracheotomy 888
Clinical Case Discussion 888
Questions 888
Answers 888
Question 889
Answer 889
Questions 889
Answers 889
References 889
55: Postoperative Management of Respiratory Failure: Extracorporeal Ventilatory Therapy 895
Introduction 895
Lung-Protective Ventilatory Strategies 896
Lung-Protective Ventilation 896
Extracorporeal Ventilatory Therapy in ARDS Patients 896
Separation of Ventilation and Oxygenation (Concept “Lung Rest”) 897
Extracorporeal Membrane Oxygenation (ECMO) 897
Indications 897
Technical Aspects of ECMO 898
VV ECMO 898
ECMO Cannulation 898
Initiation of ECMO 900
Temperature Management on ECMO 900
Monitoring for Anticoagulation 900
Complications 901
Bleeding and Thrombosis 901
Cerebral Hemorrhage and Infarction 901
Weaning of ECMO 901
Extracorporeal Carbon Dioxide Removal (ECCO2R) 901
Indications for ECCO2R 903
Complications 903
Multimodal Therapeutic Approach 905
Weaning of Sedation 905
Early Spontaneous Breathing 905
Clinical Case Discussion 905
Questions 905
References 906
56: Cardiovascular Adaptations and Complications 909
Introduction 909
Cardiac Adaptation 910
Intraoperative Changes in Right Ventricular Function and Anatomy Related to One-Lung Ventilation and Positioning 910
Acute and Late Phase Changes in Right Ventricular Anatomy After Lung Resection 911
Cardiac Complications 911
Supraventricular Tachyarrhythmias (Atrial Fibrillation, Atrial Flutter, and Supraventricular Tachycardia) 911
Role of Medications Used for Treatment and Prevention 913
Rate Control Agents 913
Rhythm Control Medications 915
Novel Medications 915
Role of Postoperative Chemical and Electrical Cardioversion 916
Acute Coronary Syndrome 916
Heart Failure and Cardiac Herniation 917
Mediastinal Shift and Post-pneumonectomy Syndrome 918
Conclusion 918
Clinical Case Discussion 919
Questions 919
Specifically 919
Back to the Case 919
References 920
57: Post-thoracic Surgery Patient Management and Complications 923
General Principles of Postoperative Care 923
Preoperative Preparation 923
Preoperative Teaching 923
Preoperative Pulmonary Exercise and Training 923
Smoking 924
Anticoagulant and Anti-aggregant Medication 924
Postoperative Management 925
Postoperative Pain Management 925
Respiratory Care 925
Intravenous Fluids 925
Chest Drainage System 927
Postoperative Nutrition 928
Prevention of Venous Thromboembolism 928
General Complications of Thoracotomy 929
Pneumonia 929
Atrial Fibrillation 929
Pleural Space Problems 930
Air Leak 930
Empyema 931
Nerve Injury 933
Postoperative Hemorrhage 934
Chylothorax 934
Torsion of a Residual Lobe 934
Postpneumonectomy Syndrome 934
Cardiac Herniation 935
Clinical Case Discussion 936
References 937
58: Troubleshooting Chest Drains 939
Introduction and Relevance 939
Indications and Physiology 939
Chest Tubes and Insertion 939
Chest Tube Insertion Techniques 940
Postsurgical Chest Drains 942
Indwelling Pleural Catheters 943
Drainage Collection Systems 944
Drainage Volume 945
Air Leak 945
Complications of Insertion 946
Chest Tube Removal and Thresholds 946
Special Situations 947
Bronchopleural Fistula 947
Post-pneumonectomy Chest Tubes 947
Abrupt Changes in Chest Tube Output 947
Clamping Chest Tubes 948
Summary 948
References 948
59: Pain Management After Thoracic Surgery 950
Introduction 951
Pathophysiology of Post-Thoracotomy Pain 951
Factors Influencing Pain After Thoracic Surgery 952
Preoperative Preparedness and Use of Perioperative Clinical Pathways 952
Opioid Tolerance 952
Preemptive Analgesia 953
Sex 953
Age 953
Psychological Factors 953
Surgical Approach 953
Sternotomy 953
Video-Assisted Thoracoscopic Surgery 953
Open Thoracotomy 954
Posterolateral Incision 954
Muscle-Sparing Incision 954
Anterior Incision 954
Transverse Sternothoracotomy 954
Analgesic Drugs and Techniques 955
Systemic Opioids 955
Non-opioid Analgesic Drugs 956
Nonsteroidal Anti-inflammatory Drugs 956
COX-2 Inhibitors 956
Acetaminophen 956
NMDA Antagonists 957
Gabapentinoids 958
?2 Adrenergic Agonists 959
Glucocorticoids 959
Non-pharmacologic Techniques 959
Transcutaneous Nerve Stimulation 959
Cryoanalgesia 960
Regional Techniques 960
Consent for Regional Analgesia 960
Local Anesthetic Patches 961
Continuous Wound Infiltration Catheters 961
Intercostal Nerve Blocks 961
Interpleural Blocks 961
Serratus Anterior Plane Blocks 963
Introduction 963
SAPB in Clinical Practice 963
Technique 964
Paravertebral Blocks 964
Anatomy 965
Methods of Performing Paravertebral Blocks 965
Landmark Methods 965
Ultrasound-Guided Methods 967
Open Methods 970
Management of Paravertebrals 971
Advantages of Paravertebral Analgesia 972
Limitations and Complications of Paravertebral Blocks 972
Erector Spinae Plane Blocks 973
Technique (See Figs. 59.19 and 59.20) 973
Intrathecal Analgesia 973
Epidural Analgesia 974
Lumbar Epidural Analgesia 974
Thoracic Epidural Analgesia 974
Technique of Insertion 974
Epidural Solutions 976
Impact of Thoracic Epidural Analgesia 976
Improvement of Postoperative Diaphragmatic Dysfunction 977
Incidence of Cardiovascular Complications 977
Thoracic Epidurals and Outcome 977
Limitations and Adverse Effects 977
Urinary Retention 978
Gastric Emptying 978
Hypotension 978
Neuraxial Block and Coagulation 979
Heparin and Thromboprophylaxis 979
Fondaparinux 980
Warfarin 980
NOACs: Novel Oral Anticoagulants 980
Antiplatelet Medications 980
NSAIDs (Including Aspirin) 980
Thienopyridine Derivatives 980
Platelet Glycoprotein IIb/IIIa Inhibitors 980
Herbal (Alternative) Medication 981
Coronary Stents 981
Techniques for Specific Situations 981
Sternotomy 981
Video-Assisted Surgery 981
Open Thoracotomy 981
Esophageal Surgery 982
Shoulder Pain 983
Opioid-Tolerant Patients 984
Conclusion 985
Case Study 986
Questions 986
References 986
60: Long-Acting Local Anesthetics for Analgesia Following Thoracic Surgery 997
Introduction 997
History of Local Anesthetics 998
Origins in the Americas 998
Synthetic Anesthetics 998
Current Long-Acting Local Anesthetics 999
Liposomal Bupivacaine and the Introduction of a New Class of Anesthetics 1000
Safety 1000
Preparation and Application 1001
Contraindications and Precautions 1001
Regional Anesthetic Techniques for Thoracic Surgery 1001
Thoracic Epidural Anesthesia 1001
Shift Toward More Peripheral Regional Techniques 1001
Thoracic Paravertebral Blockade (Please See Figs. 59.5 and 59.6 from Chap. 59) 1003
Intercostal Nerve Block 1003
Direct Interpleural Anesthesia 1005
Serratus Plane (SAP) Block 1005
Local Surgical Site Infiltration 1006
Phrenic Nerve Block and Other Blocks Targeting Ipsilateral Shoulder Pain (ISP) 1006
Etiology 1006
Treatment 1007
Conclusion 1007
Case Discussion 1008
References 1008
61: Chronic Post-thoracotomy Pain 1012
Introduction 1012
Characteristics and Prevalence of Chronic Post-thoracotomy Pain 1013
The Impact of Chronic Post-thoracotomy Pain on Function 1014
Factors Influencing the Development of Chronic Post-thoracotomy Pain 1014
Pain Before and After Surgery 1014
Genetic Factors 1015
Anesthetic Factors 1015
Surgical Factors 1016
Prevention of Chronic Post-thoracotomy Pain 1018
Management of Chronic Post-thoracotomy Pain 1019
Clinical Case Discussion 1020
Past Medical/Surgical History 1020
Perioperative Course 1020
First Visit 1020
Second Visit 1020
Third Visit 1020
Fourth Visit 1020
References 1020
Index 1025