Slinger Principles and Practice of Anesthesia for Thoracic Surgery

2. Auflage 2019
ISBN: 978-3-030-00859-8
Verlag: Springer International Publishing
Format: PDF
Kopierschutz: 1 - PDF Watermark

E-Book, Englisch, 1047 Seiten

Updated and expanded, this comprehensive new edition captures the considerable evolution in the anesthetic management of patients requiring anesthesia for non-cardiac intrathoracic diagnostic and therapeutic procedures. Major advances addressed include the expanded role of ultrasound beyond trans-esophageal echocardiography, the role of extra-corporeal membrane oxygenation in thoracic anesthesia, and postoperative pain management for thoracic surgery. Chapters are authored by prominent anesthesiologists and feature cases commonly encountered in clinical practice. Authoritative and the leading text in the field, this book will serve as an indispensible guide to practitioners of thoracic anesthesia at all levels.


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

Autoren/Hrsg.

Slinger, Peter

Inhaltsverzeichnis

1;Preface;6
2;Contents;8
3;Contributors;12
4;Part I: Introduction;18
4.1;1: History of Thoracic Anesthesiology;19
4.1.1;Introduction;19
4.1.2;Ages of Thoracic Surgery;20
4.1.2.1;Surgery for Infective Lung Disease;20
4.1.2.2;Surgery for Lung Cancer;21
4.1.2.3;Surgery for Respiratory Failure;22
4.1.2.4;Lung Separators;22
4.1.2.5;The Blocker Story;22
4.1.2.6;The Endobronchial Tube Story;22
4.1.2.7;The Double-Lumen Tube Story;23
4.1.2.8;Origins of Thoracic Endoscopy;23
4.1.2.9;Tracheobronchial Stenosis;25
4.1.2.10;Esophageal Surgery;25
4.1.2.11;Pain Relief;25
4.1.3;Conclusion;25
4.1.4;Further Reading;26
5;Part II: Preoperative Evaluation;27
5.1;2: Preanesthetic Assessment for Thoracic Surgery;28
5.1.1;Introduction;28
5.1.2;Assessment of Respiratory Function;29
5.1.2.1;Lung Mechanical Function;30
5.1.2.2;Pulmonary Parenchymal Function;32
5.1.2.3;Cardiopulmonary Interaction;33
5.1.2.4;Regional Lung Function;35
5.1.2.5;Split-Lung Function Studies;36
5.1.2.6;Combination of Tests;36
5.1.3;Concomitant Medical Conditions;37
5.1.3.1;Cardiac Disease;37
5.1.3.1.1;Ischemia;38
5.1.3.1.2;Arrhythmias;39
5.1.3.2;Age;40
5.1.3.3;Renal Dysfunction;41
5.1.3.3.1;Chronic Obstructive Pulmonary Disease;41
5.1.3.3.2;Carbon Dioxide Retention;41
5.1.3.3.3;Preoperative Therapy of COPD;41
5.1.3.3.4;Physiotherapy;42
5.1.3.3.5;Restrictive Lung Diseases;42
5.1.3.3.6;Pulmonary Hypertension;43
5.1.3.4;Smoking;43
5.1.3.4.1;Type of Surgical Procedure;43
5.1.3.4.2;Combined Strategies for Preoperative Assessment;43
5.1.3.4.3;Perioperative Considerations in Thoracic Malignancies;44
5.1.3.5;Non-Small Cell Lung Cancer (NSCLC);46
5.1.3.5.1;Adenocarcinoma;46
5.1.3.5.2;Squamous Cell Carcinoma;48
5.1.3.5.3;Large Cell Undifferentiated Carcinoma;48
5.1.3.6;Small-Cell Lung Cancer;49
5.1.3.7;Carcinoid Tumors;49
5.1.3.8;Pleural Tumors;49
5.1.4;Preoperative Assessment of the Patient with Lung Cancer;50
5.1.4.1;Postoperative Analgesia;50
5.1.4.2;Premedication;51
5.1.4.3;Summary of The Initial Preoperative Assessment;51
5.1.4.3.1;Final Preoperative Assessment.;51
5.1.4.3.2;Difficult Endobronchial Intubation;52
5.1.4.3.2.1;Prediction of Desaturation During One-Lung Ventilation;52
5.1.5;Assessment for Repeat Thoracic Surgery;53
5.1.6;Clinical Case Discussion;53
5.1.6.1;Questions;53
5.1.7;References;54
5.2;3: Thoracic Imaging;57
5.2.1;Introduction;57
5.2.2;Normal Tracheobronchial Anatomy;57
5.2.3;Chest Radiographs;58
5.2.4;Chest Radiographs and Pulmonary Disease;58
5.2.5;Lung Mass and Chest X-Rays;59
5.2.6;Mediastinal Mass and Chest X-Rays;59
5.2.7;Bullae;61
5.2.8;Pneumothorax;62
5.2.9;Pleural Effusion;64
5.2.10;Chest Tube Placement;64
5.2.11;Previous Lobectomy;65
5.2.12;Pneumonectomy;65
5.2.13;Double-Lumen Endotracheal Tubes;67
5.2.14;Postoperative Acute Lung Injury;68
5.2.15;Computed Tomography Scan and Pulmonary Disease;69
5.2.16;Computed Tomography Scan and Lung Mass, Mediastinal Mass, Pleural Effusion, and Pericardial Effusion;69
5.2.17;Multidetector Computer Tomography Scan of the Chest;71
5.2.18;Magnetic Resonance Imaging and Pulmonary Disease;71
5.2.19;Summary;74
5.2.20;References;74
6;Part III: Thoracic Anatomy, Physiology, and Pharmacology;76
6.1;4: Essential Anatomy and Physiology of the Respiratory System and the Pulmonary Circulation;77
6.1.1;Introduction;77
6.1.2;Functional Anatomy;77
6.1.2.1;Upper Airway Anatomy;77
6.1.2.1.1;Oropharynx and Nasopharynx;77
6.1.2.1.2;Larynx;78
6.1.2.1.3;Pharyngeal Innervation;79
6.1.2.2;Upper Airway Function;79
6.1.2.2.1;Homeostatic Mechanisms;79
6.1.2.2.2;The Cough Reflex;80
6.1.2.3;Clinical Issues;80
6.1.2.3.1;Airway Obstruction;80
6.1.2.3.2;Nebulized Medications;80
6.1.2.4;Tracheobronchial and Respiratory Anatomy;81
6.1.2.4.1;Tracheal and Bronchial Structure;81
6.1.2.4.2;Tracheobronchial Circulation and Lymphatic System;81
6.1.2.4.3;Respiratory Airways and Alveolar Histology;82
6.1.2.4.4;Innervation;83
6.1.3;Neural Control of Respiration;83
6.1.3.1;Respiratory Centers;83
6.1.3.2;Chemoreception and Respiratory Control;84
6.1.3.3;Neural Control of the Airways;85
6.1.3.4;Respiratory Muscles;86
6.1.3.5;Inspiration;86
6.1.3.6;Expiration;87
6.1.4;The Respiratory “System”;87
6.1.4.1;The Pleural Pressure;87
6.1.4.2;Lung Volumes;87
6.1.5;Dynamic Mechanical Aspects of the Respiratory System;89
6.1.5.1;The Pressure-Volume Relationship;89
6.1.5.2;Lung Compliance, Lung Volume, and Dynamic Modifiers;90
6.1.6;Distribution of Ventilation;91
6.1.7;The Physiology of the Pulmonary Circulation;91
6.1.7.1;Anatomical Considerations;91
6.1.7.2;Pulmonary Hemodynamics;91
6.1.8;Cardiopulmonary Interactions;92
6.1.8.1;Factors Affecting Right Ventricular Performance;92
6.1.8.1.1;Pulmonary Vascular Resistance;92
6.1.8.1.2;Changes in Intrathoracic Pressure;93
6.1.8.1.3;Systemic Venous Return;93
6.1.8.2;Factors Affecting Left Ventricular Performance;93
6.1.8.2.1;LV Preload and Ventricular Interdependence;93
6.1.8.2.2;LV Afterload;93
6.1.8.3;Impact of Weaning from Mechanical Ventilation;94
6.1.9;Distribution of Lung Perfusion;94
6.1.9.1;Gravity and Pulmonary Blood Flow;94
6.1.9.2;Architecture and Pulmonary Blood Flow;94
6.1.9.3;Regional “Zones of Blood Flow”;95
6.1.10;Ventilation to Perfusion Matching (The VA/Q Ratio);96
6.1.11;Hypoxic Pulmonary Vasoconstriction;97
6.1.12;Clinical Applications;98
6.1.12.1;Anesthesia and Atelectasis;98
6.1.12.2;Anesthesia and VA/Q Matching;99
6.1.12.3;Non-anesthetic Drugs and HPV;99
6.1.13;References;100
6.2;5: Physiology of the Lateral Decubitus Position, Open Chest, and One-Lung Ventilation;105
6.2.1;Introduction;105
6.2.2;Perfusion;105
6.2.3;Hypoxic Pulmonary Vasoconstriction (HPV);108
6.2.4;Anesthetic Modifiers;109
6.2.5;Other Modifiers of HPV;110
6.2.6;Cardiac Output and Arterial Oxygenation;111
6.2.7;Ventilation;111
6.2.8;Ventilation–Perfusion Matching;112
6.2.9;V/Q Matching in the Lateral Position;112
6.2.9.1;Awake;112
6.2.9.2;Anesthetized;112
6.2.9.3;Paralyzed/Ventilated;113
6.2.10;Open Chest;113
6.2.10.1;Positions Other Than Lateral;114
6.2.10.2;Supine;114
6.2.10.3;Prone;114
6.2.11;Alternative Approaches;114
6.2.11.1;Capnothorax;114
6.2.11.2;Awake Non-intubated Lung Surgery;114
6.2.12;Summary;114
6.2.13;References;115
6.3;6: Clinical Management of One-Lung Ventilation;118
6.3.1;Introduction;118
6.3.2;Acute Lung Injury;118
6.3.3;Individual Ventilator Settings;120
6.3.3.1;Tidal Volume;120
6.3.3.2;PEEP;123
6.3.3.3;FiO2;125
6.3.3.4;Minute Ventilation/Permissive Hypercapnia;126
6.3.4;I:E Ratio and Respiratory Rate;127
6.3.5;Peak/Plateau Pressure;127
6.3.6;Driving Pressure;127
6.3.7;Ventilatory Mode;128
6.3.8;Recruitment/Re-expansion;129
6.3.9;OLV Duration;131
6.3.10;Combined Ventilator Strategy;131
6.3.11;Hypoxemia;132
6.3.11.1;Prediction;132
6.3.11.2;Treatment;133
6.3.11.3;Systemic Effects;134
6.3.12;Alternatives to One-Lung Ventilation;135
6.3.13;Conclusion;135
6.3.14;References;136
6.4;7: Nonrespiratory Functions of the Lung;141
6.4.1;Introduction;141
6.4.2;Uptake and Metabolism Within the Lung;141
6.4.3;Drugs;143
6.4.3.1;Opioids;143
6.4.3.2;Muscle Relaxants;144
6.4.3.3;Local Anesthetics;144
6.4.3.4;Hypnotics;145
6.4.3.5;Inhaled Medications;145
6.4.4;Pulmonary Handling of Endogenous Substances;146
6.4.4.1;Angiotensin-Converting Enzyme;146
6.4.4.2;Biogenic Amines;147
6.4.4.3;Arachidonic Acid Metabolites;148
6.4.4.4;Natriuretic Peptides;149
6.4.4.5;Other Endogenous Substances;149
6.4.5;The Lung as Vascular Reservoir and Filter;150
6.4.6;The Respiratory Epithelium;150
6.4.7;The Cells of the Respiratory Epithelium;150
6.4.7.1;Ciliated Columnar Cells;150
6.4.7.2;Goblet Cells;151
6.4.7.3;Submucosal Secretory Cells;151
6.4.7.4;Clara Cells;152
6.4.7.5;Mast Cells;152
6.4.7.6;Macrophages and Monocytes;152
6.4.7.7;Alveolar Epithelial Cells;153
6.4.8;Functions of the Respiratory Epithelium;153
6.4.8.1;Airway Surface Film;153
6.4.8.2;Humidification;153
6.4.8.3;Removal of Inhaled Particles;154
6.4.8.4;Response to Inhaled Organisms;154
6.4.9;Summary;154
6.4.10;References;155
6.5;8: Pharmacology of the Airways;160
6.5.1;Introduction;160
6.5.2;Influence of the Autonomic Nervous System on the Airway and Modulation of the Response;161
6.5.3;Inhaled Adrenergic Agonists;161
6.5.3.1;Mechanism of Action;161
6.5.3.2;Clinical Applications;161
6.5.3.3;Side Effects;162
6.5.3.4;Safety Concerns;162
6.5.4;Systemic Adrenergic Agonists;163
6.5.4.1;Mechanism of Action;163
6.5.4.2;Clinical Applications;163
6.5.4.3;Side Effects;163
6.5.5;Inhaled Cholinergic Antagonists;163
6.5.5.1;Mechanism of Action;163
6.5.5.2;Clinical Applications;163
6.5.5.3;Side Effects;164
6.5.6;Systemic Cholinergic Antagonists;164
6.5.7;Influence of Inflammation on the Airway and Modulation of the Response;164
6.5.8;Inhaled Corticosteroids;165
6.5.8.1;Mechanism of Action;165
6.5.8.2;Clinical Applications;165
6.5.8.3;Side Effects and Safety Concerns;165
6.5.9;Systemic Corticosteroids;166
6.5.10;Leukotriene Modifiers;166
6.5.10.1;Mechanism of Action;166
6.5.10.2;Clinical Applications;166
6.5.10.3;Side Effects;166
6.5.11;Mast Cell Stabilizers;166
6.5.11.1;Mechanism of Action;167
6.5.11.2;Clinical Applications;167
6.5.11.3;Side Effects;167
6.5.12;Methylxanthines;167
6.5.12.1;Mechanism of Action;168
6.5.12.2;Clinical Applications;168
6.5.12.3;Side Effects;168
6.5.13;Phosphodiesterase 4 Inhibitors;168
6.5.13.1;Mechanism of Action;168
6.5.13.2;Clinical Applications;168
6.5.13.3;Side Effects;168
6.5.14;Influence of Anesthetics on the Airway;168
6.5.14.1;Volatile Anesthetics;168
6.5.14.2;Mechanism of Action;168
6.5.14.3;Clinical Applications;169
6.5.14.4;Side Effects;169
6.5.15;Intravenous Anesthetics;169
6.5.15.1;Mechanism of Action;169
6.5.15.2;Clinical Applications;169
6.5.15.3;Side Effects;169
6.5.16;Local Anesthetics;169
6.5.17;Influence of Adjunctive Agents on the Airway;169
6.5.17.1;Heliox;169
6.5.17.2;Antihistamines;170
6.5.17.3;Magnesium Sulfate;170
6.5.18;Summary;170
6.5.19;Clinical Case;170
6.5.19.1;Questions;170
6.5.19.2;Answers;170
6.5.20;References;171
6.6;9: Pharmacology of the Pulmonary Circulation;174
6.6.1;Introduction;174
6.6.2;Anesthetic Drugs;175
6.6.2.1;Introduction;175
6.6.2.2;Ketamine;175
6.6.2.3;Propofol;175
6.6.2.4;Etomidate;176
6.6.2.5;Dexemedetomidine;176
6.6.2.6;Opioids;176
6.6.2.7;Neuromuscular Blockers;177
6.6.2.8;Vasopressors and Inotropes;177
6.6.2.9;Magnesium;177
6.6.2.10;Volatile Anesthetics;177
6.6.2.11;Perioperative Analgesia;178
6.6.2.12;Conclusion;178
6.6.3;Support of the Right Ventricle;178
6.6.4;Pulmonary Vasodilators (PO/IV/Inhaled);179
6.6.5;Nitric Oxide/Cyclic-GMP Pathway;179
6.6.6;Nitric Oxide;179
6.6.7;cGMP/cAMP Pathway;180
6.6.8;Endothelin Antagonists;180
6.6.9;Prostaglandins;181
6.6.10;Pulmonary Vasodilators in Thoracic Surgery;182
6.6.11;Clinical Case Study;182
6.6.12;References;183
6.7;10: Perioperative Lung Injury;189
6.7.1;Introduction;189
6.7.2;Acute Lung Injury in Patients with Healthy Lungs;189
6.7.3;Pulmonary Resection;191
6.7.4;The Role of the Glycocalyx in Lung Injury;195
6.7.5;Transfusion-Related Acute Lung Injury (TRALI);196
6.7.6;Prevention and Therapy for Acute Lung Injury;196
6.7.7;Outcomes;197
6.7.8;Avoiding One-Lung Ventilation;198
6.7.9;Clinical Case Discussion;199
6.7.10;References;200
7;Part IV: Diagnostic and Therapeutic Procedures of the Trachea and Airways;202
7.1;11: Bronchoscopic Procedures;203
7.1.1;Introduction;203
7.1.2;Anesthetic Considerations;204
7.1.3;Central Airway Obstruction;205
7.1.4;Airway Stents;207
7.1.5;Other Modalities;209
7.1.5.1;Laser;209
7.1.5.2;Endobronchial Electrosurgery;209
7.1.5.3;Argon Plasma Cautery;210
7.1.5.4;Balloon Bronchoplasty;210
7.1.5.5;Delayed Resection Techniques;210
7.1.6;Foreign Body Extraction and Emerging Techniques;211
7.1.6.1;Endobronchial Valves;212
7.1.6.2;Bronchial Thermoplasty;212
7.1.7;Diagnostic Bronchoscopy;213
7.1.8;Noninvasive Techniques;214
7.1.9;Invasive Techniques;216
7.1.10;Awake Fiber-Optic Intubation;216
7.1.11;Clinical Case Discussion;218
7.1.11.1;Questions;218
7.1.11.2;Authors’ Management;218
7.1.12;References;220
7.2;12: Intravenous Anesthesia for Thoracic Procedures;224
7.2.1;Introduction;224
7.2.2;Rationale for Total Intravenous Anesthesia;224
7.2.2.1;TIVA in Special Thoracic Surgical Conditions;226
7.2.2.2;Scenarios that Benefit from TIVA;227
7.2.3;Intravenous Anesthetic Agents;227
7.2.3.1;Propofol;227
7.2.3.2;Dexmedetomidine;228
7.2.3.3;Remifentanil;228
7.2.3.4;Ketamine;228
7.2.3.5;Lidocaine;229
7.2.4;Infusion Systems;229
7.2.5;Anesthetic Depth Monitors;231
7.2.6;Methodology;231
7.2.6.1;Premedication and Thoracic Epidural Placement;231
7.2.6.2;Induction;231
7.2.6.3;Maintenance;232
7.2.6.4;Emergence;232
7.2.7;Clinical Case Discussion: TIVA for Thoracic Procedures (Fig. 12.2);232
7.2.7.1;Questions;232
7.2.8;References;233
7.3;13: Tracheal Resection and Reconstruction;236
7.3.1;Historical Note;236
7.3.2;Etiology of Tracheal Lesions;237
7.3.3;Planning Tracheal Surgery;238
7.3.4;Tracheal Anatomy and Surgical Management;239
7.3.5;The Subglottis and Upper Trachea;239
7.3.6;Mid-Trachea;239
7.3.7;Carinal Resection;240
7.3.8;Patient Characteristics;240
7.3.9;Preoperative Assessment;241
7.3.10;Patient Monitoring;242
7.3.11;Ventilation Strategies;242
7.3.11.1;Distal Tracheal Intubation, Intermittent Positive Pressure Ventilation (IPPV);242
7.3.11.2;Low-Frequency Jet Ventilation (LFJV);245
7.3.11.3;High-Frequency Jet Ventilation;245
7.3.11.4;High-Frequency Positive Pressure Ventilation (HFPPV);246
7.3.11.5;Extraordinary Ventilation Strategies;247
7.3.11.5.1;Cardiopulmonary Bypass (CPB) and Extracorporeal Oxygenation (ECMO);247
7.3.11.5.2;Spontaneous Ventilation;247
7.3.11.5.3;Hyperbaric Oxygenation;247
7.3.12;Anesthesia Induction and Maintenance;247
7.3.13;Reconstruction of the Airway;248
7.3.14;Emergence After Airway Surgery;249
7.3.15;Immediate Postoperative Complications Specific to Airway Surgery;249
7.3.16;Tracheal Procedures with Specific Considerations;250
7.3.16.1;Airway Trauma;250
7.3.16.2;Tracheoesophageal Fistula;251
7.3.17;Pediatrics;251
7.3.18;Management of the Patient with a T-Tube;251
7.3.19;References;252
8;Part V: Diagnostic and Therapeutic Procedures of the Mediastinum;254
8.1;14: Anesthesia for Patients with Mediastinal Masses;255
8.1.1;Introduction;255
8.1.2;Anatomy and Pathophysiology;256
8.1.3;Preanesthetic Assessment;257
8.1.3.1;Clinical Signs and Symptoms;257
8.1.3.2;Investigations;257
8.1.4;Anesthetic Risks;258
8.1.4.1;Risk Stratification (Fig. 14.2);258
8.1.4.2;Preoperative Treatment;258
8.1.5;Anesthetic Management;258
8.1.5.1;Sedation;258
8.1.5.2;Induction and Intubation;259
8.1.5.3;Maintenance of Anesthesia and Intraoperative Monitoring;260
8.1.5.4;Emergence and Postoperative Care;260
8.1.6;Complications;260
8.1.6.1;Airway Compression;260
8.1.6.2;Cardiovascular Compression;261
8.1.6.3;Extracorporeal Circulation (ECC);261
8.1.7;Anesthesia for Mediastinoscopy;261
8.1.8;Summary;262
8.1.9;Clinical Case Discussion;262
8.1.9.1;Question 1;262
8.1.9.2;Answer;262
8.1.9.3;Question 2;263
8.1.9.4;Answer;263
8.1.9.5;Question 3;263
8.1.9.6;Answer;263
8.1.10;References;266
8.2;15: Thymic Surgery and Paraendocrine Syndromes;268
8.2.1;Introduction;269
8.2.2;Thymic Surgery;269
8.2.3;Myasthenia Gravis;269
8.2.4;Pathophysiology;270
8.2.5;Presentation;270
8.2.6;Diagnosis;270
8.2.7;Classification;270
8.2.8;Medical Management;270
8.2.9;Surgical Management;272
8.2.10;Myasthenic vs Cholinergic Crisis;272
8.2.11;Anesthetic Considerations;273
8.2.12;Paraendocrine and Paraneoplastic Syndromes;275
8.2.13;Carcinoid Tumors;275
8.2.14;Lambert-Eaton Myasthenic Syndrome (LEMS);277
8.2.15;Case Discussion;278
8.2.16;References;279
9;Part VI: Anesthetic Management for Intra-Thoracic Surgery;283
9.1;16: Lung Isolation;284
9.1.1;Introduction;284
9.1.2;Double-Lumen Endotracheal Tubes;284
9.1.3;Size Selection;285
9.1.4;Methods of Insertion;286
9.1.5;Right-Sided Double-Lumen Endotracheal Tubes;289
9.1.6;Safety;289
9.1.7;Placement Technique;289
9.1.8;Left-Sided Double-Lumen Endotracheal Tubes;290
9.1.8.1;Placement Technique;290
9.1.8.2;VivaSight Double-Lumen Tube;291
9.1.8.3;Auscultation and Fiberoptic Bronchoscopy when Placing Double-Lumen Endotracheal Tubes;292
9.1.8.4;New Technology with Double-Lumen Endotracheal Tubes;294
9.1.9;Complications Associated with Double-Lumen Endotracheal Tube Placement;295
9.1.10;Bronchial Blockers;295
9.1.11;Torque Control Blocker Univent;295
9.1.12;Independent Bronchial Blockers During Lung Isolation;296
9.1.13;Arndt® Wire-Guided Endobronchial Blocker;296
9.1.13.1;Methods of Placement;297
9.1.14;Cohen® Flexitip Endobronchial Blocker;298
9.1.14.1;Methods of Placement;298
9.1.15;Fuji Uniblocker®;299
9.1.15.1;Methods of Placement;300
9.1.16;The EZ-Blocker;301
9.1.16.1;Methods of Placement;302
9.1.17;Complications with the Use of Bronchial Blockers;302
9.1.18;Lung Isolation in Patients with Tracheostomy in Place;303
9.1.19;Lung Collapse During Lung Isolation;303
9.1.20;Future Trends in Lung Isolation;304
9.1.21;Summary;305
9.1.22;Clinical Case Discussion;305
9.1.22.1;Questions;305
9.1.22.2;Focus on the Patient’s Gender, Size, Height, and Preoperative Chest Radiograph;307
9.1.22.3;Choice of Lung Isolation Device;307
9.1.22.4;Expected Intraoperative Problems During Lung Isolation;307
9.1.23;References;307
9.2;17: Fiberoptic Bronchoscopy for Positioning Double-Lumen Tubes and Bronchial Blockers;311
9.2.1;Introduction;311
9.2.2;Flexible Fiberoptic Bronchoscopy and Double–Lumen Endotracheal Tube Placement;312
9.2.2.1;Optimal Position of the Left-Sided Double-Lumen Tube with Flexible Bronchoscopy;312
9.2.2.2;Optimal Position of a Right-Sided Double-Lumen Tube with Flexible Bronchoscopy;314
9.2.3;Flexible Fiberoptic Bronchoscopy and Bronchial Blockers;314
9.2.3.1;Placement of the Arndt® Blocker with Fiberoptic Bronchoscopy;314
9.2.3.2;Placement of the Cohen® Blocker with Fiberoptic Bronchoscopy;315
9.2.3.3;Placement of the Fuji Uniblocker® with the Fiberoptic Bronchoscopy;316
9.2.3.4;Placement of the EZ-Blocker with Fiberoptic Bronchoscopy;316
9.2.4;Selective Lobar Blockade with Bronchial Blocker and Flexible Fiberoptic Bronchoscopy;317
9.2.5;Other Uses of Flexible Fiberoptic Bronchoscopy During Double-Lumen Tubes or Bronchial Blockers;320
9.2.6;Summary;320
9.2.7;References;321
9.3;18: Lung Isolation in Patients with Difficult Airways;323
9.3.1;Introduction;323
9.3.2;Preoperative Evaluation of the Difficult Airway and Lung Isolation Techniques;323
9.3.3;Difficult Airway and Lung Isolation: Securing the Airway First;324
9.3.4;Use of a Flexible Bronchoscope During Awake Intubation;325
9.3.5;Special Consideration for Patients with High Aspiration Risk;326
9.3.6;Use of Laryngeal Mask Airway and a Bronchial Blocker During Difficult Airways;326
9.3.7;Use of a Double-Lumen Endotracheal Tube in Patients with Difficult Airways;326
9.3.8;Lung Isolation Techniques in Patients with Tracheostomies;330
9.3.9;Lower Airway Abnormalities and Lung Isolation;330
9.3.10;Lung Isolation in Patients with Cervical Spine Abnormalities;333
9.3.11;Extubation or Mechanical Ventilation After Surgery;334
9.3.12;Summary;334
9.3.13;Clinical Case Discussion;334
9.3.13.1;Questions;334
9.3.13.2;Suggested Management;334
9.3.14;References;335
9.4;19: Intraoperative Patient Positioning and Neurological Injuries;337
9.4.1;Central Neurological Injuries;340
9.4.2;Clinical Case Discussion;341
9.4.3;References;342
9.5;20: Intraoperative Monitoring;343
9.5.1;Introduction;343
9.5.2;ECG;344
9.5.3;Pulse Oximetry;344
9.5.4;Capnography;345
9.5.5;Intraoperative Spirometry;346
9.5.6;Arterial Blood Pressure Monitoring;346
9.5.7;Central Venous Pressure;347
9.5.8;Pulmonary Artery Catheter Monitoring;348
9.5.9;Transesophageal Echocardiography;349
9.5.10;Minimally and Noninvasive Hemodynamic Monitoring Devices and Tissue Perfusion Monitoring;349
9.5.11;Esophageal Doppler Monitoring;350
9.5.12;Continuous Pulse Contour Analysis (PiCCO);352
9.5.13;Lithium Dilution Cardiac Output;352
9.5.14;Arterial Pressure Cardiac Output Device (APCO, FloTrac/Vigileo);353
9.5.15;BioReactance (Cheetah);353
9.5.16;References;354
9.6;21: Fluid Management in Thoracic Surgery;356
9.6.1;Introduction;356
9.6.2;The Fluid Problem;356
9.6.3;Lung Injury After Thoracic Surgery;356
9.6.3.1;Incidence;356
9.6.3.2;Factors Contributing to Postoperative Lung Injury;357
9.6.3.3;Surgical Risk Factors;357
9.6.3.4;Patient-Related Risk Factors;357
9.6.3.5;Intraoperative Management;358
9.6.4;Perioperative Fluid Administration and Acute Lung Injury;358
9.6.5;Physiologic Basis of Fluid Overload;359
9.6.5.1;Role of the Glycocalyx;359
9.6.5.2;Hypervolemia and the Glycocalyx;361
9.6.5.3;Mechanical Ventilation and the Glycocalyx;361
9.6.6;Fluid Composition;362
9.6.7;Risks of Fluid Restriction in Thoracic Surgery;362
9.6.8;Methods of Targeting Fluid Management;363
9.6.9;Approach to Fluid Management in Thoracic Surgery;365
9.6.9.1;ERAS-Based Fluid Management;365
9.6.9.2;Managing Fluids in Lung Surgery;365
9.6.9.3;Managing Fluids in Esophagectomy;366
9.6.10;Conclusion;367
9.6.11;References;367
9.7;22: Intraoperative Ventilation Strategies for Thoracic Surgery;373
9.7.1;Introduction;373
9.7.2;Physiology of One-Lung Mechanical Ventilation (See Chap. 6 for a More Complete Discussion);374
9.7.3;Modes of Mechanical Ventilation for OLV in the Operating Room;376
9.7.4;Pressure- Versus Volume-Controlled Ventilation;376
9.7.5;High Versus Low Tidal Volume;378
9.7.6;Positive End-Expiratory Pressure;379
9.7.7;Lung Opening Procedures;381
9.7.8;Conclusion;382
9.7.9;Clinical Case Discussion;382
9.7.10;References;383
9.8;23: Anesthesia for Open Pulmonary Resection: A Systems Approach;386
9.8.1;General Concepts;386
9.8.2;A Systems Approach;388
9.8.3;Patient Care Processes in Thoracic Anesthesia;388
9.8.4;Preoperative Care;391
9.8.5;Intraoperative Care;392
9.8.6;Postoperative Care;397
9.8.7;Lung Cancer;397
9.8.8;Intrathoracic Manifestations;397
9.8.9;Extrathoracic Metastatic Manifestations;397
9.8.10;Extrathoracic Nonmetastatic Manifestations;397
9.8.11;Treatment Options;398
9.8.12;Anesthesia and Long-Term Cancer Outcomes;399
9.8.13;Surgical Procedure;399
9.8.14;Pulmonary Resection;399
9.8.15;Lobectomy;400
9.8.16;Sleeve Lobectomy;401
9.8.17;Pneumonectomy;401
9.8.18;Sleeve Pneumonectomy;403
9.8.19;Limited Pulmonary Resections: Segmentectomy and Wedge Resection;403
9.8.20;Bronchopleural Fistula;403
9.8.21;Clinical Case Discussion;404
9.8.21.1;Questions;404
9.8.22;Discussion;404
9.8.23;References;405
9.9;24: Anesthesia for Video-Assisted Thoracoscopic Surgery (VATS);410
9.9.1;Historical Considerations of Video-Assisted Thoracoscopy;410
9.9.1.1;Indications;411
9.9.1.2;Diagnostic Procedures;411
9.9.1.3;Therapeutic Procedures;412
9.9.1.4;Benefits;412
9.9.2;Surgical Technique;413
9.9.3;Anesthetic Management;413
9.9.3.1;Local/Regional Anesthesia;414
9.9.3.2;General Anesthesia;414
9.9.4;Management of OLV;417
9.9.5;Localization of Small Parenchymal Lesions;418
9.9.6;Uniportal VATS;418
9.9.7;Pain Management Techniques;418
9.9.8;Clinical Case Discussion;419
9.9.9;References;420
9.10;25: Anesthesia for Non-intubated Thoracic Surgery;422
9.10.1;Techniques of Non-intubated Thoracic Anesthesia;423
9.10.2;Conversion to General Anesthesia and Endotracheal Intubation;423
9.10.3;Clinical Case Discussion;423
9.10.4;References;424
9.11;26: Troubleshooting One-Lung Ventilation;425
9.11.1;Introduction;425
9.11.2;Hypoxia;425
9.11.2.1;Permissive Hypoxia;425
9.11.2.2;Management of Hypoxia;426
9.11.2.2.1;Ventilation of the Dependent Lung;426
9.11.2.2.2;Management of the Non-ventilated Lung;427
9.11.2.2.3;Regulation of Perfusion;428
9.11.2.2.4;Pharmacology;429
9.11.3;Lung Collapse;430
9.11.4;Case Discussion;430
9.11.5;References;431
9.12;27: Intraoperative Extracorporeal Life Support for Thoracic and Airway Surgery;433
9.12.1;Introduction;433
9.12.2;Brief History;434
9.12.3;Components of the ECMO Circuit;434
9.12.3.1;Oxygenator;434
9.12.3.2;Pump (When Applicable);435
9.12.3.3;Reservoir, Circuit and Connectors;435
9.12.4;ECMO Configurations;436
9.12.4.1;Configurations of ECMO;436
9.12.4.1.1;Veno-venous ECMO;436
9.12.4.1.2;Veno-arterial ECMO;437
9.12.4.1.3;AV-ECMO (Pumpless);437
9.12.4.1.4;PA-LA Novalung (Pumpless);438
9.12.5;Applications in Thoracic Surgery;438
9.12.5.1;Lung Transplantation;438
9.12.5.2;Airway Surgery;439
9.12.5.3;Impossible One-Lung Ventilation;440
9.12.5.4;Mediastinal Masses;440
9.12.5.5;Advanced Surgical Resections;440
9.12.5.6;Thoracic Emergencies;441
9.12.6;Preoperative Planning of ECMO;441
9.12.6.1;Are the Proposed Vessels Big Enough?;441
9.12.6.2;Will the Patient Tolerate the Procedure?;442
9.12.6.3;Are the Cannulas Correctly Positioned?;442
9.12.6.4;What Are the Risks of Anticoagulation, and How Should It Be Managed?;442
9.12.6.5;Vascular Access;442
9.12.6.6;Ventilation Strategies for ECMO;443
9.12.6.7;Monitoring Patients on ECMO;443
9.12.7;Troubleshooting ECMO;443
9.12.7.1;Hypoxia;443
9.12.7.1.1;Flows Are Insufficient;443
9.12.7.1.2;Recirculation;443
9.12.7.1.3;Differential Hypoxia/Watershed Phenomenon;443
9.12.7.2;Hypotension;444
9.12.7.2.1;VA-ECMO Flows Are Insufficient;444
9.12.7.2.2;The Patient’s Afterload Is Too Low;444
9.12.8;Weaning ECMO;444
9.12.8.1;VA-ECMO;444
9.12.8.2;VV-ECMO;445
9.12.9;Complications of ECLS;445
9.12.10;Clinical Case Discussion;446
9.12.11;Summary;447
9.12.12;References;447
10;Part VII: Applications of Ultrasound in Thoracic Anesthesia;451
10.1;28: Pulmonary Ultrasound;452
10.1.1;Introduction;452
10.1.2;Ultrasound Physics;452
10.1.3;Transducers;453
10.1.4;Ultrasound Nomenclature;454
10.1.5;Clinical Environment;455
10.1.6;Image Acquisition;455
10.1.7;Machine Settings;456
10.1.8;Lung Sliding, Lung Pulse, and Lung Point;456
10.1.9;A-Lines, B-Lines, and Consolidation Patterns;457
10.1.10;Clinical Applications;459
10.1.10.1;Assessment of the Patient in Undifferentiated Respiratory Failure;459
10.1.10.2;Assessment of Pneumothorax;459
10.1.10.3;Assessment of Pulmonary Edema and Fluid Tolerance;460
10.1.10.4;Assessment for the Presence of Pneumonia and Atelectasis;460
10.1.10.5;Assessment of Acute Respiratory Distress Syndrome;460
10.1.10.6;Assessment of Pleural Effusions;461
10.1.11;Pleural Fluid Volume (Ml) = Maximal Subpulmonic Distance (Mm) * 20;461
10.1.11.1;Assessment of Respiratory Complications Post-brachial Plexus Blockade;462
10.1.12;Case Presentation;462
10.1.12.1;Case Resolution;462
10.1.13;References;463
10.2;29: Ultrasound for Vascular Access;465
10.2.1;Introduction;465
10.2.2;Why Use Ultrasound?;466
10.2.3;Which Ultrasound Probe Should I Use?;466
10.2.3.1;Before Placing the Probe: A Word About Aseptic Technique;466
10.2.4;Image Optimization;467
10.2.5;Distinguishing the Vein from the Artery;467
10.2.6;Limitations of Ultrasound Technique;467
10.2.7;Summary;468
10.2.8;Ultrasound for Internal Jugular Vein Cannulation;468
10.2.8.1;Anatomy;468
10.2.8.2;Short Axis Technique;469
10.2.8.3;Long Axis Technique;469
10.2.8.4;Wire Confirmation, Trouble Shooting, and Complications;470
10.2.8.5;Summary;470
10.2.9;Ultrasound for Subclavian Vein Cannulation;470
10.2.9.1;Anatomy;470
10.2.9.2;Infraclavicular Approach;471
10.2.9.3;Supraclavicular Approach;472
10.2.9.4;Wire Confirmation, Trouble Shooting, and Complications;472
10.2.9.5;Summary;472
10.2.10;Ultrasound for Femoral Vein Cannulation;473
10.2.10.1;Anatomy;473
10.2.10.2;Ultrasound Technique;473
10.2.10.3;Long Axis Technique;474
10.2.10.4;Wire Confirmation, Trouble Shooting, and Complications;474
10.2.10.5;Summary;474
10.2.11;Ultrasound for Radial Artery Cannulation;474
10.2.11.1;Anatomy;474
10.2.11.2;Ultrasound Technique;474
10.2.11.3;Summary;475
10.2.12;References;475
10.3;30: Intraoperative Transesophageal Echocardiography for Thoracic Surgery;477
10.3.1;Introduction;478
10.3.2;Indications for TEE in Thoracic Surgery;478
10.3.3;Safety and Complications of TEE Probe Insertion;478
10.3.4;Basic Hemodynamic Assessment;480
10.3.4.1;Assessment of Left Ventricular (LV) Function;480
10.3.4.2;Assessment of Right Ventricular (RV) Function;484
10.3.5;TEE Assessment of PFO;487
10.3.6;Specific Applications;489
10.3.6.1;Lung Transplant;489
10.3.6.2;Heart-Lung Transplant;493
10.3.7;Pulmonary Embolism;493
10.3.8;Lung and Mediastinal Masses;494
10.3.9;Clinical Case Discussion;495
10.3.10;References;496
11;Part VIII: Specific Patient Consideration;500
11.1;31: Anesthesia for Patients with End-Stage Lung Disease;501
11.1.1;Introduction;501
11.1.2;Preoperative Optimization;502
11.1.2.1;Smoking Cessation;502
11.1.2.2;Pulmonary Rehabilitation;503
11.1.2.3;Medical Optimization;504
11.1.2.4;Chest Physiotherapy;505
11.1.3;General Considerations;505
11.1.3.1;Preoperative Assessment;505
11.1.3.2;Nocturnal Hypoxemia;506
11.1.3.3;Pulmonary Hypertension and Right Ventricular Function;506
11.1.4;Intraoperative Monitoring;507
11.1.5;General Versus Regional Anesthesia;507
11.1.6;Ventilation and ESLD;509
11.1.7;Minimally Invasive Surgery;510
11.1.8;Optimizing Emergence;510
11.1.9;Postoperative Management;510
11.1.10;Chronic Obstructive Pulmonary Disease;511
11.1.10.1;Diagnosis and Staging of COPD;511
11.1.10.2;Etiology of COPD;511
11.1.11;Causes of Expiratory Flow Obstruction;512
11.1.12;Dynamic Hyperinflation;514
11.1.13;Respiratory Drive in COPD;515
11.1.14;Bullae;516
11.1.15;Ventilation Strategies in Patients with Obstructive Disease;516
11.1.16;Cystic Fibrosis;517
11.1.17;Pulmonary Manifestations of CF;517
11.1.18;Management of CF;518
11.1.19;Extrapulmonary Manifestations of CF;518
11.1.20;Pregnancy and CF;519
11.1.21;Interstitial Lung Diseases;519
11.1.22;Pulmonary Manifestations of ILDs;519
11.1.23;Medical Management of ILDs;520
11.1.24;Ventilation Strategy for Restrictive Lung Diseases;520
11.1.25;ILDs and Thoracic Surgery;520
11.1.26;Clinical Case Discussion;521
11.1.26.1;How Would You Optimize This Patient for Surgery?;521
11.1.26.2;What Investigations Would You Like Prior to Induction?;521
11.1.26.3;How Would You Provide an Anesthetic for This Case?;521
11.1.27;References;522
11.2;32: Thoracic Surgery in the Elderly;526
11.2.1;Introduction;526
11.2.2;Physiology of Aging;526
11.2.2.1;Cardiovascular;527
11.2.2.2;Pulmonary;527
11.2.2.3;Hepatorenal;528
11.2.2.4;Nervous System;528
11.2.3;Aging and the Thoracic Surgical Population;528
11.2.4;The Risk-Benefit Relationship of Surgical Intervention in the Elderly;529
11.2.5;Age-Related Perioperative Morbidity and Mortality;529
11.2.6;Risk and Oncological Outcome;529
11.2.7;The Emerging Role of Minimally Invasive Surgical (MIS) Techniques;531
11.2.8;Preoperative Evaluation and Postoperative Care;532
11.2.8.1;Preoperative Assessment;532
11.2.8.2;Postoperative Planning;532
11.2.9;Conclusion;532
11.2.10;Clinical Case Discussion;533
11.2.10.1;Questions;533
11.2.10.2;Discussion;533
11.2.11;References;534
11.3;33: Thoracic Anesthesia for Morbidly Obese Patients and Obese Patients with Obstructive Sleep Apnea;536
11.3.1;Introduction;536
11.3.2;Preoperative Considerations;537
11.3.2.1;Weight;537
11.3.2.2;Pulmonary Function;537
11.3.2.3;Obstructive Sleep Apnea;538
11.3.2.4;Obesity Hypoventilation Syndrome;539
11.3.2.5;Cardiovascular Function;539
11.3.2.6;Premedication;539
11.3.3;Intraoperative Management;539
11.3.3.1;Induction Dosing of Anesthetic Agents;539
11.3.3.2;Patient Position;540
11.3.3.3;Airway;540
11.3.3.4;Lung Separation;541
11.3.3.5;One-Lung Ventilation;542
11.3.3.6;Anesthetic Drugs/Maintenance of Anesthesia;543
11.3.3.7;Intravenous Fluid Management;543
11.3.3.8;Emergence and Extubation;543
11.3.4;Postoperative Pain Control;544
11.3.5;Complications;544
11.3.6;Surgical Issues;545
11.3.7;Conclusion;545
11.3.8;Clinical Case Discussion;545
11.3.8.1;Preoperative Management;546
11.3.8.2;Intraoperative Management;546
11.3.8.3;Postoperative Management;547
11.3.9;References;547
11.4;34: Pulmonary Resection in the Patient with Pulmonary Hypertension;551
11.4.1;Introduction;552
11.4.2;Perioperative Risk;552
11.4.3;Preoperative Assessment;553
11.4.3.1;History, Physical Exam, and Investigations;553
11.4.3.2;Treatment and Consultations;554
11.4.4;Intraoperative Management;555
11.4.4.1;Premedication;556
11.4.4.2;Intraoperative Monitoring;556
11.4.4.3;Anesthetic Management;557
11.4.4.3.1;Intravenous Agents;557
11.4.4.3.2;Volatile Anesthetics;558
11.4.4.3.3;Vasopressor Agents;558
11.4.4.3.4;Vasodilator Agents;558
11.4.4.4;Analgesia;559
11.4.4.5;Management of One-Lung Ventilation;560
11.4.4.6;Intraoperative Fluid Management;561
11.4.4.7;Use of Extracorporeal Support for Pulmonary Resection (See Also Chap. 27);562
11.4.5;Postoperative Management;562
11.4.6;Conclusion;563
11.4.7;Clinical Case Discussion;564
11.4.8;References;566
12;Part IX: Complex Thoracic Surgical Procedures;571
12.1;35: Surgery of the Chest Wall and Diaphragm;572
12.1.1;Chest Wall Surgery;572
12.1.1.1;Tumors;572
12.1.1.2;Congenital Deformities;572
12.1.1.3;Thoracic Outlet Syndrome;573
12.1.2;Diaphragm Surgery;574
12.1.2.1;Hernia;574
12.1.2.2;Eventration;575
12.1.3;References;575
12.2;36: Extrapleural Pneumonectomy;576
12.2.1;Introduction;576
12.2.1.1;Malignant Pleural Mesothelioma and Pleural Dissemination of Malignancy;577
12.2.1.2;Intraoperative Intracavitary Heated Chemotherapy;577
12.2.2;Surgical Considerations;577
12.2.2.1;Technique of IOHC;578
12.2.2.2;Patient Selection;579
12.2.3;Preoperative Patient Preparation;579
12.2.3.1;Cardiopulmonary Risk Assessment;579
12.2.3.2;Radiologic Studies;579
12.2.4;Anesthetic Considerations;579
12.2.4.1;Specific Anesthetic Issues for EPP;579
12.2.4.2;Lines and Monitors;580
12.2.4.3;Choice of Anesthesia;580
12.2.4.3.1;Thoracic Epidural Analgesia;580
12.2.4.4;One-Lung Anesthesia;580
12.2.4.4.1;Lung Isolation Techniques;580
12.2.4.4.2;Optimizing Oxygenation During One-Lung Ventilation (OLV);580
12.2.4.5;Hemodynamic Management;581
12.2.4.5.1;Hypertension;581
12.2.4.5.2;Hypotension;581
12.2.4.5.3;Induction;581
12.2.4.5.4;Dissection Phase;581
12.2.4.5.5;Repositioning and Emergence;581
12.2.4.6;Fluid Management;581
12.2.4.7;Postpneumonectomy Pulmonary Edema (PPE);582
12.2.4.8;Cardiovascular Considerations;582
12.2.4.8.1;Dysrhythmias;582
12.2.4.8.2;Myocardial Ischemia;582
12.2.4.9;Perioperative Pain Management;583
12.2.4.10;Early Postoperative Considerations;583
12.2.4.10.1;Management of the Ipsilateral Thoracic Space;583
12.2.4.10.2;Other Issues Specific to EPP;583
12.2.5;Conclusion;583
12.2.6;Clinical Case Discussion;583
12.2.6.1;Questions;583
12.2.7;References;584
12.3;37: Pancoast Tumors and Combined Spinal Resections;586
12.3.1;Introduction;586
12.3.2;Anatomy of Pancoast Tumors;586
12.3.3;Initial Assessment;587
12.3.4;Multimodality Treatment;588
12.3.5;Surgical Approaches to Resection;590
12.3.6;Posterior Approach;590
12.3.7;Tumors Involving the Vertebral Bodies and Epidural Region;590
12.3.8;Anterior Approaches;592
12.3.9;Anesthetic Considerations;593
12.3.10;Postoperative Considerations;595
12.3.11;Clinical Case Discussion;595
12.3.11.1;Questions;595
12.3.11.2;Discussion;595
12.3.12;References;596
12.4;38: Anesthesia for Esophageal Surgery;597
12.4.1;Anatomy and Physiology of the Esophagus;598
12.4.2;Nonmalignant Disorders of the Esophagus and Surgical Therapies;599
12.4.2.1;Hiatal Hernia, Gastroesophageal Reflux Disease (GERD), and Esophageal Stricture;599
12.4.3;Esophageal Perforation and Rupture;601
12.4.4;Achalasia and Motility Disorders;602
12.4.5;Tracheoesophageal Fistula (TEF);603
12.4.6;Esophageal Diverticula;603
12.4.7;Malignant Disease of the Esophagus and Esophagectomy;604
12.4.7.1;Esophageal Cancer;604
12.4.7.2;Esophagectomy;605
12.4.7.3;Esophageal Conduits;606
12.4.8;Anesthetic Management of Esophageal Surgery Patients;607
12.4.8.1;Preoperative Evaluation and Preparation;607
12.4.8.2;Intraoperative Monitoring;608
12.4.8.3;Pain Control;608
12.4.9;Induction and Airway Management;609
12.4.9.1;Intraoperative Management;611
12.4.9.2;Lung Isolation and One-Lung Ventilation;612
12.4.9.2.1;Fluid Management;612
12.4.9.3;Intraoperative Complications;614
12.4.9.4;Postoperative Management and Complications;615
12.4.10;Anesthetic Considerations for Specific Esophageal Procedures and Disorders;616
12.4.10.1;Esophagoscopy;616
12.4.10.2;Tracheoesophageal Fistula (TEF);616
12.4.10.3;Transthoracic Nissen and Belsey Fundoplication, Collis Gastroplasty, and Paraesophageal Hernia Repair;617
12.4.10.4;Esophagectomy;618
12.4.10.4.1;Transhiatal Esophagectomy (THE);618
12.4.10.4.2;Transthoracic Esophagectomy (Ivor Lewis; TTE);618
12.4.10.5;Minimally Invasive Esophagectomy (MIE);620
12.4.10.6;Robotic Esophagectomy;620
12.4.10.7;Postoperative Care of the Esophagectomy Patient;620
12.4.10.7.1;Adverse Outcomes After Esophagectomy;621
12.4.10.8;Esophageal Anastomotic Leaks;621
12.4.10.9;Cardiovascular Complications;621
12.4.10.10;Pulmonary Complications;622
12.4.10.11;Improving Outcomes After Esophagectomy;622
12.4.10.12;Surgery for Esophageal Rupture and Perforation;624
12.4.10.13;Surgery for Achalasia;624
12.4.10.14;Surgery for Esophageal Diverticula;625
12.4.10.14.1;Zenker’s Diverticulum;625
12.4.10.14.2;Thoracic Diverticula;625
12.4.11;Esophageal Surgery Clinical Case Discussion;625
12.4.11.1;Questions;625
12.4.12;References;626
12.5;39: Anesthesia for Robotic Thoracic Surgery;638
12.5.1;Introduction;638
12.5.2;The da Vinci® Robot Surgical System;638
12.5.3;Anesthetic Implications in Robotic Thoracic Surgery;639
12.5.4;Robotic-Assisted Surgery and Anesthesia for Mediastinal Masses;640
12.5.5;Robotic-Assisted Pulmonary Lobectomy;641
12.5.6;Carbon Dioxide Insufflation During Robotic Surgery;642
12.5.7;Robotic-Assisted Esophageal Surgery and Anesthetic Implications;643
12.5.8;Summary;644
12.5.9;References;645
12.6;40: Anaesthesia for Combined Cardiac and Thoracic Procedures;647
12.6.1;Introduction;647
12.6.2;Structure of the Alveolar-Capillary Barrier;647
12.6.3;Lung Injury During Surgery with Use of Cardiopulmonary Bypass;650
12.6.4;Prevention of Lung Injury After Cardiac Procedures;652
12.6.5;Surgical Considerations;653
12.6.6;Anaesthetic Management for Combined Cardiac and Thoracic Procedures;653
12.6.6.1;Preoperative Assessment;654
12.6.6.2;Anaesthetic Management;654
12.6.7;Summary;656
12.6.8;Case Presentation;656
12.6.8.1;Questions;657
12.6.8.2;Questions;657
12.6.9;References;658
12.7;41: Open Thoracoabdominal Aortic Aneurysm Repair;660
12.7.1;Introduction;660
12.7.2;Anatomy and Physiology;661
12.7.2.1;Crawford Classification of TAAA Repair;661
12.7.2.2;Pathophysiology of Aortic Cl662
12.7.2.3;Pathophysiology of Spinal Cord Injury;662
12.7.2.3.1;Blood Supply of the Spinal Cord;662
12.7.2.3.2;A Physiological Approach to SCI;663
12.7.3;Surgical Technique;664
12.7.4;Preoperative Evaluation;665
12.7.5;Intraoperative Management;666
12.7.5.1;Monitoring;666
12.7.5.1.1;Five-Lead Electrocardiogram (ECG) and Defibrillation Pads;666
12.7.5.1.2;Invasive Blood Pressure;666
12.7.5.1.3;Pulmonary Artery Catheter (PAC);666
12.7.5.1.4;Transesophageal Echocardiogram (TEE);667
12.7.5.1.5;Spinal Cord Monitoring;667
12.7.5.1.6;Cerebral Monitoring;667
12.7.5.1.7;Temperature;667
12.7.5.2;Vascular Access;668
12.7.5.3;Other Tubes;668
12.7.5.4;Anesthetic Technique;668
12.7.5.5;Positioning;668
12.7.5.6;One-Lung Ventilation;668
12.7.5.7;Hemodynamic Management;669
12.7.5.8;Fluid Management with Massive Blood Loss;669
12.7.5.9;Spinal Cord Protection Strategies;670
12.7.5.9.1;Cerebrospinal Fluid Drainage (CSFD);671
12.7.5.9.2;Supporting SCPP;671
12.7.5.9.3;Hypothermia;672
12.7.5.9.4;Drugs;672
12.7.5.9.5;Hyperbaric Oxygen;672
12.7.5.10;Technical Specifics of Cerebrospinal Fluid Drainage;672
12.7.5.11;Renal Protection Strategies;674
12.7.6;Postoperative Care;675
12.7.7;Summary;675
12.7.8;Clinical Case Discussion;675
12.7.9;References;675
13;Part X: Anesthetic Management of Uncommon Pulmonary Procedures;681
13.1;42: Thoracic Anesthesia in the Developing World;682
13.1.1;Introduction;682
13.1.1.1;Challenges Faced by Thoracic Anesthesiologist in the Developing World;682
13.1.2;Conduct of Thoracic Anesthesia in Developing World: Meeting the Challenge;683
13.1.2.1;Preoperative Care: Assessment and Optimization;684
13.1.2.2;Intraoperative Care;684
13.1.2.2.1;Selection of Lung Isolation Devices;685
13.1.2.2.2;Methods to Aid Insertion of Lung Isolation Devices;686
13.1.2.2.3;Methods to Monitor the Position of the Lung Isolation Device;686
13.1.2.3;Postoperative Care and Analgesia for Thoracic Patients;687
13.1.3;Anesthesia for Thoracic Surgeries in Patients with Infective Lung Diseases;688
13.1.4;Tuberculosis;688
13.1.4.1;Incidence and Prevalence;688
13.1.4.2;Pathophysiology;689
13.1.4.3;Surgery and TB;690
13.1.4.4;TB and Anesthesia Implications;691
13.1.4.5;Preventing Transmission of TB to Other Patients and Healthcare Workers (HCW);691
13.1.4.6;Postoperative Care;692
13.1.5;Bronchiectasis;692
13.1.5.1;Pathophysiology and Causes;692
13.1.5.2;Anesthetic Considerations;694
13.1.6;Empyema;694
13.1.6.1;Bacteriology;695
13.1.6.2;Pathophysiology;695
13.1.6.3;Surgery for Empyema;696
13.1.7;Lung Abscess;696
13.1.8;Pneumatoceles;697
13.1.9;Hydatid Disease of the Lung or Pulmonary Echinococcosis;697
13.1.9.1;Cyst Composition;697
13.1.9.2;Surgical Options;697
13.1.9.3;Anesthesia Considerations;698
13.1.10;References;698
13.2;43: Bronchopleural Fistulae;700
13.2.1;Summary;700
13.2.1.1;Pathophysiology and Pathogenesis of Bronchopleural Fistulae;700
13.2.1.2;The Pathophysiological Consequences of Large Air Leaks;703
13.2.1.3;Bronchopleural Fistula, Intermittent Positive Pressure Ventilation, and Effective Fistula Size;703
13.2.2;Anesthesia and BPF;704
13.2.2.1;Interventional Pulmonology Management of Bronchopleural Fistula;708
13.2.2.2;Management of Bronchopleural Fistula in Ventilated Patients;709
13.2.3;References;710
13.3;44: Massive Hemoptysis;715
13.3.1;Introduction;715
13.3.2;Historical Considerations;716
13.3.3;Etiologies;716
13.3.4;Clinical Manifestation;717
13.3.5;Initial Management of MH;717
13.3.6;Life-Threatening Intervention;717
13.3.7;Diagnostic Tools and Therapeutic Approaches;719
13.3.7.1;Bronchoscopy;719
13.3.7.1.1;Timing;719
13.3.7.1.2;Type of Bronchoscopy;720
13.3.7.1.2.1;Rigid;720
13.3.7.1.2.2;Flexible;720
13.3.7.1.2.3;Endobronchial Therapy;720
13.3.7.1.2.4;Pharmacologic Adjuncts;720
13.3.7.1.2.5;Mechanical Therapy;720
13.3.7.2;Systemic Therapy;720
13.3.7.3;Bronchial Artery Embolization (BAE);721
13.3.7.4;Surgery;721
13.3.7.5;Iatrogenic Pulmonary Artery Rupture (IPAR);722
13.3.7.5.1;Intensive Care Unit Setting;722
13.3.7.5.2;Operating Room Setting;723
13.3.7.5.3;Radiological Setting;724
13.3.7.5.3.1;Pulmonary Artery False Aneurysm (PAFA);724
13.3.7.5.4;Other Causes;724
13.3.8;Management Post Hemoptysis;724
13.3.9;Tracheostomy Hemorrhage;724
13.3.10;Conclusion;725
13.3.11;Clinical Case Discussion;725
13.3.11.1;Questions;726
13.3.12;References;726
13.4;45: Whole Lung Lavage;728
13.4.1;Introduction;728
13.4.2;Historical Consideration;728
13.4.3;Indications;728
13.4.3.1;Pulmonary Alveolar Proteinosis;728
13.4.3.1.1;Pathogenesis and Classification;729
13.4.3.1.2;Clinical Manifestations;729
13.4.3.1.3;Radiographic Findings;729
13.4.3.1.4;Physiological Testing;729
13.4.3.1.5;Laboratory Investigation;729
13.4.3.1.6;Therapy;730
13.4.3.1.6.1;Whole Lung Lavage;730
13.4.3.1.6.2;GM-CSF;730
13.4.3.1.6.3;Other Therapies;730
13.4.4;Whole-Lung Lavage Technique;730
13.4.4.1;Monitoring;730
13.4.4.2;General Anesthesia;731
13.4.4.3;Lung Separation;731
13.4.4.4;Lung Lavage;731
13.4.4.5;Bilateral WLL;732
13.4.4.6;Associated Bronchoalveolar Lavage (BAL);732
13.4.4.7;Complications;733
13.4.4.7.1;Desaturation;733
13.4.4.7.2;Leakage;733
13.4.4.8;Ending;734
13.4.5;Post Whole-Lung Lavage Evolution;735
13.4.6;Pediatric Whole Lung Lavage;736
13.4.7;Conclusion;737
13.4.8;Clinical Case Discussion;737
13.4.9;References;737
14;Part XI: Anesthesia for Surgical Procedures for End-Stage Lung Diseases;739
14.1;46: Lung Volume Reduction;740
14.1.1;Introduction;740
14.1.2;History of Lung Volume Reduction Surgery (LVRS);740
14.1.3;Clinical Features of Emphysema;741
14.1.4;Preoperative Medical Management of Emphysema Patients;741
14.1.5;Evaluation of Patients for LVRS and Selection Criteria;742
14.1.5.1;General Evaluation;742
14.1.5.2;Anatomic/Radiologic Evaluation;742
14.1.5.3;Physiologic Evaluation;743
14.1.6;Approach: Surgical vs. Bronchoscopic;744
14.1.6.1;Video-Assisted Thoracoscopic Surgery (VATS);744
14.1.6.2;Bronchoscopic Placement of Endobronchial Valves and Blockers;744
14.1.7;Anesthetic Management;746
14.1.7.1;Preoperative Assessment;746
14.1.7.1.1;Pharmacologic Preparation;746
14.1.7.2;Pain Management;746
14.1.7.2.1;Thoracic Epidural Analgesia;746
14.1.7.2.2;Paravertebral Nerve Block;747
14.1.7.3;Intraoperative Management;747
14.1.7.3.1;Monitors;747
14.1.7.3.2;General Anesthesia;747
14.1.7.3.3;Mechanical Ventilation;747
14.1.7.3.4;Early Extubation;747
14.1.7.4;Postoperative Management;748
14.1.8;Summary;748
14.1.9;Clinical Case Discussion;748
14.1.9.1;Questions;748
14.1.10;References;749
14.2;47: Lung Transplantation;751
14.2.1;Introduction;751
14.2.2;Donor Organ Management;751
14.2.3;Recipient Candidates;753
14.2.4;Anesthesia for Lung Transplantation;755
14.2.4.1;Preoperative Assessment;755
14.2.4.2;Monitoring;755
14.2.4.3;Transesophageal Echocardiography;755
14.2.4.4;Induction of Anesthesia;756
14.2.5;Maintenance of Anesthesia;757
14.2.6;Management of RV Dysfunction;757
14.2.7;Extracorporeal Support;758
14.2.8;Organ Reperfusion;758
14.2.9;Analgesia;758
14.2.9.1;Postoperative care;758
14.2.10;Clinical Case Discussion;759
14.2.10.1;Case Presentation;759
14.2.10.1.1;Questions;759
14.2.10.2;Case Continuation;760
14.2.10.2.1;Questions;760
14.2.10.3;Case Continuation;760
14.2.10.3.1;Questions;760
14.2.10.4;Case Continuation;760
14.2.10.4.1;Questions;760
14.2.10.4.2;Discussion;760
14.2.11;References;763
14.3;48: Anesthesia for the Patient with a Previous Lung Transplant;768
14.3.1;Introduction;768
14.3.2;Common Procedures After Lung Transplantation;768
14.3.3;Pulmonary Physiology Post Lung Transplantation;768
14.3.4;Anesthetic Considerations;769
14.3.5;Intraoperative Airway and Ventilation Management;770
14.3.6;Intraoperative Management;771
14.3.7;Postoperative Care;771
14.3.8;Clinical Case Discussion;771
14.3.8.1;Questions;771
14.3.8.1.1;Transplant-Related History;771
14.3.8.1.2;Intraoperative Concerns;771
14.3.8.1.3;Postoperative Analgesia;772
14.3.9;References;772
14.4;49: Anesthesia for Pulmonary Thromboendarterectomy;773
14.4.1;Introduction;773
14.4.2;Classification of Pulmonary Hypertension;774
14.4.3;Chronic Thromboembolic Pulmonary Hypertension (CTEPH);774
14.4.3.1;Incidence;774
14.4.3.2;Etiologic Factors;774
14.4.3.3;Pathology and Pathogenesis;774
14.4.3.4;Clinical Presentation;775
14.4.4;The Surgical Procedure;776
14.4.4.1;Surgical Approach and Technique;776
14.4.4.2;Surgical Subtypes;777
14.4.5;Anesthetic Management;778
14.4.5.1;Setup and Preparation;778
14.4.5.2;Anesthetic Induction and Pre-CPB Management;778
14.4.5.3;Management of Deep Hypothermic Circulatory Arrest (DHCA);780
14.4.5.4;Post-DHCA Rewarming;781
14.4.5.5;Separation from CPB;781
14.4.5.6;Post-CPB Management;781
14.4.5.7;Postoperative Management;782
14.4.5.8;Outcome After PTE;784
14.4.6;Future;785
14.4.7;Clinical Case Discussion;785
14.4.7.1;Questions;785
14.4.8;References;785
15;Part XII: Anesthesia for Pediatric Thoracic Surgical Procedures;788
15.1;50: Anesthesia for Pediatric Thoracic Surgery;789
15.1.1;Introduction;789
15.1.2;Pediatric Growth and Development;790
15.1.3;Special Considerations;791
15.1.3.1;Prematurity;791
15.1.3.2;Pulmonary Hypertension;791
15.1.3.3;Cardiac Disease;792
15.1.3.4;Preoperative Evaluation;792
15.1.3.5;Strategies for Lung Isolation;793
15.1.4;Anesthetic Management of Specific Procedures and Diseases;796
15.1.4.1;Bronchoscopy;796
15.1.4.2;Thoracotomy and Video-Assisted Thoracoscopic Surgery (VATS);798
15.1.4.3;Empyema;799
15.1.4.4;Patent Ductus Arteriosus (PDA);799
15.1.4.5;Tracheoesophageal Fistula (TEF);800
15.1.4.6;Mediastinal Mass;801
15.1.4.6.1;Diagnosis and Risk Stratification;802
15.1.4.7;Congenital Diaphragmatic Hernia (CDH);804
15.1.4.8;Lung Biopsy;806
15.1.4.9;Cystic Fibrosis (CF);806
15.1.4.10;Pulmonary Alveolar Proteinosis;807
15.1.4.11;Trauma, Pneumothorax, and Hemothorax;808
15.1.4.12;Lung Transplantation;809
15.1.4.13;Postoperative and Pain Management;810
15.1.5;Clinical Case Discussion;811
15.1.6;References;811
16;Part XIII: Trauma;816
16.1;51: Anesthetic Management of Thoracic Trauma;817
16.1.1;Introduction;817
16.1.1.1;Anatomy;818
16.1.1.2;Initial Approach to the Patient with Thoracic Trauma;818
16.1.1.2.1;Echocardiography in Thoracic Trauma;819
16.1.1.2.2;Image Acquisition;820
16.1.1.2.3;Blunt Cardiac Injury (Myocardial Contusion, Valvular Insufficiency, Pericardial Effusion, and Tamponade);821
16.1.1.2.4;Aortic Injury;822
16.1.1.2.5;Hypovolemia;823
16.1.1.2.6;Training and Certification;824
16.1.1.3;Traumatic Airway Management;824
16.1.1.4;Lung Isolation;826
16.1.1.5;Tracheobronchial Injury;826
16.1.1.5.1;Aortic Injury;827
16.1.1.5.2;Pulmonary Contusion;829
16.1.1.5.3;Blunt Cardiac Injury;829
16.1.1.5.4;Chest Wall Injury;831
16.1.1.5.5;Flail Chest;831
16.1.1.5.6;Pleural Space;832
16.1.1.5.7;Pain Management for Blunt Thoracic Trauma;833
16.1.2;Clinical Case Discussion;837
16.1.2.1;Questions;837
16.1.2.2;Questions;837
16.1.2.3;Questions;838
16.1.3;References;838
17;Part XIV: Post-operative Management;843
17.1;52: Enhanced Recovery After Surgery (ERAS) for Thoracic Surgery;844
17.1.1;Background;844
17.1.2;ERAS General Overview;845
17.1.3;ERAS for Thoracic Surgery: Rationale;846
17.1.4;ERAS Thoracic Surgery: Pre-operative Components;846
17.1.5;Optimization of Comorbid Conditions;847
17.1.6;Nutrition;847
17.1.7;Anemia Screening;848
17.1.8;Tobacco;848
17.1.9;ERAS Thoracic Surgery: Intraoperative Components;848
17.1.9.1;Analgesia;848
17.1.9.1.1;Mechanical Ventilation Strategy;849
17.1.9.1.2;Maintenance of Anesthesia;849
17.1.9.1.3;Fluid Management;849
17.1.10;ERAS Thoracic Surgery: Post-operative Components;850
17.1.11;Removal of Lines and Drains;850
17.1.12;Chest Drains;850
17.1.13;Early Mobilization;851
17.1.14;Incentive Spirometry;851
17.1.15;Multimodal Analgesia;851
17.1.16;Barriers to Implementation and Sustainability;852
17.1.17;Current State, Future Directions, and Applicability;852
17.1.18;References;852
17.2;53: Anesthetic Management of Post-thoracotomy Complications;856
17.2.1;Introduction;856
17.2.2;Mechanical Ventilation and Extubation;857
17.2.2.1;Classification of Respiratory Failure;857
17.2.2.2;Criteria for Extubation;857
17.2.2.3;Complications of Prolonged Intubation and Mechanical Ventilation;857
17.2.2.4;Independent Lung Ventilation;858
17.2.3;Airway Complications;858
17.2.3.1;Endotracheal Intubation and Airway Injury;858
17.2.3.2;Airway Bleeding and Secretions;859
17.2.3.3;Vocal Cord Injuries;859
17.2.3.4;Intrathoracic Complications;859
17.2.4;Air Leak, Pneumothorax, and Bronchopleural Fistula;859
17.2.4.1;Mediastinal Emphysema;860
17.2.4.2;Deep Vein Thrombosis and Pulmonary Embolism;860
17.2.4.3;Postpneumonectomy Syndrome;860
17.2.4.4;Post Lung Resection Pulmonary Edema;861
17.2.4.5;Phrenic Nerve Injury;861
17.2.5;Cardiac Complications;861
17.2.5.1;Cardiac Failure and Arrhythmias;861
17.2.5.2;Cardiac Herniation;862
17.2.5.3;Interatrial Shunting;862
17.2.6;Clinical Case Discussion;863
17.2.6.1;Questions;863
17.2.7;References;863
17.3;54: Postoperative Respiratory Failure and Treatment;866
17.3.1;Definition;867
17.3.2;Preoperative Predictors of Postoperative Respiratory Failure;868
17.3.2.1;History;868
17.3.2.2;Procedure and Extent of Resection;869
17.3.2.2.1;Thoracotomy for Lung Resection;869
17.3.2.2.2;Video-Assisted Thoracic Surgery for Lung Resection;869
17.3.2.2.3;Robot Video-Assisted Thoracic Surgery for Lung Resection;869
17.3.2.2.4;Lung Volume Reduction Surgery;869
17.3.2.2.5;Trans-sternal Thymectomy;869
17.3.2.2.6;Esophagogastrectomy;870
17.3.2.2.7;Lung Transplantation;870
17.3.2.2.8;Thoracoabdominal Aortic Aneurysm (TAAA) Repair;870
17.3.2.3;Specific Etiologies of Respiratory Failure: Their Prevention and Treatment;870
17.3.2.4;Atelectasis;870
17.3.2.5;Bronchospasm;873
17.3.2.6;Retained Secretions;874
17.3.2.7;Pneumonia;874
17.3.2.8;Pulmonary Embolism;875
17.3.2.9;Pulmonary Edema;875
17.3.2.10;Pneumothorax;876
17.3.2.11;Persistent Air Leaks and Bronchopleural Fistula;876
17.3.2.12;Aspiration of Gastric Contents;876
17.3.2.13;Torsion of Residual Lobe;877
17.3.2.14;Neurologic Injuries;877
17.3.3;Mechanical Ventilation After Thoracic Surgery;877
17.3.3.1;Preoperative Indications for Postoperative Mechanical Ventilation;878
17.3.3.2;Intraoperative Indications for Postoperative Mechanical Ventilation;878
17.3.3.3;Immediate Postoperative Indications for Mechanical Ventilation;879
17.3.3.4;Ventilatory Modes;879
17.3.3.5;Noninvasive Ventilation;879
17.3.3.6;Lung-Protective Ventilation;881
17.3.4;Acute Respiratory Distress Syndrome;882
17.3.4.1;Therapy of ARDS;882
17.3.4.1.1;Mechanical Ventilation with PEEP;883
17.3.4.1.2;Prone Position;885
17.3.4.1.3;Alternate Modes of Ventilation;885
17.3.4.1.4;Inhaled Pulmonary Vasodilators;885
17.3.4.1.5;Extracorporeal Membrane Oxygenation (ECMO);885
17.3.5;Complications of Mechanical Ventilation;886
17.3.5.1;Trauma to the Lungs or Tracheobronchial Tree;886
17.3.5.2;Ventilator-Associated Pneumonia;886
17.3.5.2.1;Diagnosis;886
17.3.5.2.2;Prevention;886
17.3.6;Withdrawal of Mechanical Ventilation;887
17.3.6.1;Extubation;888
17.3.6.2;Tracheotomy;888
17.3.7;Clinical Case Discussion;888
17.3.7.1;Questions;888
17.3.7.2;Answers;888
17.3.7.3;Question;889
17.3.7.4;Answer;889
17.3.7.5;Questions;889
17.3.7.6;Answers;889
17.3.8;References;889
17.4;55: Postoperative Management of Respiratory Failure: Extracorporeal Ventilatory Therapy;895
17.4.1;Introduction;895
17.4.2;Lung-Protective Ventilatory Strategies;896
17.4.2.1;Lung-Protective Ventilation;896
17.4.2.2;Extracorporeal Ventilatory Therapy in ARDS Patients;896
17.4.2.3;Separation of Ventilation and Oxygenation (Concept “Lung Rest”);897
17.4.2.4;Extracorporeal Membrane Oxygenation (ECMO);897
17.4.2.4.1;Indications;897
17.4.2.4.2;Technical Aspects of ECMO;898
17.4.2.4.3;VV ECMO;898
17.4.2.4.4;ECMO Cannulation;898
17.4.2.4.5;Initiation of ECMO;900
17.4.2.4.6;Temperature Management on ECMO;900
17.4.2.4.7;Monitoring for Anticoagulation;900
17.4.2.5;Complications;901
17.4.2.5.1;Bleeding and Thrombosis;901
17.4.2.5.2;Cerebral Hemorrhage and Infarction;901
17.4.2.6;Weaning of ECMO;901
17.4.2.7;Extracorporeal Carbon Dioxide Removal (ECCO2R);901
17.4.2.8;Indications for ECCO2R;903
17.4.2.9;Complications;903
17.4.2.10;Multimodal Therapeutic Approach;905
17.4.2.10.1;Weaning of Sedation;905
17.4.2.10.2;Early Spontaneous Breathing;905
17.4.3;Clinical Case Discussion;905
17.4.3.1;Questions;905
17.4.4;References;906
17.5;56: Cardiovascular Adaptations and Complications;909
17.5.1;Introduction;909
17.5.2;Cardiac Adaptation;910
17.5.2.1;Intraoperative Changes in Right Ventricular Function and Anatomy Related to One-Lung Ventilation and Positioning;910
17.5.2.2;Acute and Late Phase Changes in Right Ventricular Anatomy After Lung Resection;911
17.5.3;Cardiac Complications;911
17.5.3.1;Supraventricular Tachyarrhythmias (Atrial Fibrillation, Atrial Flutter, and Supraventricular Tachycardia);911
17.5.3.2;Role of Medications Used for Treatment and Prevention;913
17.5.3.2.1;Rate Control Agents;913
17.5.3.2.2;Rhythm Control Medications;915
17.5.3.2.3;Novel Medications;915
17.5.3.3;Role of Postoperative Chemical and Electrical Cardioversion;916
17.5.4;Acute Coronary Syndrome;916
17.5.5;Heart Failure and Cardiac Herniation;917
17.5.6;Mediastinal Shift and Post-pneumonectomy Syndrome;918
17.5.7;Conclusion;918
17.5.8;Clinical Case Discussion;919
17.5.8.1;Questions;919
17.5.8.2;Specifically;919
17.5.8.3;Back to the Case;919
17.5.9;References;920
17.6;57: Post-thoracic Surgery Patient Management and Complications;923
17.6.1;General Principles of Postoperative Care;923
17.6.2;Preoperative Preparation;923
17.6.2.1;Preoperative Teaching;923
17.6.2.2;Preoperative Pulmonary Exercise and Training;923
17.6.2.3;Smoking;924
17.6.2.4;Anticoagulant and Anti-aggregant Medication;924
17.6.3;Postoperative Management;925
17.6.3.1;Postoperative Pain Management;925
17.6.3.2;Respiratory Care;925
17.6.3.3;Intravenous Fluids;925
17.6.3.4;Chest Drainage System;927
17.6.3.5;Postoperative Nutrition;928
17.6.3.6;Prevention of Venous Thromboembolism;928
17.6.4;General Complications of Thoracotomy;929
17.6.4.1;Pneumonia;929
17.6.4.2;Atrial Fibrillation;929
17.6.5;Pleural Space Problems;930
17.6.5.1;Air Leak;930
17.6.5.2;Empyema;931
17.6.6;Nerve Injury;933
17.6.7;Postoperative Hemorrhage;934
17.6.8;Chylothorax;934
17.6.9;Torsion of a Residual Lobe;934
17.6.10;Postpneumonectomy Syndrome;934
17.6.11;Cardiac Herniation;935
17.6.12;Clinical Case Discussion;936
17.6.13;References;937
17.7;58: Troubleshooting Chest Drains;939
17.7.1;Introduction and Relevance;939
17.7.2;Indications and Physiology;939
17.7.3;Chest Tubes and Insertion;939
17.7.3.1;Chest Tube Insertion Techniques;940
17.7.3.2;Postsurgical Chest Drains;942
17.7.3.3;Indwelling Pleural Catheters;943
17.7.3.4;Drainage Collection Systems;944
17.7.3.5;Drainage Volume;945
17.7.3.6;Air Leak;945
17.7.4;Complications of Insertion;946
17.7.5;Chest Tube Removal and Thresholds;946
17.7.6;Special Situations;947
17.7.6.1;Bronchopleural Fistula;947
17.7.6.2;Post-pneumonectomy Chest Tubes;947
17.7.6.3;Abrupt Changes in Chest Tube Output;947
17.7.6.4;Clamping Chest Tubes;948
17.7.7;Summary;948
17.7.8;References;948
17.8;59: Pain Management After Thoracic Surgery;950
17.8.1;Introduction;951
17.8.2;Pathophysiology of Post-Thoracotomy Pain;951
17.8.3;Factors Influencing Pain After Thoracic Surgery;952
17.8.3.1;Preoperative Preparedness and Use of Perioperative Clinical Pathways;952
17.8.3.2;Opioid Tolerance;952
17.8.3.3;Preemptive Analgesia;953
17.8.3.4;Sex;953
17.8.3.5;Age;953
17.8.3.6;Psychological Factors;953
17.8.3.7;Surgical Approach;953
17.8.3.7.1;Sternotomy;953
17.8.3.7.2;Video-Assisted Thoracoscopic Surgery;953
17.8.3.7.3;Open Thoracotomy;954
17.8.3.7.3.1;Posterolateral Incision;954
17.8.3.7.3.2;Muscle-Sparing Incision;954
17.8.3.7.3.3;Anterior Incision;954
17.8.3.7.3.4;Transverse Sternothoracotomy;954
17.8.4;Analgesic Drugs and Techniques;955
17.8.5;Systemic Opioids;955
17.8.6;Non-opioid Analgesic Drugs;956
17.8.6.1;Nonsteroidal Anti-inflammatory Drugs;956
17.8.6.2;COX-2 Inhibitors;956
17.8.6.3;Acetaminophen;956
17.8.6.4;NMDA Antagonists;957
17.8.6.5;Gabapentinoids;958
17.8.6.6;?2 Adrenergic Agonists;959
17.8.6.7;Glucocorticoids;959
17.8.7;Non-pharmacologic Techniques;959
17.8.7.1;Transcutaneous Nerve Stimulation;959
17.8.7.2;Cryoanalgesia;960
17.8.8;Regional Techniques;960
17.8.9;Consent for Regional Analgesia;960
17.8.10;Local Anesthetic Patches;961
17.8.11;Continuous Wound Infiltration Catheters;961
17.8.12;Intercostal Nerve Blocks;961
17.8.13;Interpleural Blocks;961
17.8.14;Serratus Anterior Plane Blocks;963
17.8.14.1;Introduction;963
17.8.14.2;SAPB in Clinical Practice;963
17.8.14.3;Technique;964
17.8.15;Paravertebral Blocks;964
17.8.15.1;Anatomy;965
17.8.15.2;Methods of Performing Paravertebral Blocks;965
17.8.15.3;Landmark Methods;965
17.8.15.4;Ultrasound-Guided Methods;967
17.8.15.5;Open Methods;970
17.8.15.6;Management of Paravertebrals;971
17.8.15.7;Advantages of Paravertebral Analgesia;972
17.8.15.8;Limitations and Complications of Paravertebral Blocks;972
17.8.16;Erector Spinae Plane Blocks;973
17.8.16.1;Technique (See Figs. 59.19 and 59.20);973
17.8.17;Intrathecal Analgesia;973
17.8.18;Epidural Analgesia;974
17.8.18.1;Lumbar Epidural Analgesia;974
17.8.18.2;Thoracic Epidural Analgesia;974
17.8.18.2.1;Technique of Insertion;974
17.8.18.2.2;Epidural Solutions;976
17.8.18.2.3;Impact of Thoracic Epidural Analgesia;976
17.8.18.2.3.1;Improvement of Postoperative Diaphragmatic Dysfunction;977
17.8.18.2.3.2;Incidence of Cardiovascular Complications;977
17.8.18.2.3.3;Thoracic Epidurals and Outcome;977
17.8.19;Limitations and Adverse Effects;977
17.8.19.1;Urinary Retention;978
17.8.19.2;Gastric Emptying;978
17.8.19.3;Hypotension;978
17.8.20;Neuraxial Block and Coagulation;979
17.8.20.1;Heparin and Thromboprophylaxis;979
17.8.20.2;Fondaparinux;980
17.8.20.3;Warfarin;980
17.8.20.4;NOACs: Novel Oral Anticoagulants;980
17.8.20.5;Antiplatelet Medications;980
17.8.20.6;NSAIDs (Including Aspirin);980
17.8.20.7;Thienopyridine Derivatives;980
17.8.20.8;Platelet Glycoprotein IIb/IIIa Inhibitors;980
17.8.20.9;Herbal (Alternative) Medication;981
17.8.21;Coronary Stents;981
17.8.22;Techniques for Specific Situations;981
17.8.22.1;Sternotomy;981
17.8.22.2;Video-Assisted Surgery;981
17.8.22.3;Open Thoracotomy;981
17.8.22.4;Esophageal Surgery;982
17.8.22.5;Shoulder Pain;983
17.8.22.6;Opioid-Tolerant Patients;984
17.8.23;Conclusion;985
17.8.24;Case Study;986
17.8.24.1;Questions;986
17.8.25;References;986
17.9;60: Long-Acting Local Anesthetics for Analgesia Following Thoracic Surgery;997
17.9.1;Introduction;997
17.9.2;History of Local Anesthetics;998
17.9.2.1;Origins in the Americas;998
17.9.2.2;Synthetic Anesthetics;998
17.9.2.3;Current Long-Acting Local Anesthetics;999
17.9.2.4;Liposomal Bupivacaine and the Introduction of a New Class of Anesthetics;1000
17.9.2.4.1;Safety;1000
17.9.2.4.2;Preparation and Application;1001
17.9.2.4.3;Contraindications and Precautions;1001
17.9.3;Regional Anesthetic Techniques for Thoracic Surgery;1001
17.9.3.1;Thoracic Epidural Anesthesia;1001
17.9.3.2;Shift Toward More Peripheral Regional Techniques;1001
17.9.3.3;Thoracic Paravertebral Blockade (Please See Figs. 59.5 and 59.6 from Chap. 59);1003
17.9.3.4;Intercostal Nerve Block;1003
17.9.3.5;Direct Interpleural Anesthesia;1005
17.9.3.6;Serratus Plane (SAP) Block;1005
17.9.3.7;Local Surgical Site Infiltration;1006
17.9.3.8;Phrenic Nerve Block and Other Blocks Targeting Ipsilateral Shoulder Pain (ISP);1006
17.9.3.8.1;Etiology;1006
17.9.3.8.2;Treatment;1007
17.9.4;Conclusion;1007
17.9.5;Case Discussion;1008
17.9.6;References;1008
17.10;61: Chronic Post-thoracotomy Pain;1012
17.10.1;Introduction;1012
17.10.2;Characteristics and Prevalence of Chronic Post-thoracotomy Pain;1013
17.10.3;The Impact of Chronic Post-thoracotomy Pain on Function;1014
17.10.4;Factors Influencing the Development of Chronic Post-thoracotomy Pain;1014
17.10.4.1;Pain Before and After Surgery;1014
17.10.4.2;Genetic Factors;1015
17.10.4.3;Anesthetic Factors;1015
17.10.4.4;Surgical Factors;1016
17.10.5;Prevention of Chronic Post-thoracotomy Pain;1018
17.10.6;Management of Chronic Post-thoracotomy Pain;1019
17.10.7;Clinical Case Discussion;1020
17.10.8;Past Medical/Surgical History;1020
17.10.9;Perioperative Course;1020
17.10.9.1;First Visit;1020
17.10.9.2;Second Visit;1020
17.10.9.3;Third Visit;1020
17.10.9.4;Fourth Visit;1020
17.10.10;References;1020
18;Index;1025