New trends in anaesthesia for thoracic surgery including thoracoscopy

Abstract

This seminar will deal with the recent advances in the anaesthetic management of patients having thoracic surgery. Specific areas in which there have been important innovations are: preoperative assessment, intraoperative monitoring, lung isolation techniques, management of one-lung anaesthesia, thoraeoscopy and postoperative analgesia. Preoperative assessmentThe morbidity and mortality rates for pulmonary resections are among the highest for any common elective surgical procedure. The 30-day operative mortality rate is approximately 4% l and severe cardiorespiratory complications occur in 30-50%2 of eases. Patients referred for surgery will usually have already met minimal surgical criteria for operability.3 However, among the patients with potentially reseetable lesions those at increased risk for perioperative morbidity and mortality should be identified: 1 Preoperative pulmonary function: The predicted postoperative forced expiratory volume in one second (FEV0 is the single most useful indicator of early morbidity.4 A postoperative FEV~ <40% of the predicted normal is associated with increased morbidity and mortality. The majority of patients with a predicted FEVt <30% will require ventilatory support at some time in the postoperative period.5 A large proportion of the patients for thoracic surgery have chronic obstructive pulmonary disease (COPD). Among patients with moderate or severe COPD (i.e., FEVI <65% predicted) it is not possible to predict on the basis of history, physical or spirometry, which patients are "CO2-retainers. "6 These patients are all at risk of requiring mechanical ventilation post-thoraeotomy. Thus, to aid in postoperative weaning, any thoracic surgical patient with COPD needs an arterial blood gas analysis preoperatively.The diffusing capacity for carbon monoxide (DLCO) is an independent predictor for post-thoracotomy respiratory complications. 7 A preoperative DLCO >80% predicted is associated with a < 10% incidence of postoperative respiratory complications while a DLCO <60% has a >30% risk. 8 For potential pneumonectomies it may be possible to downgrade the estimated risk on the basis of a preoperative venfilation/perfusion ('r scan) Exercise tolerance may become the most specific predictor of post-thoracotomy eardio-respiratory complications. A maximum oxygen consumption (VO2 max) >20 ml. kg -l. min -~ is associated with a low incidence of complications while a "r max <15 ml.kg-'-min -I has a very high risk. to Stair climbing is a similar but less reproducible test. 1~ 2 Age: Recent studies suggest that age is no longer a major independent risk factor t2 for mortality although morbidity rates are higher in the elderly. 3 Surgical incision: Many resections can be done with a median sternotomy. This is associated with lower morbidity and better postoperative pulmonary function. 13 Also, it is now possible to do some wedge resections and even lobeetomies with video-assisted thoracoscopic surgery (VATS). Fluid managementPerioperative fluid management for thoracic surgical cases is fr...

Anästhesie in der Thoraxchirurgie

“…Das Umgekehrte trifft für gesunde und damit gut perfundierte Lungen zu, welche tiefe PaO 2 -Werte erwarten lassen [6]. Die weiterhin perfundierte, aber nicht mehr ventilierte Lunge führt regelmäßig zu einer erheblichen, von Fall zu Fall aber unterschiedlich ausgeprägten venösen Beimischung (᭤ Rechts-links-Shunt) mit konsekutivem Abfall des arteriellen O 2 -Partialdrucks (PaO 2 ).…”

Fisiopatologia e manejo clínico da ventilação seletiva

“…Cohen fixed 40 cmH 2 O as the upper pressure limit during one-lung ventilation (20) . Slinger fixed 45 cmH 2 O as the highest apical pressure (21) . Ovassapian proposed that the apical pressure not surpass 150% of the basal value of traditional bilateral ventilation (22) .…”

Video‐assisted thoracoscopic surgery for right middle lobectomy in children

“…It has been suggested that ventilation of the dependent lung on pain was observed in the videosurgery group, but lung function was better for the first 72 h. Other in anaesthetized children is more impaired than in adults (15). However, in clinical practice, ventilatory retrospective and prospective studies are in favour of videosurgery as far as pain is concerned, but do tolerance is less a problem in children than in adults and positive end expiratory pressure is seldom not show any benefit on the respiratory function (1) or postoperative morbidity (4,21,23,24). Rothenberg required to achieve adequate gas exchange (16).…”