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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...
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...
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