The anesthesiologist perspective

Annals of translational medicine, 2015

Anesthetic management for awake thoracic surgery (ATS) is more difficult than under general anesthesia (GA), being technically extremely challenging for the anesthesiologist. Therefore, thorough preparation and vigilance are paramount for successful patient management. In this review, important considerations of nonintubated anesthesia for thoracic surgery are discussed in view of careful patient selection, anesthetic preparation, potential perioperative difficulties and the management of its complications.

Annals of translational medicine, 2015

Performing awake thoracic surgery (ATS) is technically more challenging than thoracic surgery under general anesthesia (GA), but it can result in a greater benefit for the patient. Local wound infiltration and lidocaine administration in the pleural space can be considered for ATS. More invasive techniques are local wound infiltration with wound catheter insertion, thoracic wall blocks, selective intercostal nerve blockade, thoracic paravertebral blockade and thoracic epidural analgesia, offering the advantage of a catheter placement which can also be continued for postoperative analgesia.

Anaesthesia & Intensive Care Medicine, 2011

Thoracic anaesthesia is a large field. This article concentrates on anaesthesia for major thoracotomy and lung resection, which is most usually carried out for malignant disease. This is a relatively small patient population, but procedures carry significant mortality of up to 6% for pneumonectomy. Physiological changes that occur during anaesthesia and one lung ventilation (OLV) are discussed, and the optimal ventilatory management of these patients is covered. Postoperative management of analgesia and chest drains is also discussed, as is the pathophysiology of acute lung injury (ALI) which may occur after lobectomy or pneumonectomy. Aspects of video-assisted thoracoscopy (VATS) and lung volume reduction surgery (LVRS) are also mentioned.

Current Anesthesiology Reports, 2016

Thoracic anesthesia is a continually evolving field due to the development of new surgical and anesthetic technologies. Advances in lung isolation techniques, ventilation strategies, and postoperative pain management have improved patient outcomes. Airway management continues to progress as different devices provide advantages and disadvantages for lung isolation, surgical visualization, and access to the operative lung. Optimal ventilation strategies are moving toward lung protection, where oxygenation and ventilation are maintained with lower, more physiologic lung volumes with judicious use of alveolar recruitment, positive end-expiratory pressure, and lower FiO 2. Neuraxial and regional anesthetics are the mainstays of postoperative analgesia, with adjuvants having roles in the acute period, but chronic post-thoracotomy pain remains challenging to treat. The role of perioperative inflammation has grown in importance, and volatile anesthetics have protective effects at the cellular and molecular levels, however the debate between the use of volatiles versus a total intravenous anesthetic technique continues. Keywords Thoracic surgery Á Lung isolation Á One-lung ventilation Á Continuous positive airway pressure Á Positive end-expiratory pressure Á Alveolar recruitment This article is part of the Topical Collection on Thoracic Anesthesia.

Current Opinion in Anaesthesiology, 2006

Purpose of the review This review presents an overview of the different problems and challenges after thoracic surgery. It covers the pathophysiological changes that may occur regularly in the early and late period following surgery. In addition, surgical complications with anesthesiological implications for diagnosis, treatment and prevention are discussed, and consequences for anesthesia in further major and thoracic surgical procedures are shown.

Translational Lung Cancer Research

Objective: To discuss and summarize the literature for airway and anesthetic management tools the anesthesiologist can use for airway surgery to both successfully manage the patient's physiological needs and provide the surgeon the optimal surgical conditions with which to perform the surgery safely. Background: The airway and anesthetic management of patients presenting for thoracic surgery poses the anesthesiologist with a unique set of challenges, but also a unique set of opportunities to artfully utilize and adapt a variety of management options that has developed over several decades of innovation. Sixty years ago, airway surgery was initially performed with the patient spontaneously breathing and providing anesthesia with halogenated agents and airway topicalization. As medicine entered the latter half of the twentieth century with its development of new airway devices and modern anesthetic agents, most airway surgeries could be safely performed under general anesthesia with secured airways. Today, with continued technological advancements in surgical techniques and an expanding population of challenging patients, the application of nonintubated anesthetic techniques and extracorporeal support is on the rise. Methods: We conduct a narrative review of the literature on the history of airway and anesthetic management for thoracic surgery, the current management methods and evidence for each modality, and discuss future directions for the field. Conclusions: While the airway and anesthetic management for airway surgery is challenging, the anesthesiologist has a variety of options including cross-field ventilation, jet ventilation, nonintubated techniques, and extracorporeal support to safely care for the patient. Whichever methods are chosen for the patient and surgery, thoracic surgery remains uniquely positioned in its need for close sharing and collaboration of all airway and anesthetic management decisions between the anesthesiologist and the surgeon.

Acta Medica Medianae, 2022

Before the advancement of anesthesia techniques in the mid-1930s, chest operations were short and difficult. Anesthesia during thoracic surgery is in itself very demanding and complicated to work with and represents a real challenge for the anesthesiologist. In order to perform the operation smoothly in patients whose respiratory reserve has already been reduced, it is necessary to exclude the lung that is being operated on and to isolate the lung that is ventilated during the surgical intervention. Double lumen tubes and endobronchial blockers are used to secure the airway and to achieve collapse and unilateral ventilation. Fiberoptic bronchoscopy is the gold standard in the world of modern thoracic anesthesia for checking the position of a double lumen tube and endobronchial blocker.

BJA: British Journal of Anaesthesia, 1984

Cardiac index, systemic and pulmonary arterial pressures, carbon dioxide elimination and ventilation of each lung were studied during thoracotomy. Seventeen patients, placed in the full lateral position, were ventilated mechanically through a Carlens' tube to moderate hypocapnia. Mean cardiac index increased by 12% as the pleura was opened (P< 0.05), with no further change during surgery on the still ventilated upper lung. Mean arterial pressure was unchanged after opening the pleura, but decreased from 114 ± 15 mm Hg (mean ± 1 SD) to 104 ±18 mm Hg during surgery on the hing(P< 0.01). Mean pulmonary artery pressure was unchanged. There was a significant (P< 0.01) increase in carbon dioxide elimination from the upper lung when the pleura was opened. In addition, the ventilation of this lung increased significantly (P< 0.05). Mean end-tidal PCO2 of the lower lung increased from 4.1 to 4.2 kPa after opening the pleura, while that of the upper lung increased from3.0to3.6kPa(P<0.01). Vb/Vr decreased from 43 to 38% as the pleura was opened (P< 0.01). During surgical handling of the lung, marked decreases in ventilation, compliance, carbon dioxide elimination and end-tidal PLXH were observed in the upper lung. We conclude that ventilation-perfumon mismatch decreased on opening the pleura, and that neither opening the pleura nor the subsequent lung surgery (both lungs being ventilated) caused any clinically important derangements in haemodynamics or oxygenation.

Journal of thoracic disease, 2014

Thoracoscopic surgery without endotracheal intubation is a novel technique for diagnosis and treatment of thoracic diseases. This study reported the experience of nonintubated thoracoscopic surgery in a tertiary medical center in Taiwan. From August 2009 through August 2013, 446 consecutive patients with lung or pleural diseases were treated by nonintubated thoracoscopic surgery. Regional anesthesia was achieved by thoracic epidural anesthesia or internal intercostal blockade. Targeted sedation was performed with propofol infusion to achieve a bispectral index value between 40 and 60. The demographic data and clinical outcomes were evaluated by retrospective chart review. Thoracic epidural anesthesia was used in 290 patients (65.0%) while internal intercostal blockade was used in 156 patients (35.0%). The final diagnosis were primary lung cancer in 263 patients (59.0%), metastatic lung cancer in 38 (8.5%), benign lung tumor in 140 (31.4%), and pneumothorax in 5 (1.1%). The median an...

Aim: To determine the anaesthesia and analgesia methods applied in thoracic surgery in our clinic and to evaluate these with current literature. Method: A retrospective evaluation was made of patients who underwent surgery in the Chest Surgery Clinic of Ankara Numune Training and Research Hospital in the period January 2011-2014. The demographic data of patients, the operation applied, the anaesthetic and analgesic agents used, monitorisation and complications which occurred perioperatively were obtained from anaesthesia notes and computer records and were recorded on scanning forms with many variables. Results: Following the scanning of the study, the data of 210 patients were accesssed. No statistical difference was determined in respect of the demographic data of the patients. The most frequent operations were found to be thoracotomy (n=103) and bronchoscopy (n=85). Benzodiazepine was used in all groups and patients. In almost all groups, propofol was found to be the most preferred agent for intravenous inducton. Vercuronium and rocuronium were the most frequently applied muscle relaxant agent, sevoflurane was generally selected as the inhalation agent and was applied with a mixture of air and oxygen. In addition to the application of standard monitorisation, in major operations such as thoracotomy where central and arterial entrance was made, contramal was used as postoperative analgesia and in thoracotomy operations, the selection of thoracic epidural route and patient-controlled analgesia was determined to be statistically significant. Postoperative complications developed in 8 patients, there was ventilator requirement in 13 patients and 53 patients were followed up in the intensive care unit in the postoperative period. Conclusion: Although the number of patients admitted for thoracic surgery in our study was low, it can be said that it was attempted to reach current standards in the application of anaesthesia and analgesia. Taking the experience of each anaesthesia clinic in thoracic surgery and the standards of the centre into consideration, there is a need for a clinic-specific anaesthesia and analgesia strategy to be developed with the aid of scientific studies.