Anesthesiology clinics
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Anesthesiology clinics · Dec 2012
ReviewTransesophageal echocardiography in noncardiac thoracic surgery.
In high-risk surgeries with medically complicated patients, transesophageal echocardiography (TEE) adds an additional level of monitoring with which few can disagree. This article presents multiple applications of TEE that can assist both the anesthesiologist and the surgeon through major noncardiac thoracic surgery. It highlights how TEE can be used as an adjuvant to lung resection surgery; TEE as a monitor during lung transplantation; TEE to assess patients for extracorporeal membrane oxygenation; TEE for thoracic aortic surgery; and TEE in the assessment of patients with acute pulmonary hypertension undergoing noncardiac thoracic surgery.
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Better understanding of the pathophysiology of acute lung injury (ALI) and the hazards inherent to extremes in volume status has led efforts toward goal-directed, individualized therapies designed to achieve optimal hemodynamic status. The role for colloids both as a volume expander and potential protective agent against ALI is receiving revived interest. The evidence for the impact of fluid therapy is encouraging and supports the undertaking of properly designed perioperative fluid trials in thoracic surgeries. Such work offers hope that optimal fluid strategies can be defined and reduce the adverse events that have affected patients having lung resection.
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Advancements in robotic-assisted thoracic surgery present potential advantages for patients as well as new challenges for the anesthesia and surgery teams. This article describes the major aspects of the surgical approach for the most commonly performed robotic-assisted thoracic surgical procedures as well as the pertinent preoperative, intraoperative, and postoperative anesthetic concerns.
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Despite advances in the therapy for acute lung injury and adult respiratory distress syndrome, mortality remains high. The iatrogenic risk of ventilator-induced lung injury might contribute to this high mortality because the lungs are hyperinflated. ⋯ Extracorporeal membrane oxygenation and interventional lung assist allow ultraprotective ventilation strategies. However, these assists have different technical aspects and different indications.
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The degree of perioperative lung injury that patients sustain results from a complex interaction between their current physiologic state, comorbidities, lifestyle choices, underlying surgical diagnosis, operative, and ultimately their cardiopulmonary interaction with a mechanical ventilator. This review addresses primarily the pathophysiology of perioperative lung injury with reference to ventilator-induced lung injury and acute respiratory distress syndrome.