Chest surgery clinics of North America
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Chest Surg. Clin. N. Am. · Nov 1997
ReviewPreoperative pulmonary evaluation of the thoracic surgical patient.
A test designed to separate those undergoing thoracic surgery without complications and those with complications must be both highly specific and sensitive. Clearly, the difference between patients at opposite ends of the population curves is easy to identify. Spirometry can be helpful for screening, although it is not a very discriminating test. ⋯ Functional indexes (PPP, PRQ) or exercise testing can aid further in the selection of those patients in whom a nonsurgical option should be considered. Flow decision chart for the preoperative evaluation of patients for pulmonary resection should continue to evolve as new information about outcome studies is gathered. Examination of outcome data will provide us with reduction of the size of the nonoperable population, so that we can deny only those patients who truly pose a prohibitive risk.
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Chest Surg. Clin. N. Am. · Nov 1997
ReviewPhysiology of the lateral position and one-lung ventilation.
The first part of this article reviews the distribution of ventilation (V) and perfusion (Q) during the supine and the lateral decubitus position. The changes in the V/Q during the lateral position with and without paralysis are discussed. The second part evaluates the degree of transpulmonary shunt during one lung ventilation (OLV) and the role of hypoxic pulmonary vasoconstriction in maintaining arterial oxygenation. Finally, the influence and the use of nitric oxide during OLV is reviewed.
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Infants and children have unique anatomic, physiologic, pharmacologic, and psychological issues relating to perioperative management. Combining this knowledge with the technical skills required for instrumentation of children is essential when contemplating anesthesia for thoracic surgery. Experience and versatility with anesthetic induction technique, airway instrumentation, vascular access and monitoring, single-lung ventilation, regional anesthesia, and postoperative pain management allow for the comprehensive management of thoracic surgical patients at any age.
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Airway management for thoracic surgery frequently requires isolation of a portion of the respiratory system. In some circumstances lung isolation is mandatory and in others elective. Several techniques utilizing specialized endotracheal tubes and blockers are currently available. There are specific advantages and complications associated with each that, in part, determine optimal outcome in this specialized group of surgical patients.
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Postoperative pain management is essential and must be approached as an integral part of the perioperative care. It should be systematic and based on sound physiologic and pharmacologic principles. The intra-operative management of pain is crucial, as there is perhaps an important role for preemptive analgesia. ⋯ The cornerstone of therapy is opioids, which can be administered by a variety of routes. The use of TEA with opioids and local anesthetics is highly beneficial, especially in high-risk patients. The aim should be to provide all patients a balanced analgesic regimen based on the identification of multiple mechanisms involved in postoperative pain.