Chest surgery clinics of North America
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The authors believe that most patients who undergo pneumonectomy do not require drainage of the postpneumonectomy space. Needle or catheter aspiration is simple and usually adequate. In cases in which significant bleeding, rapid pleural fluid accumulation, or contamination is expected, however, drainage of the space is recommended. If drainage is used, the tube probably should be connected to a balanced drainage system to ensure proper physiologic positioning of the mediastinum during the critical immediate postoperative period.
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The following techniques appear efficacious in controlling postthoracotomy pain and reducing the amount of systemic opioids consumed: continuous intercostal blockade, paravertebral blockade, and epidural opioids and/or anesthetics. The combination of thoracic epidural opioid and local anesthetic is very effective at relieving postthoracotomy pain, however, considerable experience is required for insertion of the thoracic epidural catheter and postoperative respiratory monitoring. Intercostal and paravertebral catheters can be inserted intraoperatively under direct visualization, to reduce complications of insertion. ⋯ When choosing an approach to postthoracotomy pain management, the thoracic surgeon and anesthesiologist must consider the following: (1) the physician's experience, familiarity and personal complication rate with specific techniques; (2) the desired extent of local and systemic pain control; (3) the presence of contraindications to specific analgesic techniques and medications; and (4) availability of appropriate facilities for patient assessment and monitoring postthoracotomy. Refinements in surgical technique including limited or muscle-sparing thoracotomy, video-assisted thoracoscopic surgery (VATS) and robotic surgery may lessen the magnitude of postthoracotomy pain. We encourage all thoracic surgeons to be knowledgeable of available techniques and maintain a protocol to generate a database for periodic assessment of safety and efficacy.
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Radiology in the intensive care unit (ICU) patient is dominated by plain x-rays, with noteworthy findings prompting further imaging and possible intervention. This chapter discusses interventional and minimally invasive techniques used to treat pleural, mediastinal and pulmonary parenchymal problems commonly encountered in the ICU.
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Significant advances have occurred in the knowledge of the pathogenesis of ARDS. It is now recognized that ARDS is a manifestation of a diffuse process that results from a complicated cascade of events following an initial insult or injury. Mechanical ventilation and PEEP are still important components of supportive therapy. ⋯ Apart from the challenge of testing these agents in experimental models, it seems likely that determination of the optimum combination of agents will become an equally important endeavor. A particular challenge is to develop better methods of predicting which of the many at-risk patients will go on to full-blown ARDS and MODS, thereby targeting subgroups of patients most likely to benefit from anti-inflammatory therapies. Similarly, the adverse effects of immunosuppressive therapy may be diminished by improved, perhaps molecular, techniques to detect microbial pathogens and permit differentiation between Systemic inflammatory response syndrome and sepsis.
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Despite the increasing obesity of the American population, many chronically ill patients are malnourished. When this malnutrition is combined with the hypermetabolic response and protein catabolism of an acute event, such as an operation, nutritional support becomes an important facet for optimal critical care. This chapter reviews the basic tenants of nutritional support with special emphasis on patients with pulmonary compromise. Important aspects of caloric and protein support are discussed and enteral nutrition is emphasized because of its numerous advantages and documented improvement in outcome.