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In daily practice, management of patients with thoracic trauma is challenging for the anesthetist. Injuries to airways, lungs, diaphragm, heart, and main vessels are the main difficulties. Respiratory and circulatory physiology in general is affected by general anesthesia, which may result in an increased number of perioperative complications. Therefore anesthetic management of patients with thoracic trauma needs to address different clinical topics: management of difficult airways, intrinsic effects of anesthetics and mechanical ventilation on respiratory and cardiac function, the sufficient replacement of exsanguination, as well as type and extent of the surgical intervention. Postoperatively, sufficient pain therapy avoids pulmonary complications and improves outcome. Therefore a high degree of (patho-) physiologic understanding and manual skills are required in this scenario. Interdisciplinary cooperation during diagnostics and treatment, and in the perioperative course is a prerequisite for successful management. The present work describes the main characteristics of thoracic trauma and discusses important precautions and typical problems the anesthetist has to face in the clinical setting.
This book offers a comprehensive, up-to-date overview of optimal postoperative care in patients who have undergone thoracic surgery and discusses challenging issues that are of interest not only in the context of thoracic surgery but also more generally within the fields of anesthesia, intensive care, and pain medicine. The coverage ranges, for example, from use of non-invasive ventilation, extracorporeal membrane oxygenation, and new monitoring devices to fluid management, pain control, and treatment of arrhythmias. A key feature of the book is the exceptionally attractive list of authors, who represent the most authoritative experts on the topics that they address. The approach is appropriately multidisciplinary, acknowledging that in many centers thoracic anesthetists are responsible for care during the postoperative period. This book is exceptional in being devoted solely to postoperative care in thoracic surgery, even though the difficulties involved in thoracic operations sometimes exceed those of cardiac surgery, especially in the postoperative period.
This review presents a brief overview of the non-analgetic effects of thoracic epidural anaesthesia. It covers the cardiac, pulmonary and gastrointestinal effects of thoracic epidural anaesthesia. The results of newer studies are of particular importance regarding mortality and major morbidity after thoracic epidural anaesthesia. The clinical effects of thoracic epidural anaesthesia are mainly attributed to a transient thoracic sympathetic block affecting different organs. Furthermore, local anaesthetic itself reabsorbed from the epidural space may contribute to the non-analgetic effects of thoracic epidural anaesthesia. Experimental studies have suggested that thoracic epidural anaesthesia may attenuate the perioperative stress response after major surgery. The possible beneficial mechanisms of action include an improvement of left ventricular function by direct anti-ischaemic effects, a reduction in cardiovascular complications, an advance on gastrointestinal function, and a reduction in pulmonary complications, as well as a positive impact on the coagulation system and the postoperative inflammatory response. However, it is questionable whether these effects of thoracic epidural anaesthesia may lead to an improved perioperative outcome after major surgery. Recent studies have suggested that, despite the superior quality of pain relief and better quality of life, thoracic epidural anaesthesia does not reduce mortality and major morbidity, especially after major abdominal and cardiac surgery. Despite this controversy, the numerous positive effects and advantages of thoracic epidural anaesthesia are the reasons for its increasing popularity. However, the advantages of thoracic epidural anaesthesia must be incorporated into a multimodal treatment management aimed at improving outcomes after surgery.
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. During the last decade, complications in the early period following surgery after thoracotomy have increasingly moved into the focus caused by their high morbidity and mortality. These problems, such as hemorrhagia and bronchopleural fistulas, are important because they call for a prompt revision or even an emergency operation. The therapy of acute bleeding follows general anesthesiological guidelines whereas the bronchopleural fistula demands methods to prevent aspiration pneumonia as a first priority. In the late period following surgery, typical cardiac and pulmonary modifications can be described that persist and have anesthesiological implications in the case of further surgery. Recent literature, however, lacks clear recommendations regarding anesthesiological management and practice for these cases. Current literature presents no general recommendations on how to manage patients after recent thoracic surgery. Therefore it is necessary to find an individual strategy to handle possible complications and well known pathophysiological changes. Knowledge and understanding of the etiology, the pathophysiology and the risk factors of the perioperative period, allows prevention and target intervention aimed at reducing morbidity and mortality following surgery.
Unlabelled: Mechanical ventilation (MV) may induce an inflammatory alveolar response. One-lung ventilation (OLV) with tidal volumes (Vt) as used during two-lung ventilation is a suggested algorithm but may impose mechanical stress of the dependent lung and potentially aggravate alveolar mediator release. We studied whether ventilation with different Vt modifies pulmonary immune function, hemodynamics, and gas exchange. Thirty-two patients undergoing open thoracic surgery were randomized to receive either MV with Vt = 10 mL/kg (n = 16) or Vt = 5 mL/kg (n = 16) adjusted to normal Pa(CO2) during and after OLV. Fiberoptic bronchoalveolar lavage of the ventilated lung was performed, and cells, protein, tumor necrosis factor (TNF)-alpha, interleukin (IL)-8, soluble intercellular adhesion molecule (sICAM)-1, IL-10, and elastase were determined in the bronchoalveolar lavage. Data were analyzed by parametric or nonparametric tests, as indicated. In all patients, an increase of proinflammatory variables was found. The time courses of intra-alveolar cells, protein, albumin, IL-8, elastase, and IL-10 did not differ between the groups after OLV and postoperatively. TNF-alpha (8.4 versus 5.0 microg/mL) and sICAM-1 (52.7 versus 27.5 microg/mL) concentrations were significantly smaller after OLV with Vt = 5 mL/kg. These results indicate that MV may induce epithelial damage and a proinflammatory response in the ventilated lung. Reduction of tidal volume during OLV may reduce alveolar concentrations of TNF-alpha and of sICAM-1. Implications: Reductions of tidal volume, with subsequently decreased peak airway pressures, may reduce some alveolar inflammatory responses seen with mechanical ventilation.
The implantation of cardiac resynchronization/defibrillation devices (CRT-Ds) increasingly is used in patients with congestive heart failure and left bundle-branch block. There are no data on the effects of anesthesia and surgery on outcome after implantation. A retrospective, observational study; postoperative survey. University hospital. Three hundred forty-one patients (258 men/83 women, 63 +/- 9 years) with congestive heart failure and left bundle-branch block who underwent CRT-D implantation in 1996 to 2005. Perioperative data were retrieved from the patients' records. Cardiologists caring for the patients were contacted to obtain information on current New York Heart Association (NYHA) status and mortality after CRT-D implantation. Preoperatively, 45 patients were classified as NYHA II, 246 as NYHA III, and 50 as NYHA IV. CRT was performed via thoracotomy in 100 and transvenously in 241 cases. General anesthesia (propofol or sevoflurane and remifentanil) was performed in 273 and local anesthesia (lidocaine) in 68 patients. Hypotension occurred mainly during general anesthesia (43% v 4%). The 30-day mortality was 0%. The postoperative survey started in 2006 and was completed by 215 patients. The mean survival time was 77 months; 151 patients survived the study period. Outcome was not influenced by local and general anesthesia. Presence of preoperative NYHA class >II (odds ratio [OR] = 1.6, confidence interval [CI] = 0.5-5.1), mitral regurgitation (OR = 2.5, CI = 1.2-5.5), and serum creatinine >1.1 mg/dL (OR = 3.0, CI = 1.5-6.2) resulted in an inferior prognosis. In patients with severely impaired cardiac function, general anesthesia for the implantation of a biventricular pacing device can be used with justifiable risk. The method of anesthesia did not influence outcome.
Background The increased tidal volume (V(T)) applied to the ventilated lung during one-lung ventilation (OLV) enhances cyclic alveolar recruitment and mechanical stress. It is unknown whether alveolar recruitment maneuvers (ARMs) and reduced V(T) may influence tidal recruitment and lung density. Therefore, the effects of ARM and OLV with different V(T) on pulmonary gas/tissue distribution are examined. Methods Eight anesthetized piglets were mechanically ventilated (V(T) = 10 ml/kg). A defined ARM was applied to the whole lung (40 cm H(2)O for 10 s). Spiral computed tomographic lung scans were acquired before and after ARM. Thereafter, the lungs were separated with an endobronchial blocker. The pigs were randomized to receive OLV in the dependent lung with a V(T) of either 5 or 10 ml/kg. Computed tomography was repeated during and after OLV. The voxels were categorized by density intervals (i.e., atelectasis, poorly aerated, normally aerated, or overaerated). Tidal recruitment was defined as the addition of gas to collapsed lung regions. Results The dependent lung contained atelectatic (56 ± 10 ml), poorly aerated (183 ± 10 ml), and normally aerated (187 ± 29 ml) regions before ARM. After ARM, lung volume and aeration increased (426 ± 35 vs. 526 ± 69 ml). Respiratory compliance enhanced, and tidal recruitment decreased (95% vs. 79% of the whole end-expiratory lung volume). OLV with 10 ml/kg further increased aeration (atelectasis, 15 ± 2 ml; poorly aerated, 94 ± 24 ml; normally aerated, 580 ± 98 ml) and tidal recruitment (81% of the dependent lung). OLV with 5 ml/kg did not affect tidal recruitment or lung density distribution. (Data are given as mean ± SD.) Conclusions The ARM improves aeration and respiratory mechanics. In contrast to OLV with high V(T), OLV with reduced V(T) does not reinforce tidal recruitment, indicating decreased mechanical stress.
Recent studies show that intraoperative mechanical ventilation using low tidal volumes (VT) can prevent postoperative pulmonary complications (PPCs). The aim of this individual patient data meta-analysis is to evaluate the individual associations between VT size and positive end-expiratory pressure (PEEP) level and occurrence of PPC. Randomized controlled trials comparing protective ventilation (low VT with or without high levels of PEEP) and conventional ventilation (high VT with low PEEP) in patients undergoing general surgery. The primary outcome was development of PPC. Predefined prognostic factors were tested using multivariate logistic regression. Fifteen randomized controlled trials were included (2,127 patients). There were 97 cases of PPC in 1,118 patients (8.7%) assigned to protective ventilation and 148 cases in 1,009 patients (14.7%) assigned to conventional ventilation (adjusted relative risk, 0.64; 95% CI, 0.46 to 0.88; P < 0.01). There were 85 cases of PPC in 957 patients (8.9%) assigned to ventilation with low VT and high PEEP levels and 63 cases in 525 patients (12%) assigned to ventilation with low VT and low PEEP levels (adjusted relative risk, 0.93; 95% CI, 0.64 to 1.37; P = 0.72). A dose-response relationship was found between the appearance of PPC and VT size (R = 0.39) but not between the appearance of PPC and PEEP level (R = 0.08). These data support the beneficial effects of ventilation with use of low VT in patients undergoing surgery. Further trials are necessary to define the role of intraoperative higher PEEP to prevent PPC during nonopen abdominal surgery.
Modern thoracic surgery with its emerging focus on minimally invasive techniques requires intraoperative one-lung ventilation to achieve optimal surgical exposure. The double-lumen tube has been considered to be the golden standard for almost 60 years; however, new indications and surgical techniques in thoracic, cardiac, esophageal and ventral spine surgery, as well as scheduling of formerly inoperable patients have made the use of double-lumen tubes unfeasible in some cases and not preferable in many. Modern bronchial blockers like the VivaSight endobronchial blocker or the Fuji Uniblocker have the potential to succeed the double-lumen tube. Their characteristics in daily practice will be discussed in the present article. The most exciting development is the integration of camera lenses in both single- and double-lumen tubes for endotracheal placement without additional bronchoscopy.
Background: Protective mechanical ventilation strategies using low tidal volume or high levels of positive end-expiratory pressure (PEEP) improve outcomes for patients who have had surgery. The role of the driving pressure, which is the difference between the plateau pressure and the level of positive end-expiratory pressure is not known. We investigated the association of tidal volume, the level of PEEP, and driving pressure during intraoperative ventilation with the development of postoperative pulmonary complications. Methods: We did a meta-analysis of individual patient data from randomised controlled trials of protective ventilation during general anesthaesia for surgery published up to July 30, 2015. The main outcome was development of postoperative pulmonary complications (postoperative lung injury, pulmonary infection, or barotrauma). Findings: We included data from 17 randomised controlled trials, including 2250 patients. Multivariate analysis suggested that driving pressure was associated with the development of postoperative pulmonary complications (odds ratio [OR] for one unit increase of driving pressure 1·16, 95% CI 1·13-1·19; p<0·0001), whereas we detected no association for tidal volume (1·05, 0·98-1·13; p=0·179). PEEP did not have a large enough effect in univariate analysis to warrant inclusion in the multivariate analysis. In a mediator analysis, driving pressure was the only significant mediator of the effects of protective ventilation on development of pulmonary complications (p=0·027). In two studies that compared low with high PEEP during low tidal volume ventilation, an increase in the level of PEEP that resulted in an increase in driving pressure was associated with more postoperative pulmonary complications (OR 3·11, 95% CI 1·39-6·96; p=0·006). Interpretation: In patients having surgery, intraoperative high driving pressure and changes in the level of PEEP that result in an increase of driving pressure are associated with more postoperative pulmonary complications. However, a randomised controlled trial comparing ventilation based on driving pressure with usual care is needed to confirm these findings. Funding: None.