Peter Slinger

Postpneumonectomy pulmonary edema.

The adult respiratory distress syndrome seen after pneumonectomy is an uncommon but usually lethal complication. Its etiology remains unknown, although several factors such as fluid overload, endothelial damage, lymphatic interruption, and hyperinflation are thought to be involved in its pathogenesis.

Principles and Practice of Anesthesia for Thoracic Surgery

Principles and Practice of Anesthesia for Thoracic Surgery will become the reference textbook of choice for thoracic anesthesia. This first edition covers most aspects of noncardiac, intrathoracic, diagnostic, and therapeutic procedures. Editor, Peter Slinger, from Toronto, is successful in creating a cohesive text that features more than 60 international authors reflecting on contemporary practices around the world and the evolution of thoracic surgery. This is the most comprehensive text to date on noncardiac thoracic anesthesia. Moreover, it is targeted toward all levels of practitioners providing care for these patients. Appropriately titled, in the early chapters, emphasis is placed on the basic principles involved in thoracic anesthesia with a clear mission to put this knowledge to use in clinical practice. The information is clearly readable and useful for early learners. A number of residents preparing for a thoracic case commented on using numerous resources in their struggle to answer a specific question; however, when reading this textbook, they not only found solutions to their question, they also discovered additional pertinent clinically related information. The text includes chapters on both routine and more complex considerations as well as chapters on uncommon procedures not well covered elsewhere. This aspect makes the text a useful read for less experienced and more advanced thoracic anesthesiologists alike. The book could be a useful resource and starting point for individuals preparing presentations on topics pertaining to thoracic anesthesia. Furthermore, the chapters are well referenced for additional reading if necessary. The text is organized into 47 chapters and 12 sections. The sections cover the history of thoracic anesthesia, preoperative evaluation, thoracic anatomy/physiology/ pharmacology, procedures of the airways, procedures of the mediastinum, routine thoracic procedures, as well as complex and uncommon procedures. In addition, there are sections on pediatric thoracic procedures, procedures for end-stage lung diseases, specific patient considerations, thoracic trauma, and postoperative management. The early chapters on clinical anatomy, physiology, and pathophysiology of lung injury are comprehensive, and the chapters on clinical pharmacology of the lungs and pulmonary circulation build on these foundations. A good understanding can be gained from the chapters on surgical procedures of the airway. As technology advances, these dynamic situations are increasing in frequency and can create significant clinician anxiety. This text includes sections that are not always well covered in other texts, including extrapleural pneumonectomy, robotic-assisted thoracic surgery, management of Pancoast tumours and combined spinal resections, massive hemoptysis, wholelung lavage, extracorporeal membrane oxygenation, and end-stage lung disease (lung volume reduction surgery, transplantation, pulmonary thromboendarterectomy). A chapter is also included on neurologic injuries associated with positioning the thoracic surgery patient, an aspect of thoracic surgery that is often glanced over. All of the chapters begin with ‘‘Key Points’’ listing specific objectives for the reader, and most chapters conclude with either a ‘‘Clinical Case Discussion’’ or ‘‘Clinical Applications’’ to help put the material into context. The chapters are easy to read, and they are sufficiently brief to be user-friendly for the busy clinician who needs to review C. Thompson, MD (&) Department of Anesthesiology, The Ottawa Hospital, Ottawa, ON, Canada e-mail: cthompson@ottawahospital.on.ca

CASE 4—2009 Severe Reexpansion Pulmonary Edema After Minimally Invasive Aortic Valve Replacement: Management Using Extracorporeal Membrane Oxygenation

aortic valve replacement. The patient described a 4-month history of progressive dyspnea on exertion that markedly reduced his exercise tolerance. He reported worsening orthopnea; a persistent, productive cough; paroxysmal nocturnal dyspnea; and swelling in his lower extremities, but he denied chest pain, palpitations, and syncope. The past medical history was notable for essential hypertension (treated with atenolol, losartan, and hydrochlorothiazide), hyperlipidemia (for which the patient received simvastatin), and type II diabetes mellitus (treated with insulin, glipizide, and metformin). The physical examination revealed a grade III of VI crescendo-decrescendo systolic murmur best heard in the left 2nd intercostal space that radiated to the carotid arteries bilaterally. Two-dimensional transthoracic echocardiography showed the presence of a heavily calcified trileaflet aortic valve with restricted leaflet motion consistent with severe aortic stenosis. Concentric left ventricular hypertrophy was present, but no regional wall motion abnormalities were observed. The mean and peak gradients across the aortic valve were determined to be 37.5 and 58.4 mmHg, respectively, by using continuous-wave Doppler echocardiography. Color Doppler blood flow mapping also indicated the presence of mild aortic insufficiency. The aortic valve area and left ventricular ejection fraction were estimated to be 0.93 cm 2 and 53%, respectively. A cardiac catheterization confirmed the echocardiography findings and also showed the absence of hemodynamically significant coronary artery stenoses. A posterior-anterior chest radiograph showed mild cardiomegaly and

Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS)

Enhanced recovery after surgery is well established in specialties such as colorectal surgery. It is achieved through the introduction of multiple evidence-based perioperative measures that aim to diminish postoperative organ dysfunction while facilitating recovery. This review aims to present consensus recommendations for the optimal perioperative management of patients undergoing thoracic surgery (principally lung resection). A systematic review of meta-analyses, randomized controlled trials, large non-randomized studies and reviews was conducted for each protocol element. Smaller prospective and retrospective cohort studies were considered only when higher-level evidence was unavailable. The quality of the evidence base was graded by the authors and used to form consensus recommendations for each topic. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society and the European Society for Thoracic Surgery. Recommendations were developed for a total of 45 enhanced recovery items covering topics related to preadmission, admission, intraoperative care and postoperative care. Most are based on good-quality studies. In some instances, good-quality data were not available, and subsequent recommendations are generic or based on data extrapolated from other specialties. In other cases, no recommendation can currently be made because either equipoise exists or there is a lack of available evidence. Recommendations are based not only on the quality of the evidence but also on the balance between desirable and undesirable effects. Key recommendations include preoperative counselling, nutritional screening, smoking cessation, prehabilitation for high-risk patients, avoidance of fasting, carbohydrate loading, avoidance of preoperative sedatives, venous thromboembolism prophylaxis, prevention of hypothermia, short-acting anaesthetics to facilitate early emergence, regional anaesthesia, nausea and vomiting control, opioid-sparing analgesia, euvolemic fluid management, minimally invasive surgery, early chest drain removal, avoidance of urinary catheters and early mobilization after surgery. These guidelines outline recommendations for the perioperative management of patients undergoing lung surgery based on the best available evidence. As the recommendation grade for most of the elements is strong, the use of a systematic perioperative care pathway has the potential to improve outcomes after surgery.

Preoperative Pulmonary Evaluation

Purpose of ReviewThe purpose of this article is to provide a brief review of the preoperative pulmonary evaluation of patients undergoing non-thoracic surgery, focusing on risk factor identification, assessment of specific high-risk populations, and strategies to minimize postoperative pulmonary complications (PPCs).Recent FindingsAlong with traditional risk factors, recent risk stratification indices have been developed and validated to help quantify risk of PPCs. Careful history and physical examination are key elements in the pulmonary evaluation of all pre-surgical patients. Patients with chronic obstructive pulmonary disease (COPD) are at increased risk and require more intensive optimization and perioperative monitoring. Well-controlled asthma has not been associated with increased risk of PPCs but the potential for life-threatening bronchospasm and status asthmaticus cannot be ignored. In general, the literature does not support delaying surgery for preoperative diagnosis and management of obstructive sleep apnea (OSA). Exceptions to this rule are patients presenting with evidence of obesity-hypoventilation syndrome or pulmonary hypertension. Recent literature provides more evidence of benefits of regional anesthesia and analgesia to decrease the risk of pulmonary complications, particularly in COPD patients.SummaryPPCs are major contributors to perioperative morbidity and mortality. A thorough preoperative evaluation must identify high-risk patients, optimize chronic and acute respiratory diseases, and establish a clear perioperative plan to minimize PPCs.

A Unique Strategy for Lung Isolation During Tracheobronchoplasty

TRACHEOBRONCHOMALACIA (TBM) IS A CONDITION that consists of excessive weakening of the walls of the trachea and bronchi causing collapse of the airway with expiration. The integrity of the posterior and anterior cartilaginous rings is lost, leading to dynamic obstruction. Patients with TBM present with life-altering symptoms such as dyspnea on exertion, cough, and occasionally hemoptysis. Surgical correction via tracheobronchoplasty (TBP) involves external splinting of the collapsing sections of the tracheobronchial tree, thereby increasing the airway diameter and providing symptom relief (Fig 1). The surgical approach is through a right thoracotomy. It is important to note that the surgical procedure does not involve opening trachea or bronchi; thus, the airway remains intact. Airway management is complicated by the requirement for initial right-lung deflation without any device in the right main bronchus and subsequent right-lung deflation without any device in the left main bronchus. A left-sided or right-sided double-lumen

Intraoperative Patient Positioning and Neurological Injuries

Thoracic cases usually involve repositioning the patient after induction of anesthesia. Vigilance is required to avoid major displacement of airway devices, lines, and monitors during and after position changes. Obtaining central venous access after changing to the lateral position is extremely difficult. If a central line may be needed it should be placed at induction. Prevention of peripheral nerve injuries in the lateral position requires a survey of the patient from the head and sides of the operating table prior to draping. Postthoracotomy paraplegia is primarily a surgical complication.

Anesthetic Considerations for Infectious, Congenital, and Acquired Pulmonary Disorders

The risk of contamination of healthy lung regions from infected secretions in patients with infectious processes such as lung abscess, cyst, bronchopleural fistula, etc. The risk of tension pneumothorax during positive pressure ventilation with bronchopleural fistula or bullae. The risk of inability to ventilate due to air leak with bronchopleural fistula. The increased risk of intraoperative hemorrhage due to intrathoracic inflammation and scarring with infectious diseases. The possibility of sepsis developing before or during surgery with infectious diseases. The presence of right-to-left shunt in patients with pulmonary arteriovenous malformations.

Surgery of the Chest Wall and Diaphragm

Surgery for benign chest wall deformities is most commonly performed for cosmetic reasons, but in some cases for restrictive respiratory or cardiac symptoms. Postexcision, chest wall defects larger than 5 cm will require reconstruction to diminish paradoxical motion and impaired gas exchange. All full-thickness diaphragm defects should be repaired when diagnosed to prevent late onset of perforation or strangulation of abdominal contents in the chest. Diaphragm eventration requires repair only for symptoms of impaired gas exchange.