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The lung has historically been the most challenging of the human organs to be successfully transplanted in clinical practice. It is possible to transplant lungs singly (SLT) or sequentially as a bilateral lung transplant (BSLT) depending on patient characteristics and the nature of the pathological lung condition present. Lung transplant assessment tests typically include sputum tests for Aspergillus and Aspergillus precipitins. Right heart catheterization is undertaken in patients considered for lung transplantation for pulmonary hypertension. Smokers and patients with a history of mild asthma may still be considered as potential lung donors. At many centers, anesthesia for sequential bilateral lung transplantation is undertaken as sequential single lung transplants to avoid the perceived increase in acute lung injury post-operatively which is said to accompany extracorporeal perfusion. Immunosuppression commences pre-operatively with the administration of azathioprine and cyclosporin A. Quality of life is significantly improved by transplantation for pulmonary failure.
The primary cause of emphysema is cigarette smoking. Candidates for surgery for emphysema require a complete history and examination. Three surgical treatment strategies exist for selected subgroups of emphysema patients: bullectomy, lung volume reduction surgery (LVRS), and lung transplantation (LTx). Surgical stapling devices or lasers are used to resect and seal the least functional lung segments. Stapling methods and buttressing techniques have evolved to reduce the risk of air leaks. Formal LVRS comprises a range of pulmonary resection procedures designed to achieve improved gas exchange via volumetric reduction of emphysematous lung. Lung transplantation is now an established therapeutic option for end-stage emphysema. Patients are assessed according to consensus criteria provided by the International Society for Heart and Lung Transplantation (ISHLT). The primary limitation for LTx is the shortage of suitable allograft donors, and the mortality of advanced emphysema patients on the waiting list is high.
Thoracic trauma accounts for 25% of all trauma related deaths. The majority of thoracic trauma patients can be managed conservatively by simple chest tube drainage, respiratory support and pain management. The mechanism of injury after thoracic trauma can be classified as blunt or penetrating trauma. The anesthetist plays an important role in the management of severe thoracic trauma from an initial stage of primary survey right through to management in the intensive care unit. In the emergency department, decisions and actions have to be taken without delay. In a trauma situation, there is little opportunity to obtain standard anesthetic pre-operative assessment. Video-assisted thoracic surgery is an important and extensively used diagnostic tool for suspected traumatic intrathoracic lesions, including stab wounds, in hemodynamically stable patients. Urgent thoracotomy is indicated in the presence of severe hemorrhage. A quick standard anesthetic assessment should be performed on all trauma patients.
The population in the developed world is aging, together with an increasing life expectancy for both men and women. The incidence of thoracic pathologies in the elderly of the developed world is rising. The main cautions of thoracic anesthesia in the elderly are those of geriatric anesthesia in general and those of the surgical procedure itself. In the elderly, risk assessment should focus on identifying the physiologic state and reserve of specific organ systems. It is often more challenging to identify previously undiagnosed comorbidity, optimize it and try to predict its bearing on the outcome. The aim of the pre-anesthetic assessment is to detect and optimize comorbidities, and quantify objectively the extent of reduced physiologic reserve of systems. The goalposts of healthcare delivery standards have been moved with expectations of better results following anesthesia and surgery in thoracic surgery in the elderly.
Providing an easily readable source of information about the current spectrum of anesthesia and critical care management of patients undergoing thoracic surgery, this book forms part of the successful Core Topics brand. The book provides practical assistance to those commencing careers in thoracic anesthesia and will also to be a useful aide-memoire to those already working in the field. The comprehensive content includes discussion of some of the more contentious issues in the management of thoracic patients as well as giving a flavour of the rapid evolution of new techniques that are of increasing importance in the field, such as lung-assist devices, different modes of ventilation and VAT surgery. Both editors are practising cardiothoracic anesthetists/intensivists at an internationally recognized centre for thoracic surgery, particularly lung transplantation. The contributors are chosen for their clinical expertise and to give a spectrum of opinion across the range of thoracic anesthesia.
Safe and successful treatment of the morbidly obese patient requires a level of organizational commitment, protocols, expertise and staff training. Patients with morbid obesity should be identified by the surgeons and referred to the anesthetists at an earlier stage for pre-operative assessment. Morbidly obese patients have a greater risk of pulmonary hypertension due to obstructive sleep apnea and CO2 retention. Obesity is strongly correlated with obstructive sleep apnea syndrome (OSA). Large double lumen tubes (DLT) is used to minimize airway resistance in morbidly obese patients undergoing one-lung ventilation (OLV). Direct airway measurement is an accurate way of selecting a DLT rather than tube selection based solely on patient gender, height and weight. Morbidly obese patients have a higher proportion of adipose tissue and lower proportions of tissue water and lean body mass. These can cause differing patterns of drug distributions.
This chapter summarizes current knowledge about chronic thromboembolic pulmonary hypertension (CTEPH), and discusses the perioperative and anesthetic management of patients scheduled for pulmonary endarterectomy (PEA). It discusses the pathophysiology, prognosis, diagnosis, and treatment for CTEPH. Approximately half of the patients exhibit known thrombotic tendencies like protein-C deficiency, factor V Leiden deficiency, anti-phospholipid syndrome or other autoimmune disorders. Computerized tomography scanning with pulmonary angiography is a useful tool in distinguishing between proximal and distal disease. The peri-operative management of patients undergoing pulmonary endarterectomy is complex and involves a multidisciplinary team of physicians, surgeons, anesthetists and intensivists. Thorough preoperative investigation and ascertaining the appropriateness of surgery is essential. Generally quoted and accepted peri-operative mortality risk is 10%, down to 4% in centers with large experience. In most surviving patients, a marked reduction in the pulmonary arterial pressure is observed and right heart function will return to normal within a few months.
The development of modern anesthesia techniques involving the ventilation of the patient's lungs and the use of tracheal tubes in intensive care and anesthesia was a great impetus to the development of surgery in general. The types of procedures carried out on the trachea that require general anesthesia are rigid bronchoscopy, tracheal stenting and excision of tracheal stenosis or tumors. Rigid bronchoscopy can be used for diagnostic purposes by examining and assessing the tracheobronchial tree anatomy and by the taking of a biopsy for histology. Silicone rubber stents require general anesthesia for placement while metallic expandable stents can be placed fluoroscopically or under general anesthesia. The indications for tracheal resection are symptomatic stenosis or benign and malignant tumors. Tracheal stenosis is most often caused by trauma such as prolonged intubation of the trachea in the intensive care unit.
Appropriate and timely investigations should be performed in order to assess the impact of lung resection on the patient and to guide anesthetic management. The thoracic anesthetist must have a good basic technique with which he or she is completely familiar. The chapter describes the general considerations, conduct of anesthesia and post-operative considerations for segmental or wedge resections, lobectomy, and pneumonectomy. Segmental or wedge resections are very useful surgical techniques facilitating the preservation of lung tissue. These techniques are only possible if the lesion is located in peripheral lung tissue and is well circumscribed. Lobectomy is indicated for malignancy or benign lesions such as bronchiectasis and turberculosis localized to a lobe. The surgery is usually performed through a thoracotomy. As with all thoracic surgery it is important to have thought about potential escalation of the procedure proposed and what physiological impact this may have on the patient.