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Mechanical circulatory support devices (MCSD) include the use of extra corporeal circulatory support, implantable ventricular assist devices (VAD), and total artificial hearts. The need for smaller implantable devices, with control systems that facilitated return to community living, motivated the next generation of devices. The International Registry for Mechanically Assisted Circulatory Support (INTERMACS) has developed a classification system of heart failure (HF) that best identifies their urgency and status and is tailored to the indications of MCS. Careful selection of patients is a cornerstone in a successful VAD program. VADs provide left-, right-, or bi-ventricular support. MCSD are classified according to the duration of support, low characteristics, and/or pump mechanism. Preoperative preparation should focus on optimizing end-organ function and right ventricle (RV) function. Outpatient management represents more efficient use of health care resources and is of high importance for patient quality of life.
George W. Kanellakos, Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada,
Peter Slinger, Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
Review the indications for one-lung ventilation in trauma.
Describe the physiologic effects of one-lung ventilation in trauma.
Review the modern management of one-lung ventilation, including treatment for intraoperative hypoxemia.
Discuss lung isolation techniques and relevant bronchial anatomy.
Discuss the advantages and disadvantages of equipment options for achieving lung isolation.
Trauma patients that have thoracic injuries are extremely difficult to manage and require great expertise with careful clinical management . Other major injuries may be present and management is made much more difficult by the urgency of the situation. The traditional classification of blunt versus penetrating thoracic trauma is important and both mechanisms can lead to significant respiratory injury, at any level within the tracheobronchial tree . Nevertheless, all trauma algorithms place the utmost emphasis on establishing a safe airway. In thoracic trauma, this airway often means having the ability to establish one-lung ventilation (OLV).
LUNG ISOLATION IN TRAUMA PATIENTS
Traditionally, the approach to lung isolation has been divided into absolute and relative indications (Table 19.1) . Within this table, there are two guiding principles that encompass all the indications for OLV. These two categories are:
Lung Protection: To prevent contralateral lung soiling against blood or secretions (pus), or to prevent further lung injury secondary to positive pressure ventilation, as in the case of a bronchopleural fistula or severe pulmonary contusion.
Surgical Procedures: To facilitate surgical resection. In the case of video-assisted thoracoscopic surgery, it is essential.
Both approaches can help guide the clinician, but the decision to establish OLV should be made on a case-by-case basis.