Practical Handbook of Thoracic Anesthesia

655 Pages·2012·8.96 MB·English

by  Thomas Edrich MD

Practical Handbook of Thoracic Anesthesia

Practical Handbook
of Thoracic Anesthesia
Philip M. Hartigan
Editor
Steven J. Mentzer
Consulting Surgical Editor
Editor
Philip M. Hartigan, MD
Assistant Professor of Anaesthesia
Harvard Medical School
Director, Division of Thoracic Anesthesia
Department of Anesthesiology, Perioperative and Pain Medicinea
Brigham and Women’s Hospital
Boston, MA USA
ISBN 978-0-387-88492-9 e-ISBN 978-0-387-88493-6
DOI 10.1007/978-0-387-88493-6
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2011943746
© Springer Science+Business Media, LLC 2012
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Preface
Why This Book?
The vast majority of the roughly 200,000 thoracic surgical proce-
dures this year will take place in centers where there is no dedicated,
subspecialized thoracic anesthesia service. A considerable hunger for
guidance and pearls is present among skilled generalists who occa-
sionally fi nd themselves thrust into thoracic cases with unfamiliar
problems to solve. Similarly, fellows, residents, and medical students
have expressed a need for effi ciently accessible, essential principles,
and specifi c management guidance for thoracic cases. All have expe-
rienced the frustration of wading through large, thickly referenced
tomes that are reluctant to take a stand on controversial issues.
■ W hen should one use PEEP vs. CPAP during one-lung
ventilation?
■ W hat else can one do if the patient desaturates? What really
works?
■ How do you know when it is safe to induce a patient with an
anterior mediastinal mass?
■ How do I decide whether an epidural is indicated?
■ T here is a tracheal resection/reconstruction in my room tomor-
row. What do I need to know? What are my ventilation options
while the airway is divided?
■ How should the ventilator be set for patients with severe COPD
during one-lung ventilation?
■ What is the bottom line on fl uids and post-pneumonectomy
pulmonary edema?
v
vvii Preface
W e, as authors and editors, sought to distinguish this text in
several respects. F irst , issues such as those above which are germane
to concrete management decisions have been addressed directly,
along with an assessment of the degree of certainty behind the
positions which we take several respects. Second , we have deliber-
ately included insights from the thoracic surgical perspective. Just as
we perceive surgeons to be enlightened when they demonstrate
some understanding of our issues, we believe that anesthesiologists
elevate their own performance and perception when they under-
stand key surgical considerations. Third, we have sought to make
the information as practical and accessible as possible; heavy on
bottom lines, and somewhat lighter on the evidence basis. This is not
to suggest that the evidence basis was not diligently vetted. We have
simply chosen to spare the reader most of the digestion process.
Fourth , knowledge and technical skills at the fringes of thoracic
anesthesia are given relatively more attention. The skilled thoracic
anesthesiologist needs to understand respiratory therapy equipment
(including delivery devices for inhaled nitric oxide), basic thoracic
radiology, common ICU management issues following thoracic sur-
gery, positioning issues, chronic post-thoracotomy pain syndrome,
and other related aspects of total patient care. F ifth , the reader will
fi nd abundant illustrations; in particular, nearly 40 bronchoscopic
images which will help advance his or her ability to recognize anomo-
lies, guide surgery, and correct airway device malpositions.
How to Use This Book
Nobody reads medical textbooks cover-to-cover. We under-
stand that. Most will open this book because they have a specifi c
thoracic surgical case assigned which they are unfamiliar or uncom-
fortable with.
In that case, Part IV will quickly take you to a summary of the
essential anesthetic management issues for some 30 specifi c proce-
dures. Authors were asked to “get to the point” effi ciently, and to
make the essentials easy to extract. The surgical editor was asked to
coedit this section with the following question in mind: “For each
Preface vviiii
procedure, what surgical issues do you wish that anesthesiologists
understood?” You will also fi nd the chapters in Part IV richly cross-
referenced in order to connect the reader to deeper explanations of
key points.
A challenge in putting this book together was the fact that so
many issues were relevant to multiple specifi c surgical procedures.
How to make each chapter of Part IV reasonably complete, without
making the section horrendously redundant? S tart by reading
Chapter 16 .
Chapter 16 ( Part III) takes the reader step-by-step through a
typical pulmonary resection case. The sequence of events, common
decision points, common problems and their solutions, and essen-
tial principles are summarized. Many of these serve as foundations
for the other specific surgical procedures which follow in Part IV.
It is included in Part III because it is an overview chapter, but it also
specifi cally addresses lobectomy and lesser resections, such as
s egmentectomy and wedge resection. Other chapters in Part III
p rovide overviews of preoperative, postoperative, and surgical
considerations for thoracic surgical patients.
Part I provides essential foundation concepts, principally respi-
ratory physiology, targeted specifi cally to those which are relevant
to thoracic anesthesia management. Radiology for thoracic anes-
thesia is inserted here as is a chapter specifi cally addressing the
c ontroversy of acute lung injury following pulmonary resection.
While the latter is a hotly controversial topic, it is addressed here
because of its very practical implications with regard to fl uid
m anagement and management of one-lung ventilation; central,
practical issues for so many thoracic cases.
Part II addresses very technical issues, and will be useful as a
“how-to” manual for many procedures and pieces of equipment
fairly specifi c to thoracic anesthesia.
Part V provides a practical summary of thoracic pain manage-
ment issues, both acute and chronic.
Boston, MA, USA Philip M. Hartigan

Acknowledgments
F irst and foremost, the contributing authors deserve my deepest
heartfelt gratitude for their contributions. The idea for this project
bubbled up from them during a team meeting and took off by dint
of their commitment and hard work. Their tolerance of my editing
has been nothing short of heroic. A special note of deep personal
gratitude is due Dr. Steven J. Mentzer, Professor of Surgery, Harvard
Medical School, for his surgical insights in Chapter 15 and through-
out Part IV. That “surgical dimension” to this project was a critical dis-
tinguishing feature. The “MVP Award” for this talented team must go
to Dr. Ju-Mei Ng, author of 7 chapters, and source of invaluable edi-
torial support.
Several ingredients made the soil particularly fertile at Brigham
and Women’s Hospital for the growth of this project. The sheer
v olume and acuity of thoracic surgical cases here (>3,000/year) are a
testimony to the leadership and talents of Dr. David J. Sugarbaker,
who built the Department of Thoracic Surgery here from the ground
up and created a collaborative, challenging environment in which
the Thoracic Anesthesia Division could grow and thrive. The creation
of a dedicated Thoracic Anesthesia subdivision was the vision of Dr.
Simon Gelman, Professor and Chairman of Anesthesia during the
1990s when the division was created, possibly the fi rst such division
in the world. Dr. Gelman remains a beacon of insight and vision for
this department, and for me personally. Dr. Charles Vacanti, the
c urrent Department Chairman, has generously provided support,
without which this book would not have been possible. The con-
stant parade of extraordinary thoracic anesthesia fellows-in-training
has continually injected energy and kept us honest. Perhaps most
importantly, the giants whose shoulders we stand on are Drs. Simon
Body and Stanley LeeSon, founding leaders of the Division of
Thoracic Anesthesia here at Brigham and Women’s Hospital, who lit
the torch that we carry.
ix