Anesthetic considerations in patients with previous thoracic surgery

Special Anesthesiologic Considerations in Robot-Assisted Thoracic Surgery

Purpose of Review

This review summarizes the key issues for preoperative, peri- and intraoperative, and postoperative patient management for robotic-assisted thoracic surgery (RATS). It provides practical guidance for anesthesiologists and thoracic surgeons starting a RATS program.

Recent Findings

RATS is a new technological approach to execute minimal invasive chest operations. In management of RATS patients, the established ERAS principles for video-assisted thoracoscopic surgery (VATS) apply. In addition, RATS imposes additional conditions on anesthesiologists, nurses, and surgeons alike: The spatial constriction in operation theaters caused by the large robotic equipment longs for a reallocation of the anesthetist’s and surgeon’s working environment that may vary additionally depending on the type of surgery performed in the individual patient. Additionally, the implementation of a positive pressure carbon dioxide gas cavity in the pleura has a direct effect on patient cardio-circulatory and respiratory mechanics that have to be balanced by the anesthesiologist.

Summary

RATS advances by replacing open surgery approaches and will complement—but most likely not replace—video-assisted thoracoscopic surgery (VATS). RATS brings new specific intraoperative requirements to the anesthesiological and surgical team members that have to be implemented into clinical routine.

High frequency ventilation combined with spontaneous breathing during bronchopleural fistula repair: a case report

PURPOSE

We report the addition of high frequency oscillatory ventilation (HFOV), combined with spontaneous breathing under general anesthesia, during an uncommon technique to occlude a late post-pneumonectomy bronchopleural fistula.

CLINICAL FEATURES

A 41-year-old woman underwent an extended right pneumonectomy with chest wall resection and prosthetic reconstruction for a large adenocarcinoma of the upper lobe (T3N0M0). Her postoperative recovery was satisfactory, and she subsequently received adjuvant chemotherapy. Four months later, however, she was readmitted for investigation of confusion and pink expectorations. On cerebral magnetic resonance imaging, a frontal metastasis with surrounding edema was discovered, as well as a possible secondary lesion in the occipital lobe. In view of the comorbidities, thoracoscopy was planned as an interim measure, with the goal being to debride the fistula and to seal the prosthetic plug. During this case, a HFOV system was used to allow an addition of 2.5 L.min(-1) of minute ventilation to the patient's spontaneous respiration, while maintaining eucapnia without increasing airway pressure.

CONCLUSIONS

With the addition of high frequency ventilation under general anesthesia in a patient with a persistent bronchopleural fistula, the PaCO(2) level was adequately controlled during the simultaneous use of fibreoptic bronchoscopy and video assisted thoracoscopy to facilitate a successful surgical repair.

[Emergency treatment of thoracic trauma]

Thoracic trauma, most often associated with other serious injuries, is the main cause of death in the first 45 years of life. The percentage of chest injuries in multiple trauma, mainly from blunt impact, has remained relatively constant at 80% during the last 30 years. Isolated thoracic injuries comprise only 25% of all trauma cases, 90% of chest injuries are due to blunt impact, while penetrating injuries make up 5-10%. Since 25% of deaths from trauma are attributable to chest injuries, they determine the survival rate in multiple trauma to a significant extent. The pattern of chest injuries is variable, frequently in different combinations comprising rib cage and diaphragm, lung parenchyma, airway and mediastinal organs. This article details the immediate simultaneous diagnostic and therapeutic procedures in the prehospital phase, management in the emergency room, the relative importance of computed tomography, ultrasound examination and endoscopy in the primary diagnostic evaluation and the principles of anaesthetic management of thoracic trauma.