UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Anesthesia for open pulmonary resection

Authors
Randal S Blank, MD, PhD
Stephen R Collins, MD
Section Editor
Peter D Slinger, MD, FRCPC
Deputy Editor
Nancy A Nussmeier, MD, FAHA

INTRODUCTION

Open pulmonary resection is most commonly performed to treat a known intrathoracic malignancy such as lung cancer or to diagnose pathology of a suspicious nodule or mass. Other indications for pulmonary resection include management of thoracic trauma, pulmonary infection, and bronchopleural fistula.

Surgical procedures for these indications include sublobar resection (segmentectomy, wedge resection), lobectomy, or removal of more than one lobe (bilobectomy, lobectomy plus segmentectomy). A pneumonectomy involves removal of the entire lung. Extrapleural pneumonectomy involves resection of the diseased lung, as well as mediastinal lymph nodes, ipsilateral pericardium, hemidiaphragm, or parietal or visceral pleura.

This topic will review anesthetic care for patients undergoing thoracotomy and open pulmonary resection, including preanesthetic consultation and preparation, intraoperative anesthetic management, and postoperative pain management. Management of patients undergoing video-assisted thoracoscopic surgery (VATS) for pulmonary resection is discussed separately. (See "Overview of video-assisted thoracoscopic surgery (VATS)" and "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection".)

Lung isolation techniques that are typically required for these procedures and management of one lung ventilation (OLV) are discussed separately. (See "General principles of one lung ventilation" and "Lung isolation techniques".)

PREANESTHETIC CONSULTATION

History and examination — The preoperative consultation focuses on assessment of pulmonary and cardiovascular risks:

                  

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Wed Aug 10 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Ishikawa S, Griesdale DE, Lohser J. Acute kidney injury after lung resection surgery: incidence and perioperative risk factors. Anesth Analg 2012; 114:1256.
  2. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006; 144:581.
  3. Mathew A, Devereaux PJ, O'Hare A, et al. Chronic kidney disease and postoperative mortality: a systematic review and meta-analysis. Kidney Int 2008; 73:1069.
  4. London MJ, Hollenberg M, Wong MG, et al. Intraoperative myocardial ischemia: localization by continuous 12-lead electrocardiography. Anesthesiology 1988; 69:232.
  5. Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013; 41:1774.
  6. Pedoto A, Amar D. Right heart function in thoracic surgery: role of echocardiography. Curr Opin Anaesthesiol 2009; 22:44.
  7. Neustein SM, Cohen E, Reich D, Kirschner P. Transoesophageal echocardiography and the intraoperative diagnosis of left atrial invasion by carcinoid tumour. Can J Anaesth 1993; 40:664.
  8. Suriani R, Konstadt S, Camunas J, Goldman M. Transesophageal echocardiographic detection of left atrial involvement of a lung tumor. J Cardiothorac Vasc Anesth 1993; 7:73.
  9. Cowie B. Cardiovascular collapse and hypoxemia in a man with a right-sided mediastinal mass, undiagnosed atrial septal defect, and right-to-left shunt. J Clin Anesth 2014; 26:688.
  10. Schröder C, Schönhofer B, Vogel B. Transesophageal echographic determination of aortic invasion by lung cancer. Chest 2005; 127:438.
  11. Lohser J, Slinger P. Lung Injury After One-Lung Ventilation: A Review of the Pathophysiologic Mechanisms Affecting the Ventilated and the Collapsed Lung. Anesth Analg 2015; 121:302.
  12. Wigmore TJ, Mohammed K, Jhanji S. Long-term Survival for Patients Undergoing Volatile versus IV Anesthesia for Cancer Surgery: A Retrospective Analysis. Anesthesiology 2016; 124:69.
  13. Tan CN, Guha A, Scawn ND, et al. Optimal concentration of epidural fentanyl in bupivacaine 0.1% after thoracotomy. Br J Anaesth 2004; 92:670.
  14. Jørgensen H, Wetterslev J, Møiniche S, Dahl JB. Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev 2000; :CD001893.
  15. Niemi G, Breivik H. The minimally effective concentration of adrenaline in a low-concentration thoracic epidural analgesic infusion of bupivacaine, fentanyl and adrenaline after major surgery. A randomized, double-blind, dose-finding study. Acta Anaesthesiol Scand 2003; 47:439.
  16. Licker M, de Perrot M, Spiliopoulos A, et al. Risk factors for acute lung injury after thoracic surgery for lung cancer. Anesth Analg 2003; 97:1558.
  17. Alam N, Park BJ, Wilton A, et al. Incidence and risk factors for lung injury after lung cancer resection. Ann Thorac Surg 2007; 84:1085.
  18. Yao S, Mao T, Fang W, et al. Incidence and risk factors for acute lung injury after open thoracotomy for thoracic diseases. J Thorac Dis 2013; 5:455.
  19. Ashes C, Slinger P. Volume management and resuscitation in thoracic surgery. Curr Anesthesiol Rep 2014; 4:386.
  20. Chau EH, Slinger P. Perioperative fluid management for pulmonary resection surgery and esophagectomy. Semin Cardiothorac Vasc Anesth 2014; 18:36.
  21. Licker M, Fauconnet P, Villiger Y, Tschopp JM. Acute lung injury and outcomes after thoracic surgery. Curr Opin Anaesthesiol 2009; 22:61.
  22. Della Rocca G, Coccia C. Acute lung injury in thoracic surgery. Curr Opin Anaesthesiol 2013; 26:40.
  23. Eichenbaum KD, Neustein SM. Acute lung injury after thoracic surgery. J Cardiothorac Vasc Anesth 2010; 24:681.
  24. Assaad S, Popescu W, Perrino A. Fluid management in thoracic surgery. Curr Opin Anaesthesiol 2013; 26:31.
  25. Zeldin RA, Normandin D, Landtwing D, Peters RM. Postpneumonectomy pulmonary edema. J Thorac Cardiovasc Surg 1984; 87:359.
  26. Fernández-Pérez ER, Keegan MT, Brown DR, et al. Intraoperative tidal volume as a risk factor for respiratory failure after pneumonectomy. Anesthesiology 2006; 105:14.
  27. Arslantas MK, Kara HV, Tuncer BB, et al. Effect of the amount of intraoperative fluid administration on postoperative pulmonary complications following anatomic lung resections. J Thorac Cardiovasc Surg 2015; 149:314.
  28. Thiele RH, Colquhoun DA, Blum FE, Durieux ME. The ability of anesthesia providers to visually estimate systolic pressure variability using the "eyeball" technique. Anesth Analg 2012; 115:176.
  29. Thiele RH, Bartels K, Gan TJ. Inter-device differences in monitoring for goal-directed fluid therapy. Can J Anaesth 2015; 62:169.
  30. Lee JH, Jeon Y, Bahk JH, et al. Pulse pressure variation as a predictor of fluid responsiveness during one-lung ventilation for lung surgery using thoracotomy: randomised controlled study. Eur J Anaesthesiol 2011; 28:39.
  31. Haas S, Eichhorn V, Hasbach T, et al. Goal-directed fluid therapy using stroke volume variation does not result in pulmonary fluid overload in thoracic surgery requiring one-lung ventilation. Crit Care Res Pract 2012; 2012:687018.
  32. Zhang J, Chen CQ, Lei XZ, et al. Goal-directed fluid optimization based on stroke volume variation and cardiac index during one-lung ventilation in patients undergoing thoracoscopy lobectomy operations: a pilot study. Clinics (Sao Paulo) 2013; 68:1065.
  33. Fu Q, Duan M, Zhao F, Mi W. Evaluation of stroke volume variation and pulse pressure variation as predictors of fluid responsiveness in patients undergoing protective one-lung ventilation. Drug Discov Ther 2015; 9:296.
  34. Fu Q, Zhao F, Mi W, Zhang H. Stroke volume variation fail to predict fluid responsiveness in patients undergoing pulmonary lobectomy with one-lung ventilation using thoracotomy. Biosci Trends 2014; 8:59.
  35. Ahn HJ, Kim JA, Lee AR, et al. The Risk of Acute Kidney Injury from Fluid Restriction and Hydroxyethyl Starch in Thoracic Surgery. Anesth Analg 2016; 122:186.
  36. Egal M, Erler NS, de Geus HR, et al. Targeting Oliguria Reversal in Goal-Directed Hemodynamic Management Does Not Reduce Renal Dysfunction in Perioperative and Critically Ill Patients: A Systematic Review and Meta-Analysis. Anesth Analg 2016; 122:173.
  37. Blank RS, Hucklenbruch C, Gurka KK, et al. Intraoperative factors and the risk of respiratory complications after pneumonectomy. Ann Thorac Surg 2011; 92:1188.
  38. Kozek-Langenecker SA. Fluids and coagulation. Curr Opin Crit Care 2015; 21:285.
  39. Opperer M, Poeran J, Rasul R, et al. Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis. BMJ 2015; 350:h1567.
  40. Licker M, Diaper J, Villiger Y, et al. Impact of intraoperative lung-protective interventions in patients undergoing lung cancer surgery. Crit Care 2009; 13:R41.
  41. Roceto Ldos S, Galhardo FD, Saad IA, Toro IF. Continuous positive airway pressure (CPAP) after lung resection: a randomized clinical trial. Sao Paulo Med J 2014; 132:41.
  42. Nery FP, Lopes AJ, Domingos DN, et al. CPAP increases 6-minute walk distance after lung resection surgery. Respir Care 2012; 57:363.
  43. Joshi GP, Bonnet F, Shah R, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008; 107:1026.
  44. Guay J, Choi P, Suresh S, et al. Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2014; :CD010108.
  45. Pöpping DM, Elia N, Marret E, et al. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg 2008; 143:990.
  46. Manikian B, Cantineau JP, Bertrand M, et al. Improvement of diaphragmatic function by a thoracic extradural block after upper abdominal surgery. Anesthesiology 1988; 68:379.
  47. Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg 1998; 86:598.
  48. Romero A, Garcia JE, Joshi GP. The state of the art in preventing postthoracotomy pain. Semin Thorac Cardiovasc Surg 2013; 25:116.
  49. De Cosmo G, Aceto P, Gualtieri E, Congedo E. Analgesia in thoracic surgery: review. Minerva Anestesiol 2009; 75:393.
  50. Ready LB. Acute pain: lessons learned from 25,000 patients. Reg Anesth Pain Med 1999; 24:499.
  51. Licker MJ, Widikker I, Robert J, et al. Operative mortality and respiratory complications after lung resection for cancer: impact of chronic obstructive pulmonary disease and time trends. Ann Thorac Surg 2006; 81:1830.
  52. Richardson J, Sabanathan S, Shah R. Post-thoracotomy spirometric lung function: the effect of analgesia. A review. J Cardiovasc Surg (Torino) 1999; 40:445.
  53. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy--a systematic review and meta-analysis of randomized trials. Br J Anaesth 2006; 96:418.
  54. Ding X, Jin S, Niu X, et al. A comparison of the analgesia efficacy and side effects of paravertebral compared with epidural blockade for thoracotomy: an updated meta-analysis. PLoS One 2014; 9:e96233.
  55. Yeung JH, Gates S, Naidu BV, et al. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016; 2:CD009121.
  56. Hermanides J, Hollmann MW, Stevens MF, Lirk P. Failed epidural: causes and management. Br J Anaesth 2012; 109:144.
  57. Williams SR, Belliveau M, Brulotte V, Ruel MM. Impact of thoracic epidural catheter threading distance on analgesia during the first 24 hours following thoracotomy: a randomized controlled trial. Can J Anaesth 2016; 63:691.
  58. Mahon SV, Berry PD, Jackson M, et al. Thoracic epidural infusions for post-thoracotomy pain: a comparison of fentanyl-bupivacaine mixtures vs. fentanyl alone. Anaesthesia 1999; 54:641.
  59. Hirabayashi Y, Shimizu R. Effect of age on extradural dose requirement in thoracic extradural anaesthesia. Br J Anaesth 1993; 71:445.
  60. Daly DJ, Myles PS. Update on the role of paravertebral blocks for thoracic surgery: are they worth it? Curr Opin Anaesthesiol 2009; 22:38.
  61. Conlon NP, Shaw AD, Grichnik KP. Postthoracotomy paravertebral analgesia: will it replace epidural analgesia? Anesthesiol Clin 2008; 26:369.
  62. Naja Z, Lönnqvist PA. Somatic paravertebral nerve blockade. Incidence of failed block and complications. Anaesthesia 2001; 56:1184.
  63. Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade. Failure rate and complications. Anaesthesia 1995; 50:813.
  64. Kotzé A, Scally A, Howell S. Efficacy and safety of different techniques of paravertebral block for analgesia after thoracotomy: a systematic review and metaregression. Br J Anaesth 2009; 103:626.
  65. Chan VW, Chung F, Cheng DC, et al. Analgesic and pulmonary effects of continuous intercostal nerve block following thoracotomy. Can J Anaesth 1991; 38:733.
  66. Dryden CM, McMenemin I, Duthie DJ. Efficacy of continuous intercostal bupivacaine for pain relief after thoracotomy. Br J Anaesth 1993; 70:508.
  67. Sudarshan G, Browne BL, Matthews JN, Conacher ID. Intrathecal fentanyl for post-thoracotomy pain. Br J Anaesth 1995; 75:19.
  68. Gray JR, Fromme GA, Nauss LA, et al. Intrathecal morphine for post-thoracotomy pain. Anesth Analg 1986; 65:873.
  69. Mason N, Gondret R, Junca A, Bonnet F. Intrathecal sufentanil and morphine for post-thoracotomy pain relief. Br J Anaesth 2001; 86:236.
  70. Misiołek H, Karpe J, Copik M, et al. Ipsilateral shoulder pain after thoracic surgery procedures under general and regional anesthesia - a retrospective observational study. Kardiochir Torakochirurgia Pol 2014; 11:44.
  71. Burgess FW, Anderson DM, Colonna D, et al. Ipsilateral shoulder pain following thoracic surgery. Anesthesiology 1993; 78:365.
  72. Pennefather SH, Akrofi ME, Kendall JB, et al. Double-blind comparison of intrapleural saline and 0.25% bupivacaine for ipsilateral shoulder pain after thoracotomy in patients receiving thoracic epidural analgesia. Br J Anaesth 2005; 94:234.
  73. Bunchungmongkol N, Pipanmekaporn T, Paiboonworachat S, et al. Incidence and risk factors associated with ipsilateral shoulder pain after thoracic surgery. J Cardiothorac Vasc Anesth 2014; 28:979.