Arminder Jassar and Taine T.V. Pechet

Preoperative

The preoperative evaluation of patients undergoing lung or esophageal surgery is often complex, and the decision to operate is heavily influenced by comorbid conditions and the urgency of the procedure. Although a comprehensive discussion of this topic is beyond the scope of this chapter, important elements to consider in all patients undergoing thoracic surgery include optimal imaging; evaluation for metastatic disease; and evaluation of pulmonary function, cardiac risk stratification, and management of comorbid conditions.

It is imperative to emphasize to patients the importance of smoking cessation several weeks prior to surgery. Although the optimal time interval between smoking cessation and lung resection remains poorly defined, a minimum of 2 to 3 weeks is advised. Quitting tobacco closer to the date of surgery has been shown to invoke a hypersecretory response in the airways. Additionally, patients should be encouraged to start an exercise program when appropriate. This serves as the foundation for mobilization and exercise after discharge. In patients with evidence of reactive airway disease, bronchodilator therapy should be optimized while minimizing the use of systemic steroids. Finally, all medications should be carefully reviewed with specific attention to whether the patient takes antiplatelet or anticoagulation agents. If the patient requires ongoing anticoagulation, a plan for postoperative anticoagulation should be developed.

Intraoperative

Critical elements of care during the thoracic procedure include patient positioning, analgesia strategies, ventilator and acid-base management, fluid replacement, and extubation considerations. For most thoracic procedures epidural analgesia, typically placed prior to the induction of general anesthesia, is appropriate. If placement of an epidural catheter is anticipated, the American Society of Regional Anesthesia and Pain Medicine has made specific recommendations regarding anticoagulation surrounding the time of the procedure (Table 94.1). The narcotic sparing effects of epidural analgesia combined with the excellent pain coverage make epidural analgesia optimal for thoracic surgical procedures. When this is not an option, however, intercostal nerve blockade with long-acting local anesthetic agents or placement of extrapleural or paravertebral infusion catheters may be a viable alternative (Chapter 87).

The positioning for thoracic surgical procedures can have profound implications on the conduct of the operation as well as the anesthetic management. Most pulmonary resections are conducted in the lateral decubitus position, and a beanbag or other support device can be used to maintain this position. During positioning, it is imperative to pay close attention to axillary and arm position to avoid injury to the brachial plexus or other peripheral nerves. Adequate intravenous access, typically without the requirement for central access or monitoring, is usually established prior to positioning. Radial arterial cannulation and bladder catheterization are also typically employed. As with any surgical procedure that is anticipated to last several hours, appropriate padding and cushioning to prevent rhabdomyolysis and skin breakdown are important.

Most thoracic procedures require the institution of single lung ventilation. Careful monitoring of airway pressures during the operation is critical to avoid barotrauma. The relationship between fluid management and barotrauma continues to be an active area of investigation, but barotrauma seems to predispose to capillary leak and the development of postoperative pulmonary edema. This is particularly important during lung resection or pneumonectomy. The development of postpneumonectomy pulmonary edema or acute respiratory distress syndrome (ARDS) in the remaining lung remains a vexing clinical problem that is mitigated by attention to these intraoperative factors.

Postoperative

These patients should generally be cared for in units where the nursing and ancillary staffs are familiar with the salient issues. Information that should be discussed during daily rounds includes vital signs, oxygenation, urine output, chest tube output, telemetry for arrhythmia detection, respiratory patterns and lung exam, status of air leaks, ambulation, and bowel function. The remainder of this chapter focuses on specific issues that are particularly relevant to the thoracic surgical patient in the postoperative period.