Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Do-Not-Resuscitate Orders in the Operating Room

Case Synopsis An 86-year-old woman presents as an add-on operating room case late one afternoon for treatment of a hip fracture suffered in a fall at home. She lives independently with home assistance. She is clearly competent and articulate and states that she is a “DNR” and does not want resuscitation measures in the operating room if her “heart stops.” She reasons that her likelihood of…

Dialysis-Dependent Patients

Case Synopsis A 43-year-old African American male gas station attendant is scheduled for emergency exploratory laparotomy after sustaining an abdominal stab wound in an attempted robbery. He is dialysis dependent and awaiting renal transplantation. His last hemodialysis was 52 hours earlier. He is awake and alert. His blood pressure is 102/90 mm Hg; heart rate, 114 beats per minute; and respiratory rate, 24 breaths per minute.…

Chronic Opioid Use

Case Synopsis A 38-year-old woman is transported to the emergency department (ED) via ambulance following a motor vehicle crash. Her medical history is notable for hypothyroidism, as well as a history of an intravenous (IV) opioid use disorder diagnosed at the age of 25. Her opioid use disorder is managed with medication-assisted treatment (MAT), which was started 10 years ago. She is currently receiving buprenorphine/naloxone 8…

Chemical Dependency : Opioids

Case Synopsis A 38-year-old anesthesiologist is found unresponsive and cyanotic in the call room after failing to return from a break in the case of a patient undergoing a craniotomy for tumor. Both fresh and recent venipuncture sites are found on his left forearm, along with a 1-mL insulin syringe and a rubber tourniquet. Acknowledgment The authors wish to thank Dr. Adrie Bruijnzeel for his contribution…

Chemical Dependency : Nonopioids

Case Synopses Alcohol Dr. P is a 60-year-old white male anesthesiologist with a 40-year history of alcohol abuse. Five years ago, he was questioned about alcohol on his breath before starting an 8:00 am case. He immediately took a blood alcohol concentration (BAC) test, which was below detectable limits, and proceeded with the case. Two years later, the operating room staff thought they detected the smell…

Alzheimer’s Disease

Case Synopsis A 78-year-old woman, living independently at home, falls and sustains a hip fracture. She is admitted to the hospital, and the medical history reveals only hypertension, for which she takes hydrochlorothiazide. Cleared for surgery, she undergoes a 3-hour hip arthroplasty under general endotracheal anesthesia with isoflurane with no complications. She experiences moderate blood loss (900 mL) but no episodes of hypotension or hypoxemia. After…

Adrenal Insufficiency

Case Synopsis A 68-year-old, 5-foot 10-inch, 100-kg man develops refractory hypotension toward the end of a laparotomy to remove the left colon because of recurrent diverticulitis and suspected peridiverticular abscess. The patient remains intubated at the end of the procedure and is taken to the intensive care unit (ICU), where a pulmonary artery catheter is placed and transthoracic echocardiogram (TTE) is obtained. The pulmonary artery occlusion…

Transesophageal Echocardiography in Noncardiac Thoracic Surgery

Introduction The use of transesophageal echocardiography (TEE), performed by the anesthesiologist, has become commonplace in cardiac surgery operating rooms in recent years. This has been especially prominent as the use of Swan-Ganz catheters has diminished at the same time. Outside of the cardiac surgery operating room the use of TEE has, thus far, largely been reserved for cases of unexplained hypotension/hypoxia/instability or so-called “rescue TEE.” However,…

Ultrasound of the Lung: Clinical Applications

Introduction Lung ultrasound (LUS) has become standard of care in many clinical settings and has proven feasible at the bedside for detecting life-threatening conditions, such as pneumothorax, with a sensibility and specificity often superior to standard chest radiography. For some time, the use of ultrasound (US) to assess the lung has been questioned because of the inherent physics of US and the structure of the chest…

Enhanced Recovery After Thoracic Surgery

Introduction Enhanced recovery after surgery (ERAS) refers to a comprehensive, evidence-based approach to patient-centered care in the perioperative period. The primary goals of enhanced recovery are an efficient return to baseline functional status and an avoidance of complications. Enhanced recovery has demonstrated success in multiple surgical specialties, particularly colorectal surgery. Although ERAS for thoracic surgery (ERATS) still occupies a small portion of the enhanced recovery literature,…

Robotic Thoracic Surgery

Introduction Robots have become increasingly present in contemporary reality. One can find them working in places where humans cannot reach because of biologic limitations, and helping people in different fields, as in the area of health care. In this regard, there is emphasis on the advances in the use of these devices in different surgical procedures, among them thoracic surgery, with good results for a variety…

Tracheal Stents

Introduction An airway stent is a prosthesis inserted to maintain intraluminal integrity of a compromised conducting airway, which can consist of either relief from airway obstruction or restoration of patency of the airway, such as in the case of fistulas or airway dehiscence. Placement of central airway stents is the domain of both the thoracic surgeon and interventional pulmonologists. Both benefit from the provision of expert…

Cystic Fibrosis

Clinical Case A 17-year-old male with cystic fibrosis (CF), pancreatic insufficiency and steatorrhea and severely compromised respiratory function was evaluated for lung transplantation. An episode of bowel obstruction when he was 15 years old required a laparotomy. During the months prior to admission he suffered a gradual weight loss, severe limitation of exercise tolerance, and difficulty in performing his daily activities, with several episodes of recurrent…

Thoracic Anesthesia inthe Morbidly Obese Patient: Obstructive Sleep Apnea

Introduction Over the past 3 decades, the world has experienced an obesity epidemic. Obesity is increasing rapidly in almost every part of the world; overweight and obesity rates are higher in the United States than in any other developed country. A recent report from the National Health and Nutrition Examination Survey—which examined a nationally representative sample of the U.S. population—revealed that more than two-thirds of the…

Hemoptysis, Empyema

Hemoptysis Key Points Severe hemoptysis is a life-threatening medical emergency. Careful systematic workup is needed to identify the origin and reason for hemoptysis. The anesthesiologist should play an important role in identifying the severity and origin of hemoptysis, initiation first-aid management, and follow a systematic therapeutic plan according to the severity of hemoptysis. The anesthesiologist should select the best option for securing airway and sealing the…

Myasthenia Gravis and Thymectomy

Introduction Myasthenia gravis (MG) is an autoimmune disorder affecting the neuromuscular junction for which patients commonly undergo surgical thymectomy as definitive treatment. It is therefore of great significance to the thoracic anesthesiologist. It is a chronic disorder characterized by fluctuating painless weakness and fatigability of voluntary muscles made worse on exertion with improvement following rest. The onset is usually slow and insidious; any skeletal muscle or…

Thoracic Approach to Spine Procedures

Introduction Thoracic spine surgery can be performed from anterior, posterior, or combined approaches. Selection of the appropriate surgical approach depends on the optimal surgical procedure for the patient, the complexity of intervention to be performed, the location and extent of the pathology, and the surgeon’s comfort with each technique. Thoracic spine surgery has historically been performed from a posterior approach. Recently, the anterior approach has come…

Airway Fistulas in Adults

Introduction Fistula formation in the airway may be broadly defined as any defect that allows pathologic communication between the respiratory tract and an adjacent structure. The type of airway fistula is determined by which section of the tracheobronchial tree and which adjacent structure is involved. For example, a tracheoesophageal fistula (TEF) is a communication between the trachea and the esophagus, whereas a bronchopleural fistula (BPF) is…

Esophageal Procedures

Introduction Esophageal surgery in adults is associated with a high perioperative morbidity (52%) and mortality (12%). Postoperative complications are mainly pulmonary with an incidence of up to 52%, which significantly reduces the short- and long-term survival of patients. Although patient-specific risk factors (comorbidities, age, gender, nutritional status, etc.) are difficult to influence, perioperative management and medical care research is increasingly focusing on the optimization of procedural…

Lung Transplantation

Introduction Although many disease states result in severe lung disease, lung transplantation remains the only definitive therapy. Because of heterogeneity in underlying disease states, and significant cardiopulmonary manifestations of lung disease, lung transplantation procedures carry significant risk, and careful planning with respect to intraoperative management and postoperative care is required, with attention to hemodynamics, ventilatory parameters, immunosuppression, infection prevention, and graft dysfunction. Extracorporeal membrane oxygenation (ECMO)…