Perioperative Care of the Thoracic Surgical Patient

Patients who are undergoing thoracic surgery require careful attention in the perioperative period. These patients are often older and have baseline abnormalities of lung function, decreased nutritional status, and other comorbid diseases. Postoperatively, factors that influence patient recovery include removal of all or a portion of a lung, the esophagus, or the chest wall, painful incisions, retention of secretions, change in the shape and mechanics of the thoracic cage, and reconfiguration of gastrointestinal continuity, which result in suboptimal pulmonary function, decreased appetite, decreased mobility and strength, and increased risk of aspiration.

Perioperative care of the thoracic surgical patient requires a team approach. The surgeon is uniquely qualified to be the captain of the team, because he or she is aware of the patient's functional status preoperatively, the operative findings and events, and the postoperative anatomy that will dictate each patient's needs and restrictions. Members of the team include the surgeon, anesthesiologist, pain management specialist, nurse, respiratory therapist, physical therapist, pharmacist, occupational therapist, speech pathologist, dietician, and social worker.

By the year 2030, an estimated 70 million people will be older than 65 years. A Surveillance, Epidemiology, and End Results study of lung cancer in older patients found that 14% and 33% of lung cancer patients were older than 80 years and 70-79 years, respectively. In addition to evaluating the medical benefit of thoracic surgical procedures in the elderly, the effects on baseline functioning, living situation, and quality of life need to be assessed. Multiple different assessment tools predict the risk of mortality or morbidity for these patients. Although no tool is perfectly accurate or reliable, they can be helpful for deciding whether to perform surgery, the extent of surgery, surgical approach, and hospital discharge planning and disposition.

For palliative procedures, a discussion of the patient's expected outcome from the operation—symptomatically, medically, and functionally—is prudent to ensure that the patient and family understand the benefit/risk balance of each procedure and want to move forward. Knowledge of advanced directives and Do Not Resuscitate or Do Not Intubate status before the operation is recommended.

In recent years, there has been increased focus on patient safety, quality of patient care, and cost savings. As care becomes more specialized, duty hours are restricted, and more practitioners become involved in each patient's care, communication between team members and handoffs will be critical for safe patient care. Clinical pathways, protocols for patient updates and practitioner shift changes, and checklists are tools that have been developed and implemented. Some protocols have been assessed, whereas others need further study to ensure that they address the need for cost-effective, high-quality, standardized, and error-free patient care.

Preoperative Preparation

An in-depth review of preoperative assessment is covered in Chapter 3 . Medical optimization for thoracotomy or thoracoscopy patients includes adjustment of medications for chronic obstructive pulmonary disease, including administration of bronchodilators and steroids and treatment of acute bronchitis or pneumonia. Total resolution might not be possible if the pneumonia is caused by a postobstructive process secondary to lung mass or chronic aspiration from gastroesophageal reflux disease.

Patients with borderline pulmonary function can benefit from pulmonary rehabilitation that increases their exercise tolerance and respiratory muscular strength before the resection. Preoperative pulmonary rehabilitation should be a routine component for all patients undergoing lung volume reduction surgery. Smoking cessation not only affects overall health; it also decreases postoperative morbidity and mortality of thoracic surgery. Support groups, counseling, nicotine replacement therapy, and pharmacologic treatment are available and successful. If there is no smoking cessation program associated with the provider's hospital, programs can be located by calling the local American Lung Association. Timing of smoking cessation before the operation remains debatable. Because of the number of conflicting studies, space does not allow review of this issue. Our current recommendation is that all smokers requiring lung resection should be encouraged to quit smoking, and assisted to do so, at any time before surgery.

Additional comorbid diseases that need to be managed include coronary artery disease, diabetes mellitus, and myasthenia gravis. The American Heart Association and the American College of Cardiology classify thoracic surgical procedures as medium risk. When there is no clinical history of risk factors for cardiac disease, no further workup is necessary if a preoperative 12-lead electrocardiogram (ECG) is normal. If a patient has risk factors for cardiac disease, further testing should be done to assess the presence and degree of disease. However, revascularization for significant coronary stenosis simply to decrease risk of perioperative ischemic event has not been proved beneficial to overall survival. Medical optimization with therapy such as β-blocker, statin, and afterload reduction and continuance of aspirin given for coronary disease is recommended.

Diabetic patients should have their cardiac, renal/intravascular volume, and glucose status checked before elective surgery, although there is controversy regarding rapid adjustment of chronic hyperglycemia in patients with diabetes. Electrolytes should be checked preoperatively, and abnormalities should be treated. Baseline creatinine measurement is helpful. Acute elevation in creatinine needs to be investigated before elective thoracic surgery. Orthostatic vital signs should be also performed.

Diabetic patients optimally should have good glycemic control preoperatively. Some guidelines recommend checking HbA1c and adjusting medications for better glucose control before the operation if time permits in patients with diabetes. However, other studies have shown no improvement in outcome and some adverse reactions from rapid glucose control in the weeks to months preceding elective noncardiac surgery. Long-acting sulfonylureas and thiazolidinediones should be discontinued 24 to 48 hours before elective surgery. Shorter-acting sulfonylureas, secretagogues such as metformin, or GLP-1 agonists can be stopped 12 hours before surgery. DPP-4 inhibitors can be continued preoperatively. Long-acting insulin can be continued until the day of surgery if control has been good. If there is glucose level fluctuation, long-acting insulin should be stopped 24 to 48 hours before surgery, and sliding-scale insulin should be used with frequent glucose checks.

Another challenge is the patient who is not aware that they have diabetes mellitus. Perioperative complications can be decreased, and long term well-being will be affected with discovery and treatment of undiagnosed diabetes. Therefore, we recommend that patients having thoracic surgery be evaluated for diabetes preoperatively if they are older than 45 years or are younger and overweight with 1 or more of the risk factors shown in Box 4-1 by testing a fasting glucose level or HbA1c.

Box 4-1

From Sheehy AM, Gabbay RA: An overview of preoperative glucose evaluation, management, and perioperative impact. J Diabetes Sci Technol 3:1261–1269, 2009.

Criteria Used to Screen for Diabetes Mellitus

ADA and USPSTF

American Diabetes Association *

* American Diabetes Association. Standards of Medical Care in Diabetes 2011. Diabetes Care 2011; 34:S11. Copyright © 2011 American Diabetes Association.

1
Testing should be considered in all adults who are overweight (BMI ≥25 kg/m ² ) and have additional risk factors:
- Physical inactivity
- First-degree relative with diabetes
- Members of high-risk ethnic populations
- Women who delivered a baby weighing greater than 9 pounds or were diagnosed with GDM
- Hypertension
- HDL cholesterol <35 mg/dl or triglycerides >250 mg/dl
- Women with PCOS
- IGT or IFG on prior testing
- Other clinical conditions associated with insulin resistance
- History of cardiovascular disease
2
In the absence of aforementioned criteria, testing for diabetes and prediabetes should begin at age 45 years.
3
If the results are normal, testing should be repeated at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status.

U.S. Preventive Services Task Force

Screen is recommended for asymptomatic adults with sustained blood pressure greater than 135/80 mm Hg.
No recommendation for asymptomatic adults with blood pressure less than 135/80 mm Hg.

BMI, Body mass index; GDM, gestational diabetes mellitus; HDL, high-density lipoprotein; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; PCOS, polycystic ovarian syndrome.

For patients with myasthenia gravis, the goal of preoperative preparation is to reduce the risk of myasthenic crisis, which is acute respiratory muscle malfunction leading to respiratory failure. Medication and treatment adjustments may be needed to maintain adequate function for daily living until the time of surgery. Doses of steroids and anticholinesterase medication should be tailored to the patient's symptoms. More aggressive and rapid therapies include infusion of intravenous immune globulin and plasmapheresis, and they have effects lasting weeks to months. Plasmapheresis usually requires multiple exchanges, and it is recommended for patients with a vital capacity of less than 2.0 L.

Prophylaxis

Atrial Fibrillation

The incidence of postoperative atrial fibrillation ranges between 3% and 30% in thoracic surgical patients. It increases the risk of stroke and prolongs postoperative length of stay, thus increasing hospital cost. Multiple risk factors are associated with development of atrial fibrillation after thoracic surgery including patient factors such as age, male sex, history of congestive heart failure, and previous history of atrial fibrillation. Procedural risk factors include length of procedure and dissection near the atria or pericardium. A retrospective review of more than 2900 patients revealed increased relative risks of atrial fibrillation of 3.89, 7.16, 8.91, and 2.95 for lobectomy, bi-lobectomy, pneumonectomy, and esophagectomy, respectively, compared with a single wedge resection. Numerous studies on the prevention and treatment of postoperative atrial fibrillation have been performed, but the majority were for cardiac surgical patients. The Society of Thoracic Surgeons released guidelines regarding prophylaxis and treatment of atrial fibrillation in association with general thoracic surgery. Prophylaxis recommendations include resuming β-blockade if the patient was taking a β-blocker beforehand, or the use of diltiazem, amiodarone, or a β-blocker if the patient was not taking preoperative β-blockers for lobectomy patients. The use of amiodarone for prophylaxis is not recommended for patients undergoing pneumonectomy. Magnesium supplementation has been shown to be helpful for atrial fibrillation prophylaxis.

For atrial fibrillation with rapid ventricular response, rate control is the main priority. Conversion back to normal sinus rhythm is a secondary, but not an immediate goal unless there is hemodynamic instability.

Deep Venous Thrombosis

Postoperatively, a majority of thoracic surgery patients are slow to move because of pain, respiratory distress, and age. Venous thromboembolism (VTE) includes deep venous thrombosis and pulmonary embolism and causes an estimated 300,000 deaths annually in the United States. VTE prophylaxis could prevent 100,000 of these deaths. The current recommendations for deep venous thrombosis prophylaxis from the American College of Chest Physicians vary depending on patient risk. A useful risk stratification model is the Caprini scoring system, which has been validated for general, vascular, urologic, and plastic and reconstructive surgery ( Table 4-1 ). The risk of VTE is even greater in patients undergoing treatment for cancer. VTE prophylaxis is not recommended for outpatients undergoing thoracic surgery ( Box 4-2 ).

TABLE 4-1

Caprini Risk Assessment Model

From Gould MK, Garcia DA, Wren SM, et al: Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, ed 9: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 141(Suppl 2):e227S–277S, 2012.

1 Point	2 Points	3 Points	5 Points
41-60 yr old	61-74 yr old	≥75 yr old	Stroke (<1 mo)
Minor surgery	Arthroscopic surgery	History of VTE	Elective arthroplasty
BMI > 25 kg/m ² Swollen legs Varicose veins Pregnancy or postpartum History of unexplained or recurrent spontaneous abortion Oral contraceptives or hormone replacement Sepsis (<1 mo)	Major open surgery (>45 min)	Family history of VTE Factor V Leiden Prothrombin 20210A Lupus anticoagulant Anticardiolipin antibodies Elevated serum homocysteine Heparin-induced thrombocytopenia Other congenital or acquired thrombophilia	Hip, pelvis, or leg fracture
	Laparoscopic surgery (>45 min)		Acute spinal cord injury (<1 mo)
	Malignancy
	Confined to bed (>72 h)
	Immobilizing plaster castCentral venous access
	Immobilizing plaster castCentral venous access

Serious lung disease, including pneumonia (<1 mo)
Abnormal pulmonary function
Acute myocardial infarction
Congestive heart failure (<1 mo)
History of inflammatory bowel disease
Medical patient at bed rest

BMI, Body mass index; VTE, venous thromboembolism.

Box 4-2

© 2013 by American Society of Clinical Oncology. Published in Lyman GH, Khorana AA, Kuderer NM, et al: Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 31:2189–2204, 2013. The Data Supplement, including evidence tables, and clinical tools and resources, can be found at www.asco.org/guidelines/vte .

ASCO Guideline

Venous Thromboembolism Prophylaxis and Treatment in Patients with Cancer

Interventions

Pharmacologic anticoagulation

Target Audience

Medical oncologists, surgical oncologists, hospitalists, oncology nurses

Key Recommendations

Most hospitalized patients with cancer require thromboprophylaxis throughout hospitalization.
Thromboprophylaxis is not routinely recommended for ambulatory patients with cancer; it may be considered for select high-risk patients.
Patients with multiple myeloma receiving antiangiogenesis agents with chemotherapy or dexamethasone should receive prophylaxis with either LMWH or low-dose aspirin to prevent VTE.
Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days.
Extending postoperative prophylaxis up to 4 weeks should be considered in those with high-risk features.
LMWH is recommended for the initial 5 to 10 days of treatment for patients with established deep vein thrombosis and pulmonary embolism, as well as for long-term (6 months) secondary prophylaxis.
Use of novel oral anticoagulants is not currently recommended for patients with malignancy and VTE.
Anticoagulation should not be used to extend survival in patients with cancer in the absence of other indications.
Patients with cancer should be assessed periodically for VTE risk.
Oncology professionals should provide patient education about the signs and symptoms of VTE.

Methods

An expert panel was convened to develop clinical practice guideline recommendations based on a review of evidence provided by a systematic review of the medical literature.

ASCO, American Society of Clinical Oncology; LMWH, Low-molecular-weight heparin; VTE, venous thromboembolism.

Stress Ulceration and Gastritis

Stress ulceration prophylaxis is recommended in critically ill patients with coagulopathy, expected mechanical ventilation for longer than 48 hours, on antiplatelet or anticoagulant medications, a history of gastrointestinal bleeding or gastric ulceration in the past year, and at least two of the following: sepsis, intensive care unit stay longer than 1 week, high-dose steroid administration, or occult bleeding lasting 6 or more days. The incidence of clinically significant bleeding remains low with the use of pharmacologic agents for prophylaxis in these high-risk patients. The risk of gastritis and stress ulceration in patients without risk factors is low; therefore, routine prophylaxis is not recommended. Multiple studies have evaluated the use of proton pump inhibitors (PPIs) compared with histamine 2 receptor blockers (H ₂ blockers) with respect to incidence of bleeding and incidence of nosocomial pneumonia. The data are not strong, and the use of either PPI or H ₂ blockers for high-risk patients is recommended for the duration of their time in intensive care, but may not be necessary when patients are no longer critically ill or are discharged from the hospital. In addition, PPI may be associated with a higher rate of nosocomial pneumonia, whereas H ₂ blockers can interfere with other medications metabolized by the P450 cytochrome pathway.

Infection

A properly timed dose of intravenous first-generation cephalosporin is efficacious in preventing wound infections from skin pathogens. For patients with β-lactam allergy, vancomycin or intravenous clindamycin are the substitutes of choice. Vancomycin administration must be started early enough to ensure that the dose is completely infused before the first incision. There are insufficient data to support the administration of more than one dose of prophylactic antibiotic for elective nontransplant thoracic surgical procedures. If the prophylactic antibiotic is continued beyond the preoperative dose, no data have supported the use of antibiotic beyond 24 hours for wound prophylaxis ( Table 4-2 ).

TABLE 4-2

Perioperative Antimicrobial Recommendations for Thoracic Surgery

From Chang SH, Krupnick AS: Perioperative antibiotics in thoracic surgery. Thorac Surg Clin 22:35–45, 2012.

Procedure	Common Pathogens	Antibiotic Regimen
Pulmonary resections	Staphylococcus aureus Coagulase-negative staphylococci Streptococcus pneumoniae Gram-negative bacilli	Cefazolin 1 g IV preoperatively, with a total of 1-3 doses every 8 hours If penicillin allergic, vancomycin 1 g IV preoperatively, with a total of 1-3 doses every 12 hours
Esophageal surgeries	Enteric gram-negative bacilli Streptococci Oropharyngeal anaerobes	Cefazolin 1 g IV preoperatively, with a total of 1-3 doses every 8 hours If penicillin allergic, vancomycin 1 g IV preoperatively, with a total of 1-3 doses every 12 hours If high anaerobic burden likely, cefepime 1 g IV preoperatively, with a total of 1-3 doses every 12 hours
Lung transplantation	Pseudomonas spp. Burkholderia cepacia Gram-negative bacilli Methicillin-resistant Staphylococcus aureus Cytomegalovirus Candida spp. Aspergillosis spp. Pneumocystis carinii	Cefepime 1 g IV preoperatively, with a 7-10 day course * For cystic fibrosis patients, sensitivities are sent and for multidrug-resistant Pseudomonas spp., inhaled colistin should be added perioperatively Vancomycin 1 g IV preoperatively, with a 7-10 day course * For seropositive recipients, valganciclovir 900 mg PO daily or ganciclovir 5 mg IV 5 times per week while CMV PCR positive * For seronegative recipients with seropositive donors, valganciclovir 900 mg PO daily for 6 months * or ganciclovir 5 mg IV 5 times per week or 1 g PO tid for 6 months Amphotericin B, itraconazole, or voriconazole for 1 year Trimethoprim-sulfamethoxazole prophylaxis 3 times per week For sulfa allergies, dapsone and inhaled pentamidine can be used
Empyema	Staphylococcus aureus Streptococcus milleri Escherichia coli Pseudomonas spp. Haemophilus influenzae Klebsiella spp. Anaerobes	Antibiotics should be based on culture and sensitivity from empyema; if not available, the following regimens are appropriate for 3 weeks Community acquired (all are acceptable periop abx) Cefuroxime 500 mg IV tid plus metronidazole 500 mg PO or 400 mg IV tid Penicillin 1 g qid plus metronidazole 500 mg PO or 400 mg IV tid Meropenem 1g tid plus metronidazole 500 mg PO or 400 mg IV tid Augmentin 875/125 mg PO tid Amoxicillin 1g PO tid plus metronidazole 400 mg PO tid Clindamycin 300 mg PO qid Hospital acquired (all are acceptable periop abx) Piperacillin-tazobactam 4.5g IV qid Ceftazidime 2 g IV tid Meropenem 1 g IV tid ± metronidazole 500 mg IV tid or 400 mg PO tid

abx, Antibiotics; CMV, cytomegalovirus; IV, intravenous; PCR, polymerase chain reaction; periop, perioperative; PO, by mouth; preop, preoperative; qid, four times per day; tid, three times per day.

* Based on empiric evidence gathered at Washington University in St. Louis, Mo.

Prophylaxis for pneumonia and empyema in patients undergoing lung resection or esophageal resection is an attractive concept, because these prophylaxes involve clean-contaminated operative fields. Postoperative pneumonia was found in approximately 25% of patients undergoing lung resection in two different studies. Radu and colleagues demonstrated that only 18% of the pathogens postoperatively isolated from patients with pneumonia were susceptible to first-generation cephalosporin. They recommend consideration of use of prophylactic antibiotics to cover gram-positive and gram-negative organisms.

Unfortunately, no clear data support this practice. The Surgical Care Improvement Project is a national program sponsored by the Center for Medicare and Medicaid Services along with other health organizations (e.g., American Hospital Association, Centers for Disease Control and Prevention) to decrease the number of surgical complications. Randomized trials showing an improved outcome with the use of antibiotics effective on gram-negative organisms are needed for surgeons in the United States to justify their practice. Surgical Care Improvement Project participation delineates the timing of prophylactic antibiotic administration (within 1 hour of surgical incision), the type of antibiotic (first-generation cephalosporin with exceptions for allergies), and the duration of prophylactic antibiotic administration (limited to 24 hours or less for all surgeries except cardiac surgery; for cardiac surgery, 48 hours). If a patient is receiving antibiotics for a therapeutic reason, prophylactic antibiotic use does not apply.

Anticoagulation

Management of anticoagulation before thoracic surgery varies depending on the reason for anticoagulation, patient risk factors for bleeding or thrombosis, the urgency of the procedure, and which anticoagulant the patient is being given.

For patients who are taking anticoagulation because of the risk of a thromboembolic event, risk stratification helps to guide management ( Table 4-3 ). When bridging with unfractionated or low-molecular-weight heparin (LMWH) or when continuing anticoagulation is the recommended strategy, assessment of the risk of bleeding perioperatively should be done. Some of the newer anticoagulants have a short half-life and do not require bridging. For patients taking anticoagulation for drug-eluting coronary artery stents, a period of 12 months before interrupting anticoagulation for elective surgery is recommended to prevent in-stent stenosis, which can have a mortality of 50%. For bare metal stents, a 6-week period of uninterrupted anticoagulation is recommended. If surgery is urgent or emergent, the risks of operation on anticoagulation versus in-stent stenosis should be weighed. If the risk of bleeding is thought to be such that anticoagulation needs to be stopped, treatment with antiplatelet medications with a short half-life such as tirofiban, cangrelor, or eptifibatide until several hours before surgery can be considered. If double antiplatelet treatment with aspirin and another antiplatelet medication such as clopidogrel is being used, continuation of the aspirin perioperatively is recommended. More extensive discussion about managing the different types of target specific anticoagulants is not possible in this generalized chapter. The references are helpful in describing specific patient situations.

TABLE 4-3

Risk Stratification of Anticoagulated Patients for Further Thromboembolic Events

From McKenzie JL, Douglas G, Bazargan A: Perioperative management of anticoagulation in elective surgery. ANZ J Surg 83:814–820, 2013.

Risk Stratum	Indication for Anticoagulation
Risk Stratum	Atrial Fibrillation	Mechanical Heart Value	Venous Thromboembolic Disease
High >10% risk per annum	CHADS2 ≥ 5 Stroke or TIA within last 3 months Rheumatic valvular heart disease	Any mitral valve prosthesis Aortic valve prosthesis with tilting disc or caged ball Stroke or TIA in last 6 months	VTE within last 3 months Severe thrombophilia (deficiency in antithrombin, protein C or S)
Moderate 5-10% risk per annum	CHADS2 score of 3 or 4	Bileaflet aortic valve prosthesis with other stroke risk factors	Clot within last 3-12 months Recurrent VTE Active cancer
Low <5% risk per annum	CHADS2 score 2 or less and no previous stroke	Bileaflet aortic valve prosthesis	VTE > 12 months ago

CHADS2, 1 point each allocated for congestive heart failure, hypertension, age greater than 75 years, and diabetes mellitus, and 2 points for previous stroke; TIA, transient ischemic attack; VTE, venous thromboembolic disease.

Miscellaneous

Blood products are reserved for patients who have anemia preoperatively or a chance of significant blood loss during the surgical procedure. There are no studies that identify an unequivocal hemoglobin threshold for patient transfusion before or during surgery, but multiple studies have found that even critically ill patients will tolerate a hemoglobin of 7 mg/dL. An exception may be if the patient has acute ischemic cardiac disease. Previously, patients having elective major thoracic surgery were thought to be good candidates for the benefits of autologous blood donation, including decreased risk of infection, transfusion reaction, and immune modulation. However, the acceptance of lower patient hemoglobin levels, techniques leading to decreased intraoperative blood loss, and lack of cost effectiveness because of the processing and administration decreases the recommendation for autologous blood donation. The use of erythropoietic agents has been effective in eliminating or decreasing the amount of anemia in patients with cancer who have received chemotherapy or radiation therapy. Although preoperative or postoperative use of erythropoietin or darbepoetin is an attractive idea for thoracic oncology patients, increased mortality was found in patients who had not had neoadjuvant therapy. In addition, there are reports of increased risk of deep venous thrombosis in oncology patients who are given erythropoietic agents for anemia.

In the past, bowel preparation before esophageal resection was justified when colon interposition was planned. Some surgeons also used bowel preparation for all patients undergoing esophagectomy, with gastric pull-up as a precaution should the stomach be found to be unusable during operation. Bowel preparation for colon resection has been studied by multiple randomized controlled trials and meta-analyses. Evidence shows no benefit with mechanical bowel preparation regarding anastomotic leak or superficial surgical site infection for colon resection. Whether there is increased risk of anastomotic leak, deep or superficial surgical site infection for colon interposition after esophagectomy without bowel preparation has not been studied systematically. Histologic changes in colon mucosa were of a greater degree in patients who underwent mechanical bowel preparation, but it is not known whether these changes are clinically relevant. Electrolyte and intravascular volume changes with bowel preparation may be magnified in esophageal surgery patients who have challenges with oral intake and hydration.

Surgery should never be delayed because of the unavailability of equipment. Hospitals often have equipment (laparoscopes, thoracoscopes, video equipment, operative microscopes, lasers, vessel sealing and energy devices, ultrasonic devices, radiofrequency devices, cryoablation equipment, robots, specialized retractors) that is used by several different services. Such equipment should be reserved before the surgery to ensure that it is available and functioning properly. Perioperative management software allows for procedure scheduling, inventory maintenance, automatic supply reordering, and equipment conflict checking.

Intraoperative Care

Good communication with the anesthesiologist or anesthetist is essential. Airway management should be discussed beforehand if there are special circumstances. The entire operative team should know the plan of the operation including (1) anticipated anatomic outcome of the procedure, (2) position and planned position changes, (3) instrument, equipment, and medication needs (e.g., fluoroscopy devices, drainage tubes, local anesthetic), (4) general length of the operation, (5) possible unanticipated occurrences and treatment (e.g., bleeding), and (6) postoperative disposition (e.g., extubation versus postoperative ventilation, ward versus intensive care).

Ventilation

Single-lung ventilation during thoracotomy or thoracoscopy is accomplished by placing a double-lumen tube, bronchial blocker, endotracheal tube with in-line bronchial blocker, intermittent ventilation (for procedures of short duration) or, as a last resort, a single-lumen tube down the desired main-stem bronchus. Because of improvements in care, patients are living longer and selective lobar ventilation techniques may be necessary if previous lobectomy or pneumonectomy has been performed. The use of lower intraoperative tidal volumes during single-lung ventilation has been shown to decrease the incidence of respiratory failure in lung resection patients. Increased peak inspiratory pressure, decreased oxygen saturation, and increased end-tidal CO ₂ during the procedure without a known etiology from the surgical field lead to a differential diagnosis of retained secretions or blood, dislodgement of the endotracheal tube or blocker, or contralateral pneumothorax. Stabilization may require reinflation of the operative-side lung if increased fraction of inspired O ₂ (Fi o ₂ ) administration and oxygen flow and gentle bagging by the anesthesiologist do not improve the situation. Investigations and treatments include suctioning of obstructing blood or mucus, bronchoscopy and repositioning of single-lung ventilation equipment, or decompression of the contralateral pleural space of air.

Monitoring

Different operations require different levels of monitoring. ECG monitoring and continuous pulse oximetry measurements are necessary in all cases. An arterial line is placed if there is a need for multiple blood samples. Continuous arterial pressure monitoring is useful during procedures involving mediastinal dissection, such as transhiatal esophagectomy, to gauge cardiac or great vessel compression. Temperature monitoring by bladder temperature probe or esophageal temperature probe is necessary for major procedures (see Body Temperature ).

Intravenous access should be appropriate for the invasiveness and potential blood loss of the procedure. Anticipated blood loss is rarely sufficient to justify the need for large-bore central lines. However, adequate access is necessary before the procedure starts, because the arms, chest, and groin are often inaccessible for line placement during an operation with a patient in the decubitus or prone position. In an emergency, a large-bore line can be placed in the operative field via the subclavian vein, superior vena cava, inferior vena cava, or azygous vein.

Body Temperature

Mild hypothermia has been shown to increase wound infection, blood loss and transfusion requirements, and cardiac events including ventricular tachycardia, cardiac arrest, and myocardial infarction. Heat loss through thoracotomy, sternotomy, and laparotomy incisions can be lessened by keeping the room temperature greater than 21° C, using airway heating and humidification devices, covering portions of the patient not in the operative field, and using forced-air warming blankets. Warm saline lavage intrapleurally and intraperitoneally can also be performed. Intravenous fluid warmers are rarely necessary.

Positioning

Careful positioning of the patient is of utmost importance in the operating room. The surgeon needs to ensure adequate access for the planned operation and any potential counterincisions or chest wall resection. The use of muscle flaps often requires planning ahead to protect the vascular supply and to leave adequate skin coverage. Padding to prevent neuropathy includes the use of an axillary roll and head support to maintain neck alignment in the lateral decubitus position. Padding of all pressure points includes between the legs, the greater trochanter, fibular head, and lateral malleolus of the lower extremities. The dependent arm is supported on a padded board, the nondependent arm is slightly abducted, and the shoulder and elbow are slightly flexed and rested on pillows or an arm support. Stability of the patient during the operation can be achieved using a deflatable beanbag, sand bags, laminectomy rolls, padded supports and posts, and security straps or tapes. The lithotomy position also requires careful positioning to prevent postoperative neuropathy, musculoskeletal strain to the lower spine, and skin and muscle ischemia.

Fluid Administration

Fluid administration during pulmonary resection is kept to a minimum. If pneumonectomy is planned, administration of 1 L of fluid during the intraoperative course has been advocated. During esophagectomy, additional fluid administration may be needed because of increased blood loss and third space fluid distribution. Clear communication between surgeon and anesthesiologist regarding blood loss, hemodynamic trends, and pressor and fluid administration during the operation is crucial.

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