Although many of the challenges to the anesthesiologist posed by lung resection surgery are similar to those with other surgeries, acute major hemorrhage is one that is particularly lethal and requires serious preparation for every case.
Lung resection surgeries are a highly morbid group of procedures, with mortality rates that are equivalent to or exceed elective coronary artery bypass surgery. Notably, a significant number of the serious complications of lung resection occur beyond the immediate surgical period and are related to postoperative respiratory insufficiency.
The anesthesiologist makes many decisions perioperatively that influence respiratory function and can conceivably contribute to postoperative insufficiency. It is imperative in caring for lung resection patients that the anesthesiologist be conscious of these issues and avoid any unwitting contribution to the burden of risk for respiratory impairment and failed tracheal extubation after lung resection surgery.
The patient is a 59-year-old man with a 150 pack-year history of cigarette smoking. After being treated with antibiotics for a persistent productive cough, his sputum has become blood tinged over the past 2 weeks, and a chest x-ray revealed a right upper lobe coin lesion.
Health background includes longstanding hypertension, an anxiety disorder, and peripheral vascular disease, for which he underwent a left femoral-popliteal artery bypass 1 year ago. Current medications include lisinopril, atenolol, aspirin, and alprazolam.
Vital signs: BP 189/88 mm Hg, HR 55, room air SaO2 92%.
Laboratory investigations are notable for white blood cell count 12.1 and prothrombin time 14.0 seconds (normal 12.5-13.8). Pulmonary function tests are notable for a FEV1 of 50% predicted, FEV1/FVC 60%, and DLCO of 45% predicted.
In the past two decades, significant research and innovation has improved both therapy and prognosis for lung cancers and benign tumors. Medical gains in imaging, better timing, prescription, and selectivity of radiation and chemotherapy have complemented surgical advances, including routine tumor staging, port access video-assistance, titanium staplers with scalpel blades, and more targeted operations designed to preserve unaffected lung tissue. Anesthesia advances have kept pace, with better lung isolation methods and a broadened pharmacologic armamentarium providing an enhanced flexibility that combines safe surgery with multiple options for postoperative analgesia and prompt wake-up and extubation, even for patients with limited respiratory reserve or when a procedure is terminated prematurely. Notably, many of these improvements have expanded the candidate pool for lung resection to include patients who would previously have been ineligible due to their marginal lung function.
Despite advances, perioperative morbidity and mortality rates for lung resection still exceed those for many major procedures (eg, aortocoronary bypass surgery), and few dispute the important role of the anesthesiologist's actions in influencing patient outcome.1-3 The aim of this chapter is to address and integrate numerous elements of thoracic anesthesia, some outlined in more detail in other chapters, which combine to optimize anesthesia provision for lung resection surgery for cancer and benign chest tumors.