RT Book, Section A1 Butterworth IV, John F. A1 Mackey, David C. A1 Wasnick, John D. SR Print(0) ID 1190606877 T1 Anesthesia for Thoracic Surgery T2 Morgan & Mikhail’s Clinical Anesthesiology, 7e YR 2022 FD 2022 PB McGraw-Hill Education PP New York, NY SN 9781260473797 LK accessanesthesiology.mhmedical.com/content.aspx?aid=1190606877 RD 2024/11/13 AB KEY CONCEPTS During one-lung ventilation, the mixing of unoxygenated blood from the collapsed upper lung with oxygenated blood from the still-ventilated dependent lung widens the alveolar-to-arterial (A-a) O2 gradient and often results in hypoxemia. There are certain clinical situations in which the use of a right-sided double-lumen tube is recommended: (1) distorted anatomy of the left main bronchus by an intrabronchial or extrabronchial mass; (2) compression of the left main bronchus due to a descending thoracic aortic aneurysm; (3) left-sided pneumonectomy; (4) left-sided single lung transplantation; and (5) left-sided sleeve resection. If epidural or intrathecal opioids are to be used for postoperative pain control, intravenous opioids should be limited during surgery to prevent excessive postoperative respiratory depression. Postoperative hemorrhage complicates about 3% of thoracotomies and may be associated with up to 20% mortality. Signs of hemorrhage include increased chest tube drainage (>200 mL/h), hypotension, tachycardia, and a falling hematocrit level. Bronchopleural fistula presents as a sudden large air leak from the chest tube that may be associated with an increasing pneumothorax and partial lung collapse. Acute herniation of the heart into the operative hemithorax can occur through the pericardial defect that is left following a radical pneumonectomy. Nitrous oxide is contraindicated in patients with cysts or bullae because it can expand the air space and cause rupture. The latter may be signaled by sudden hypotension, bronchospasm, or an abrupt rise in peak inflation pressure and requires immediate placement of a chest tube. Following transplantation, peak inspiratory pressures should be maintained at the minimum pressure compatible with good lung expansion, and the inspired oxygen concentration should be maintained as close to room air as allowed by a PaO2 greater than 60 mm Hg. Regardless of the procedure, a common anesthetic concern for patients with esophageal disease is the risk of pulmonary aspiration.