Extrapleural pneumonectomy (EPP) is a formidable surgical procedure performed on patients with limited life expectancy. Anesthetic management may contribute to containment of perioperative morbidity and mortality through the control of intraoperative physiologic disruptions and postoperative pain, and an appreciation of the associated postoperative complications to effect early intervention. Beyond standard anesthetic management issues for pneumonectomy, there exist a number of important “EPP-specific” anesthetic concerns. These include significantly greater blood loss, more delicate management of intravascular fluid and blood components, greater operative impairment of venous return, high probability of arrhythmias and greater potential for hemodynamic instability related to pericardial window and its patch. Common causes of hypotension during EPP include compression of the heart or great vessels by tumor or surgical pressure/retraction, blood loss and/or inadequate fluid resuscitation and thoracic epidural sympathetic blockade. No single anesthetic recipe is of proven superiority for either EPP or lung resection surgery in general. The priority for early extubation favors the use of short-acting modern inhalational and intravenous agents, with limited use of traditional parenteral narcotics. Thoracic epidural analgesia is widely employed intraoperatively to facilitate extubation at the conclusion of surgery by providing dense analgesia without depression of sensorium or respiratory drive. Fluid management remains a challenge due to the increased blood loss in EPP, hemodynamic instability, renal toxicity of chemotherapy agents, and the potential for exacerbation of acute lung injury.
KeywordsAcute Lung Injury Venous Return Malignant Pleural Mesothelioma Thoracic Epidural Analgesia Dependent Lung
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