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Preanesthetic Assessment for Thoracic Surgery

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Book cover Principles and Practice of Anesthesia for Thoracic Surgery

Abstract

All patients having pulmonary resections should have a preoperative assessment of their respiratory function in three areas: lung mechanical function, pulmonary parenchymal function, and cardiopulmonary reserve (the “three-legged stool” of respiratory assessment). Following pulmonary resection surgery, it is usually possible to wean and extubate patients with adequate predicted postoperative respiratory function in the operating room provided they are “AWaC” (alert, warm, and comfortable). Preoperative investigation and therapy of patients with coronary artery disease for noncardiac thoracic surgery are becoming a complex issue. An individualized strategy in consultation with the surgeon, cardiologist, and patient is required. Myocardial perfusion, CT coronary angiography, and other advances in imaging are used increasingly in these patients. Geriatric patients are at a high risk for cardiac complications, particularly arrhythmias, following large pulmonary resections. Preoperative exercise capacity is the best predictor of post-thoracotomy outcome in the elderly.

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Author information

Authors and Affiliations

  1. Department of Anesthesia, Toronto General Hospital, Toronto, ON, Canada

    Peter Slinger

  2. Department of Surgery, Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada

    Gail Darling

Authors
  1. Peter Slinger
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  2. Gail Darling
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Corresponding author

Correspondence to Peter Slinger .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Clinical Case Discussion

Clinical Case Discussion

Case

A 65-year-old male presents for anesthesia preoperative assessment (Fig. 2.22). He is scheduled for a bronchoscopy/mediastinoscopy and right pneumonectomy. He is a smoker who presented to his family doctor 2 weeks ago after minor hemoptysis. He has no significant known comorbidities and past history is otherwise unremarkable. A fine needle biopsy has confirmed the diagnosis of non-small cell lung cancer. The anesthesia team will need to decide if the patient will tolerate the proposed procedure and, if so, then what management strategies can be used to improve the perioperative outcome.

Fig. 2.22
figure 22

Chest X-ray of a 65-year-old male with carcinoma involving the right middle and lower lobes, being assessed for possible right pneumonectomy

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Questions

Apart from routine preoperative assessment for major surgery:

  • What pulmonary function tests are indicated?

  • What cardiac investigations are indicated?

  • What specific anesthetic considerations are related to the patient’s lung cancer?

  • What other system function should be documented?

Focused Preoperative History, Physical and Investigations:

  • Pulmonary function evaluation: lung mechanical function (spirometry: FEV1), pulmonary parenchymal function (DLCO), exercise capacity, and ventilation/perfusion scan (see Assessment of Respiratory Function)

  • Cardiac evaluation: ECG (echocardiography and stress testing not indicated) (see Cardiovascular Disease)

  • Tumor mass effects, metabolic (paraneoplastic) effects, metastases, and adjuvant medications

Other systems: renal function

Will the patient tolerate the procedure?

  • Results of investigations: FEV1 65%, DLCO 70%, exercise tolerance: the patient can climb four flights of stairs without stopping. V/Q scan R/L 40/60 for both V and Q. Other investigations are all within normal limits.

  • Predicted postoperative (ppo) FEV1 and DLCO will be in the range of 30–35% and adjusted for the V/Q scan possibly higher. These indicate increased risk but acceptable survival given the patient’s age < 70. A bi-lobectomy could be considered for elderly or high-risk patients (see Age).

What management strategies will improve the patient’s outcome?

  • Smoking cessation

  • Pre- and postoperative chest physiotherapy

  • Thoracic epidural analgesia has not been clearly proven to improve outcomes in patients with normal pulmonary function but does improve function in moderate and severe COPD. This patient’s risk of respiratory complications may be improved by either thoracic epidural or paravertebral analgesia (see also Chap. 59).

  • Moderate perioperative fluid restriction and lung-protective ventilation are associated with a decreased risk of postoperative acute lung injury particularly after pneumonectomy (see also Chap. 10 and 21).

  • Calcium channel blockers may be associated with a decreased risk of postoperative atrial fibrillation (see also Chap. 56).

  • Preoperative ß-blockade, statins, or α-2 blockers are not proven to decrease cardiac ischemic risks in this patient at low risk of perioperative ischemia.

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Slinger, P., Darling, G. (2019). Preanesthetic Assessment for Thoracic Surgery. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_2

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