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Principles and Practice of Anesthesia for Thoracic Surgery

2013; Elsevier BV; Volume: 110; Issue: 5 Linguagem: Inglês

10.1093/bja/aet080

1471-6771

J. H. Mackay, Stephen J. Gray,

Cardiac, Anesthesia and Surgical Outcomes

This book sets out to be a comprehensive and up-to-date reference textbook suitable for all grades of practitioners in thoracic anesthesia. The editor has made enormous contributions to both the literature and international thoracic meetings and is extremely well qualified to edit the first edition of this major textbook. Peter Slinger has solicited the help of more than 60 contributors, of whom the vast majority practice in North America. After a short historical introduction, the book is divided into 12 main sections. The first preoperative evaluation section is particularly strong. Slinger reminds us that ‘anesthesiologists are not gate keepers and that our primary function is to identify those patients at elevated risk and then to use that risk assessment to stratify perioperative management and focus resources on the high-risk patients to improve their outcome'. The ‘three legged stool' of lung mechanics, parenchymal function, and cardiopulmonary reserve provides an excellent starting point to assess risk. Anatomy, physiology, and pharmacology are the core topics covered in the second section. Owners of Benumof's classic 1995 textbook1Benumof JL Anesthesia for Thoracic Surgery. 2nd Edn. Saunders, Philadelphia1995Google Scholar will recognize many of the figures in the physiology chapter confirming that the basic principles of physiology have changed little over the last two decades. In contrast, there have been significant changes in one-lung ventilatory strategies to minimize lung injury and pulmonary therapy over the past two decades and these are covered in detail in the latter part of this section. Diagnostic and therapeutic procedures of the trachea and airways are covered in the third section which contains much useful advice on management of foreign bodies, use of lasers in the airway, and tracheal resection. The diagrams in the bronchoscopic procedures chapter are of a particularly high standard. Clinical case discussions feature at the end of many of the clinical chapters from this section on provide valuable reinforcement of many learning objectives. The rationale and thoracic surgical indications for total i.v. anaesthesia are discussed in some detail. Target-controlled infusion (TCI) is not currently utilized in North America because of regulatory problems. The US Food and Drug Administration impasse has deprived North American anaesthesiologists of the opportunity to fully assess the current status of TCI devices. The North American author intimates that TCI systems only target plasma concentration, yet virtually all the newer pumps have both plasma and effect-site concentrations. Clinical anaesthetists wanting advice on induction of anaesthesia in the patient with an anterior mediastinal mass will take a close interest in the fourth section. Although the key issues are discussed in detail and the chapter includes a useful clinical vignette, the reviewers were disappointed by the flow chart summarizing risk assessment for airway obstruction. Better risk stratification advice can be found elsewhere. The fifth section on anaesthetic management for intra-thoracic surgery starts with two generally outstanding chapters on lung isolation in patients with normal and difficult airways, respectively. Both chapters are extremely well illustrated and contain much invaluable information. Given the international profile of this book, many UK anaesthetists will be disappointed by the section quoting two papers from Great Britain perpetuating the myth that fibreoptic bronchoscopy is not a standard of care in confirming double-lumen tube position in the UK. In reference to the first undated paper, the author states that ‘30% of oesophagogastrectomy deaths in a national confidential enquiry into perioperative deaths (NCEPOD) were associated with malposition of DLTs'. Having revisited the 1998 NCEPOD report, the reviewers believe that ‘association' and ‘causation' are very different and that other perioperative factors (lack of invasive monitoring and suitable postoperative follow-up care) were responsible for many of the 78 perioperative deaths. The author then quotes a second 2004 paper from a single UK institution where only 56% of double-lumen tubes were checked with a bronchoscope. The reviewers believe that this centre was an outlier and confirm that FOB has been a standard of care in the vast majority of UK units for over a decade.2Ghosh S Latimer RD Thoracic Anaesthesia: Principles and Practice. Butterworth-Heinemann, Oxford1999Google Scholar The author of the chapter on intraoperative transoesophageal echocardiography (TOE) was set the unenviable task of covering basic introductory TOE principles and detailed assessment of specific thoracic surgical TOE applications in just 20 pages. The reviewers believe that most beginners would be better served by a small TOE handbook and that the chapter should have focused on the latter objective. However, the section finishes very strongly with excellent reviews of intraoperative ventilation strategies, anaesthesia for open pulmonary resection, and video-assisted thoracoscopic surgery. Specific patient considerations and anaesthetic management of complex and uncommon pulmonary procedures are covered in the next three sections, all of which contain a wealth of useful information. Management of bronchopleural fistula, massive haemoptysis, and whole-lung lavage are particularly well covered. In practice, many anaesthetists will refer to these sections before embarking on particularly challenging or unfamiliar cases. Lung volume reduction, lung transplantation, and pulmonary thromboendarterectomy are the three self-contained topics in the ninth section on anaesthesia for surgical procedures for end-stage lung diseases. Management of these particularly high-risk patient populations will be of great interest to those working in large specialist thoracic centres. The final three sections deal with paediatric thoracic surgical procedures, trauma, and postoperative management. The pain management chapter includes a detailed discussion on the pros and cons of thoracic epidurals and paravertebral blocks. Recognition of the risks of perioperative epidural analgesia and renewed interest in the surgical insertion of paravertebral catheters under direct vision has led to a recent shift in favour of paravertebral analgesia in many units. This book is generally excellent with numerous high-quality bronchoscopy images and will become the standard international large reference textbook. Unsurprisingly with a book of this size, the reviewers did have some niggles, although these are outweighed by the pearls of wisdom. All thoracic surgical centres should have a copy in their libraries. Many senior thoracic anaesthetists and fellows will want to own their own copies. Residents and occasional thoracic anaesthetists could probably learn the basic key principles more easily in one of the smaller handbook of thoracic anesthesia. All anaesthetists who may be called upon to provide one-lung anaesthesia should visit the free online bronchoscopy simulator at www.thoracicanesthesia.com.