Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Feb 2008
ReviewGenetic and environmental determinants of postthoracotomy pain syndrome.
Pain after thoracic surgery may persist for up to a year or longer in as many as 50% of patients undergoing lung resection. There is currently no specific therapy, and our ability to predict who will develop a persistent pain syndrome is poor at best. Persistent pain after thoracotomy is not an acute somatic pain, rather it is a complex syndrome with many of the characteristics of neuropathic, dysesthetic pain. ⋯ Postthoracotomy pain syndrome likely arises as a direct result of an environmental stress (surgery) occurring on a landscape of susceptibility that is determined by an individual's behavioral, clinical and genetic characteristics.
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Curr Opin Anaesthesiol · Feb 2008
ReviewA logical approach to the selection and insertion of double-lumen tubes.
There has been a progressive evolution in double-lumen tubes to separate the right and left lungs. The appreciation of the anatomical advantage of the longer left main bronchus has directed anesthetists to prefer a left tube if possible for lung separation. Understanding the dimensions of the tube as well as the variations in the left main bronchus has improved the process of selection and insertion of the double-lumen tubes for lung isolation. ⋯ Measurement of patient's airway dimensions combined with knowledge of the dimensions of the double-lumen (tracheobronchial) tube plays an important role in lung separation.
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Pulmonary endarterectomy is the treatment of choice for many patients with chronic thromboembolic pulmonary hypertension. Although potentially curative, some patients receive no benefit and have poor outcomes. This review will look at the new research in the pathophysiology of the disease and developments in perioperative care, which may help to understand the difference in outcomes. ⋯ Pulmonary endarterectomy is a successful treatment of chronic thromboembolic pulmonary hypertension. Better understanding of the underlying pathophysiology will help in patient selection for surgical intervention.
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Perioperative beta-blockade and statin therapy have been advocated to reduce cardiac risk of noncardiac surgery. This review evaluates recent articles published on the cardioprotective effects of perioperative therapy with these medications. ⋯ Based upon the available evidence and guidelines, patients currently taking beta-blockers should continue these agents. Patients undergoing vascular surgery who are at high cardiac risk should also take beta-blockers. The question remains regarding the best protocol to initiate perioperative beta-blockade. Statins should be continued in patients already taking these agents prior to surgery. The optimal duration and time of initiation of statin therapy remains unclear.
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The article reviews the rationale for using intravenous anesthesia for thoracic operations, the drugs and equipment required, and the methodology involved. ⋯ Total intravenous anesthesia is indicated for procedures in which inhalational anesthetics may not be safely or effectively delivered, including endobronchial procedures using flexible or rigid bronchoscopy and proximal airway-disrupting surgeries. Total intravenous anesthesia may be beneficial in lung volume reduction surgery, lung transplantation and thymectomy. Total intravenous anesthesia is safer and more practical for thoracic procedures performed outside of the operating room, such as offsite locations, military field or impoverished areas of the world. Propofol, dexmedetomidine, ketamine and remifentanil may be used in combination with anesthetic depth monitoring to execute an effective total intravenous anesthesia regimen. Target-controlled infusion may improve the delivery of total intravenous anesthesia and is a focus for future research. This article reviews the balanced total intravenous anesthesia technique currently used at the University of Texas M.D. Anderson Cancer Center.