Clinical Thoracic Anesthesia

Preface
Acknowledgment
Contents
About the Editors
Part I: Preoperative Considerations
	1: History of Thoracic Surgery and Anesthesia
		1.1	 Negative Pressure, Positive Pressure Ventilation, and Endotracheal Tubes
		1.2	 The Biggest Obstacle in the Way of Successful Thoracic Surgery
		1.3	 Bronchoscopy
		1.4	 The Problem of Cross-Contamination
		1.5	 Patient Position and Lung Contamination
		1.6	 Chest Tubes
		1.7	 Role of Physiologists
		1.8	 DLT in Clinical Use
		1.9	 Bronchial Blockers
		1.10	 Modification and Further Advancements
		1.11	 Evolution of Lung Isolating Devices
		1.12	 Arrival of Fiberoptics
		References
	2: Ethical and Philosophical Considerations in Thoracic Anesthesia
		2.1	 Introduction
		2.2	 Philosophical Considerations of Thoracic Anesthesia
		2.3	 Ethical Considerations
			2.3.1	 Ethical Principles Governing Medical Ethics
				2.3.1.1	 The Golden Four Principles of Ethics: [13]
					Principle of Respect for Patient Autonomy
					Principle of Beneficence
					Principle of Non-maleficence
					Principle of Justice
			2.3.2	 The ICMR Twelve Principles of Ethics
		2.4	 Special Considerations in Thoracic Anesthesia
			2.4.1	 The Communication Challenge
			2.4.2	 Managing Conflicts of Interest (COI)
			2.4.3	 Research in Thoracic Anesthesia
			2.4.4	 Blood Transfusion Practices in Thoracic Anesthesia
		2.5	 Conclusions
		References
	3: Functional Anatomy of Thorax
		3.1	 Upper Airway
		3.2	 Pharynx
		3.3	 Larynx
		3.4	 Trachea and Bronchial Tree
			3.4.1	 Relations of Trachea
			3.4.2	 Bronchus
			3.4.3	 Innervation
			3.4.4	 Circulation of the  Tracheobronchial Tree
		3.5	 Pleura and Lungs
			3.5.1	 Clinical Implication
		3.6	 Lungs
			3.6.1	 Lung Border
			3.6.2	 Innervation of the Lungs
			3.6.3	 Nutrition to the Lungs
		3.7	 Conclusion
		References
	4: Lung Physiology Relevant to Thoracic Anesthesia
		4.1	 Ventilation
		4.2	 Compliance
		4.3	 Resistance of the Respiratory System
		4.4	 Distribution of Inhaled Air
		4.5	 Closure of Airways
		4.6	 Diffusion of Gas
		4.7	 Distribution of Blood Flow
		4.8	 Perfusion
		4.9	 Hypoxic Pulmonary Vasoconstriction (HPV)
		4.10	 Anesthesia and Lung Function
		4.11	 Gas Exchange and Ventilation–Perfusion Inequality
		4.12	 Ventilation–Perfusion During One Lung Ventilation (OLV) and Anesthesia
		4.13	 Lateral Position V/Q Mismatch
			4.13.1	 Conscious Awake Patient
		4.14	 Effect of Ventilation
		4.15	 pH Manipulation
		4.16	 Supine Position
		4.17	 Prone Position
		4.18	 Conclusion
		References
	5: Thoracic Anesthesia Equipment
		5.1	 Introduction
		5.2	 Double-Lumen Endotracheal Tubes
		5.3	 Selection of the Proper Size of DLT (Refer Chap. 10 for Further Details)
			5.3.1	 Margin of Safety (Fig. 5.1)
				5.3.1.1	 Left-Sided Tube
				5.3.1.2	 Right-Sided Tube
			5.3.2	 Specific Tubes
				5.3.2.1	 Carlens Double-Lumen Tube (Fig. 5.2)
				5.3.2.2	 White Double-Lumen Tube
				5.3.2.3	 Robertshaw Double-Lumen Tube (Figs. 5.3 and 5.4)
				5.3.2.4	 Broncho-Cath Double Lumen
				5.3.2.5	 Sher-I-Bronch Double Lumen Tube
				5.3.2.6	 Silbroncho DLT (Fig. 5.5)
				5.3.2.7	 Cliny Right-Sided DLT (Fig. 5.6)
				5.3.2.8	 Papworth Bivent Tube (Fig. 5.7)
				5.3.2.9	 Vivasight-DLT (Fig. 5.8)
				5.3.2.10 Complications of DLT Placement (Refer Chap. 10 for Further Details)
		5.4	 Bronchial Blockers
			5.4.1	 Indications and Use
			5.4.2	 Types of Blockers
			5.4.3	 Torque Controlled Blocker Univent® (Fig. 5.9)
				5.4.3.1	 Placement, Position, and Confirmation of Univent® Tubes
				5.4.3.2	 Complications and Pitfalls
			5.4.4	 Wire-Guided Endobronchial Blocker (Arndt® Blocker) (Fig. 5.10)
				5.4.4.1	 Placement, Position, and Confirmation of Arndt® Blocker
				5.4.4.2	 Complications and Pitfalls
			5.4.5	 Cohen® Flexitip Endobronchial Blocker (Fig. 5.11)
				5.4.5.1	 Placement, Position, and Confirmation of Cohen® Blocker
			5.4.6	 Fuji Uniblocker™ (Fig. 5.12)
				5.4.6.1	 Placement, Position, and Confirmation of Fuji Uniblocker™
			5.4.7	 Rusch® EZ-Blocker™ (Fig. 5.13)
				5.4.7.1	 Placement, Position, and Confirmation of EZ-Blocker™
			5.4.8	 Fogarty Embolectomy Catheter as a Bronchial Blocker (Fig. 5.14)
				5.4.8.1	 Placement, Position, and Confirmation of Fogarty Catheter
				5.4.8.2	 Complications and Pitfalls
		5.5	 Lung Isolation in Presence of a Tracheostomy
		5.6	 Lung Isolation in an Anticipated Difficult Airway
		5.7	 Need for Postoperative Ventilation
		5.8	 Single-Lumen Tubes
			5.8.1	 Standard Single-Lumen Tube
			5.8.2	 Special Single-Lumen Endobronchial Tubes (Fig. 5.15)
		5.9	 CPAP Devices (Fig. 5.16)
		5.10	 Airway Exchange Catheters (AEC) (Fig. 5.17)
		5.11	 Fiberoptic Bronchoscope
		5.12	 Videolaryngoscopes
		5.13	 Conclusion
		References
	6: Preoperative Assessment of Thoracic Surgery Patient
		6.1	 Introduction
		6.2	 Preoperative Evaluation
			6.2.1	 Respiratory System
				6.2.1.1	 Clinical History
					Bronchopulmonary Symptoms
					Extrapulmonary Intrathoracic Symptoms
					Extra-thoracic Metastatic Symptoms
					Extra-thoracic Nonmetastatic Symptoms
					Nonspecific Symptoms
				6.2.1.2	 Investigations
					Laboratory Investigations
					Radiology Investigations
					Pulmonary Function Assessment
						Respiratory Mechanics
						Pulmonary Parenchymal Function
						Cardiopulmonary Function
							Stair Climbing Test (SCT)
							6-Minute Walk Test
							Shuttle-Walk Test (SWT)
			6.2.2	 Cardiovascular System Evaluation
			6.2.3	 Airway Evaluation
		6.3	 Preoperative Preparation
			6.3.1	 Respiratory System
				6.3.1.1	 Cessation of Smoking
				6.3.1.2	 Bronchodilator Therapy
				6.3.1.3	 Loosening of Secretions
				6.3.1.4	 Removal of Secretions
				6.3.1.5	 Patient Motivation and Preoperative Stabilization
			6.3.2	 Cardiovascular System
		6.4	 Conclusion
		References
	7: Patient Positioning in Thoracic Surgery
		7.1	 Introduction
			7.1.1	 Lateral
			7.1.2	 Reverse Trendelenburg (rT) Position
			7.1.3	 Prone
			7.1.4	 Semi-prone
		7.2	 Clinical Pearls
		References
	8: Monitoring in Thoracic Surgery
		8.1	 Introduction
		8.2	 Electrocardiogram
		8.3	 Pulse Oximetry (Plethysmography)
			8.3.1	 Recent Advances in Pulse Oximetry
				8.3.1.1	 Oxygen Reserve Index (ORI)
				8.3.1.2	 Pleth Variability Index (PVI)
		8.4	 Blood Pressure
			8.4.1	 Non-invasive Blood Pressure Monitoring
			8.4.2	 Invasive Blood Pressure
		8.5	 Central Venous Pressure (CVP)
		8.6	 End Tidal Carbon Dioxide Monitoring (EtCO2)
			8.6.1	 Airway Pressure
			8.6.2	 Loops During Mechanical Ventilation (Figs. 8.3 and 8.4)
				8.6.2.1	 Flow–Volume (F–V) Loops/Pressure–Volume (P–V) Loops
			8.6.3	 Early Detection of Displaced Double Lumen Tube
		8.7	 Cardiac Status
			8.7.1	 Trans-thoracic Echocardiography (TTE)
			8.7.2	 Trans-oesophageal Echocardiography (TEE)
		8.8	 Depth of Anesthesia
		8.9	 Analgesia
		8.10	 Temperature
		8.11	 Fluid Status
		8.12	 Monitoring of Neuromuscular Blockade
		8.13	 Clinical Pearls
		References
Part II: Anesthesia for Operative Procedures
	9: Fluid Management
		9.1	 Introduction
		9.2	 Glycocalyx
		9.3	 Glycocalyx and Normovolemia
		9.4	 Effect of Mechanical Ventilation of Glycocalyx
		9.5	 Genesis of Pulmonary Oedema in Thoracic Surgery
		9.6	 Concept of Third Space
		9.7	 Lymphatics and RV Dysfunction
		9.8	 Restrictive Fluid Therapy
		9.9	 Goal Directed Therapy (GDT)
		9.10	 Zero Balance Approach
		9.11	 Causes of Fluid Overload
		9.12	 Pitfalls of Restrictive Fluid Therapy
		9.13	 Key Points
		References
	10: Lung Isolation Techniques
		10.1	 History of Lung Isolation
		10.2	 Double-Lumen Endotracheal Tubes
		10.3	 Indications for Use of Lung Separation Techniques
			10.3.1	 Lung Isolation
			10.3.2	 Lung Separation
			10.3.3	 Absolute Indications
			10.3.4	 Relative Indications
		10.4	 Selection of Double-Lumen Bronchial Tube
			10.4.1	 Right-Sided Versus Left-Sided Double-Lumen Tubes
			10.4.2	 Size of Double-Lumen Tube
				10.4.2.1	 Based on Sex and Height of the Patient
				10.4.2.2	 Based on Radiological Studies
				10.4.2.3	 A Flexible Fiberoptic Bronchoscope (FFB)
		10.5	 Placement of Double-Lumen Tube
			10.5.1	 Blind Technique
			10.5.2	 Direct Vision Technique
		10.6	 Confirmation of Proper Placement
		10.7	 Malpositioning and Complications
			10.7.1	 Problems of Malposition of the Double-Lumen Tube
			10.7.2	 Complications
		10.8	 Exchanging the Double-Lumen Tube for a Single-Lumen Tube
			10.8.1	 Procedure
			10.8.2	 Airway Exchange Catheters
				10.8.2.1	 Advantages of DLT
				10.8.2.2	 Disadvantages of DLT
				10.8.2.3	 Contraindications for DLT placement
		10.9	 Single-Lumen Tubes
			10.9.1	 Circumstances Where Use of SLT Is Advantageous and Can Give Lung Isolation
			10.9.2	 Disadvantages of Using Single Lumen Tubes
		10.10	 Univent Tubes
			10.10.1 Anatomy
			10.10.2 Positioning
		10.11	 Endobronchial Blockers
			10.11.1 Indications for the Use of Endobronchial Blockers
		10.12	 Types
			10.12.1 Coaxial Stand-Alone Endotracheal Blockers
				10.12.1.1	 Arndt Endobronchial Blocker
				10.12.1.2	 Cohen Flexitip Endobronchial Blocker
				10.12.1.3	 Uniblocker
				10.12.1.4	 EZ-Blocker
			10.12.2 Fogarty Embolectomy Catheters
				10.12.2.1	 Fogarty Catheter
			10.12.3 Paraxial Endotracheal Blockers
		10.13	 Conclusion
		10.14	 Clinical Pearls
		References
	11: Ventilation Strategies for Thoracic Surgery
		11.1	 Introduction
			11.1.1	 OLV and Hypoxemia
			11.1.2	 OLV and Acute Lung Injury
		11.2	 Management of Ventilation During OLV
			11.2.1	 Tidal Volume (VT)
			11.2.2	 Positive End-Expiratory Pressure (PEEP)
			11.2.3	 Alveolar Recruitment
			11.2.4	 Inspired Oxygen Concentration
			11.2.5	 Inspiratory: Expiratory (I:E) Time and Respiratory Rate (RR)
			11.2.6	 Mode of Ventilation
		11.3	 Intraoperative Hypoxemia During Thoracic Surgery
			11.3.1	 Management
		11.4	 Conclusion
		References
	12: Anesthesia for Lung Resection and Pleural Surgery
		12.1	 Introduction
		12.2	 Lobectomy
		12.3	 Sleeve Lobectomy
		12.4	 Pneumonectomy
		12.5	 Limited Pulmonary Resection (Segmentectomy and Wedge Resection)
		12.6	 Pleurodesis
		12.7	 Debridement
		12.8	 Decortication
		12.9	 Urgency of Lung Resection Surgeries
		12.10	 Preoperative Evaluation
		12.11	 Implications of Coexisting Diseases on Perioperative Care
		12.12	 Preoperative Concerns Specific to Pleural Surgeries
		12.13	 Intraoperative Management
		12.14	 Equipment Required
		12.15	 Monitoring
		12.16	 Anesthesia Technique
		12.17	 Lung Isolation Techniques
		12.18	 Ventilatory Settings
		12.19	 Ventilation in Special Situations
			12.19.1 Obstructive Lung Disease
			12.19.2 Interstitial Lung Disease
		12.20	 Fluid Therapy
		12.21	 Analgesia
		12.22	 Drawbacks
		12.23	 Intraoperative Events
		12.24	 Extubation
		12.25	 Conclusion
		References
	13: Mediastinal Masses
		13.1	 Introduction
		13.2	 Anatomy
		13.3	 Clinical Presentation
			13.3.1	 Systemic Symptoms
			13.3.2	 Symptoms and Signs of Anterior Mediastinal Mass
			13.3.3	 Respiratory System
			13.3.4	 Cardiovascular
		13.4	 Diagnosis and Evaluation of Mediastinal Mass
			13.4.1	 X-ray
			13.4.2	 Computerized Axis Tomography (CAT)
			13.4.3	 Magnetic Resonance Imaging (MRI)
			13.4.4	 Angiography or Myelography
			13.4.5	 Transthoracic and Transesophageal Echocardiography
			13.4.6	 Positron Emission Tomography (PET) Scan
			13.4.7	 Bronchoscopy
			13.4.8	 Pulmonary Function Tests and Flow Volume Loops [23, 24]
		13.5	 Risk Assessment and Risk Stratification (Fig. 13.4)
			13.5.1	 Clinical Signs and Symptoms
				13.5.1.1	 Grading Scale for Symptoms in Patients with Mediastinal Mass Syndrome
			13.5.2	 Radiological Studies [26]
				13.5.2.1	 CT Scan Indices [26–28]
		13.6	 Risk Stratification
		13.7	 Perioperative Management to Reduce Pre, Intra and Postoperative Surgical and Anesthetic Complications
			13.7.1	 Reducing Size of Tumor
			13.7.2	 Preoperative Embolization of the Tumor Feeding Blood Vessels
			13.7.3	 Preoperative Maintenance of Airway [6]
			13.7.4	 Perioperative Optimization of Systemic Effects of Tumor
		13.8	 Anesthetic Management
			13.8.1	 Effect of GA in Mediastinal Mass
				13.8.1.1	 Respiratory Effects
				13.8.1.2	 Cardiovascular Effects
				13.8.1.3	 Effect of Position
			13.8.2	 Sedation
			13.8.3	 Induction and Intubation
			13.8.4	 Anesthetic Preparation
			13.8.5	 Management of Acute Airway Obstruction (Fig. 13.6) [35, 36]
			13.8.6	 Helium–Oxygen Mixture
			13.8.7	 Intraoperative Management
			13.8.8	 Pain Management
			13.8.9	 Emergence and Recovery
		13.9	 Nerve Section [2]
		13.10	 Effect of Chemotherapy [2]
		13.11	 Role of Intraoperative TEE [40–44]
		13.12	 Conclusion
		References
	14: Anesthesia Considerations for Tracheal Reconstruction
		14.1	 Introduction
		14.2	 Anatomy (Fig. 14.1)
		14.3	 Physiology of Airway Obstruction
		14.4	 Etiology
		14.5	 Clinical Presentation
		14.6	 Anesthesia Considerations
			14.6.1	 Irradiation
			14.6.2	 Laser
			14.6.3	 Dilatation
			14.6.4	 Tracheal Stents
			14.6.5	 Tracheostomy
			14.6.6	 Surgery
		14.7	 Preoperative Evaluation
			14.7.1	 Patient Selection
		14.8	 Surgical Considerations
			14.8.1	 Subglottic and Upper Tracheal Lesions
			14.8.2	 Mid Trachea
			14.8.3	 Carina
		14.9	 Anesthetic Management
			14.9.1	 Operating Room Setup
			14.9.2	 Intravenous Access and Monitors
			14.9.3	 Induction and Maintenance
			14.9.4	 Ventilation Strategies
			14.9.5	 Extubation and Emergence
			14.9.6	 Post-operative Care
			14.9.7	 Complications
		14.10	 Regional Anesthesia
		14.11	 Conclusion
		References
	15: Awake/Non-intubated Thoracic Surgery
		15.1	 History of Awake Thoracic Surgery (ATS)
		15.2	 Surgical Pneumothorax: Pathophysiology
		15.3	 Indications for Awake Thoracic Surgery
		15.4	 Advantages of Awake Thoracic Surgery
		15.5	 Contraindications to Awake Thoracic Surgery
			15.5.1	 Patient Related
			15.5.2	 Anesthesia Related
			15.5.3	 Surgery Related
		15.6	 Complications and Pitfalls
		15.7	 Patients Selection for Awake Thoracic Anesthesia
		15.8	 Techniques for ATS; Local/Regional
		15.9	 Local Anesthesia Technique of Diego Gonzalez-Rivas [46, 47]
		15.10	 Local Anesthetic Technique by Hung [29]
		15.11	 Thoracic Paravertebral Block for Awake Thoracic Surgery (PVB) [25]
		15.12	 Epidural Anesthesia
		15.13	 Serratus Anterior Plane (SAP) Block [49]
		15.14	 Sedation During ATS
		15.15	 Perioperative Monitoring for ATS
		15.16	 Lung Recruitment During ATS
		15.17	 Conversion to GA and Emergency Intubation
		15.18	 Cough During ATS
		15.19	 Conclusion
		References
	16: Anesthetic Considerations for Procedures in Bronchoscopy Suite
		16.1	 Diagnostic Intervention Procedures
		16.2	 Thoracoscopy and Therapeutic Indications
			16.2.1	 Spontaneous Pneumothorax
		16.3	 Diagnostic Bronchoscopy (Fig. 16.1)
		16.4	 Postoperative Care
		16.5	 Anesthesia for Thoracoscopy
			16.5.1	 Anesthetic Considerations
		16.6	 Palliative Procedures
			16.6.1	 Symptoms
		16.7	 Airway Stents
		16.8	 Recovery
			16.8.1	 Laser
		16.9	 Endobronchial Electrosurgery (EBES)
		16.10	 Argon Plasma Cautery (APC)
		16.11	 Balloon Bronchoplasty
		16.12	 Delayed Resection Techniques
		16.13	 Bronchial Thermoplasty
		16.14	 Total Lung Lavage
		16.15	 Foreign Body Impingement and Extraction
		16.16	 Conclusion
		References
	17: Overview of Lung Transplant
		17.1	 Introduction
		17.2	 Indications of Lung Transplant
		17.3	 Patient Selection for Lung Transplant [8]
		17.4	 Disease-Specific Timing of Listing for Transplant [8]
			17.4.1 Interstitial Lung Disease
			17.4.2 Cystic Fibrosis
			17.4.3 Chronic Obstructive Pulmonary Disease (COPD)
			17.4.4 Pulmonary Vascular Disease
		17.5	 Contraindications to Lung Transplant
			17.5.1 Absolute
			17.5.2 Relative
		17.6	 Lung Allocation
		17.7	 Donor Selection and Management
			17.7.1 General Management
			17.7.2 Pulmonary Management
		17.8	 Intraoperative Donor Management
		17.9	 Donation After Cardiac Death
		17.10	 Preservative Solution
		17.11	 Ischaemia Time
		17.12	 Choice of Procedure
		17.13	 Expanding the Donor Pool
			17.13.1 Deceased Donor
			17.13.2 Ex Vivo Lung Perfusion
			17.13.3 Living Donor Lobar Transplantation
		17.14	 Extracorporeal Life Support as Bridge to Transplant
		17.15	 Recipient
			17.15.1 Preoperative Evaluation
		17.16	 Induction Immunosuppression
		17.17	 Pre-induction and Monitoring
		17.18	 Induction
		17.19	 Airway Management
		17.20	 Positioning
		17.21	 Ventilation Strategy and Maintenance of Anesthesia
		17.22	 Surgical Procedure
		17.23	 Anastomosis of Allograft and Reperfusion
		17.24	 Transesophageal Echocardiography
		17.25	 Fluid Management
		17.26	 Extracorporeal Support
		17.27	 Primary Graft Dysfunction
		17.28	 Pain Control
			17.28.1 Other Anesthetic Concerns
		17.29	 Conclusion
		References
	18: Pediatric Thoracic Anesthesia and Challenges
		18.1	 Introduction
		18.2	 Physiology of One Lung Ventilation (OLV) in Children
		18.3	 Challenges in Preoperative Evaluation
		18.4	 One Lung Ventilation in Pediatric Patients
		18.5	 Management of Hypoxia During OLV
		18.6	 Pain Management
		18.7	 Other Modalities of Pain Relief
		18.8	 Challenges of Thoracoscopic Surgery in Pediatric Patients
		18.9	 Conclusion
		References
	19: Anesthesia for Oesophageal Surgeries
		19.1	 Anatomy and Physiology
		19.2	 Surgical Diseases and Management
			19.2.1	 Hiatus Hernia
				19.2.1.1	 Types of Hiatus Hernia
			19.2.2	 Oesophageal Carcinoma
			19.2.3	 Benign Oesophageal Stricture
			19.2.4	 Intrathoracic Oesophageal Rupture and Perforation
			19.2.5	 Achalasia
			19.2.6	 Oesophageal Respiratory Tract Fistula
			19.2.7	 Zenker’s Diverticulum
		19.3	 Anesthetic Considerations for Oesophageal Surgery
			19.3.1	 Preoperative Evaluation and Preparation
			19.3.2	 Intraoperative Monitoring
			19.3.3	 Pain Control
			19.3.4	 Induction of Anesthesia
			19.3.5	 Choice of Tracheal Tube
			19.3.6	 Intraoperative Considerations and Management
		19.4	 Anesthetic Considerations for Robotic Oesophagectomy
		19.5	 Anesthetic Considerations for Oesophageal Dilatation
		19.6	 Anesthetic Management of Oesophagorespiratory Tract Fistula Surgery
		19.7	 Postoperative Management
		19.8	 Conclusion
		References
	20: Anesthetic Management of Thoracic Trauma
		20.1	 Introduction
		20.2	 Etiology
			20.2.1	 Compression Injury
			20.2.2	 Direct Energy Transfer
			20.2.3	 Blast Injury
		20.3	 Principles of Management
		20.4	 Initial Assessment and Management
		20.5	 Tracheal Tree Obstruction
		20.6	 Pneumothorax
		20.7	 Open Pneumothorax
		20.8	 Tension Pneumothorax
		20.9	 Hemothorax
		20.10	 Cardiac Tamponade
		20.11	 Chest Wall—Rib, Clavicle, and Sternum Injuries
		20.12	 Chest Wall—Flail Chest
		20.13	 Clinical Features
		20.14	 Analgesics
		20.15	 Continuous Thoracic Epidural Analgesia (TEA)
		20.16	 Management of Flail Chest
		20.17	 Conclusion
		References
Part III: Postoperative Management
	21: General Principles of Postoperative Care
		21.1	 Introduction
		21.2	 Post-anesthesia Care Unit
			21.2.1	 Monitoring Patients with Respiratory Insufficiency
		21.3	 High Dependency Unit (HDU) and Intensive Care Unit (ICU)
		21.4	 Preoperative Optimization
			21.4.1	 Smoking
			21.4.2	 Preoperative Rehabilitation (PR)
		21.5	 Enhanced Recovery After Surgery (ERAS) [16–18]
		21.6	 Postoperative Care
			21.6.1	 Postoperative Nausea and Vomiting (PONV)
			21.6.2	 Postoperative Arrhythmias
			21.6.3	 Postoperative Analgesia
			21.6.4	 Fluid Management
			21.6.5	 Chest Drainage System
			21.6.6	 Physiotherapy
			21.6.7	 Deep Venous Thrombosis Prophylaxis
			21.6.8	 Hypothermia
		21.7	 Conclusion
		References
	22: Postoperative Management of Thoracic Surgery Patients: A Surgeon’s Perspective
		22.1	 Preoperative Counseling and Preparation
		22.2	 Postoperative Management
			22.2.1	 Need for Intensive Care
		22.3	 Medications in the Postoperative Period
			22.3.1	 Analgesics
			22.3.2	 Antibiotics
			22.3.3	 Fluid Therapy
			22.3.4	 DVT Prophylaxis
		22.4	 Postoperative Rehabilitation/Physical Therapy
		22.5	 Postoperative Nutrition
		22.6	 Management of Chest Drainage Systems
		22.7	 Management of Some Common Postoperative Complications
		22.8	 Management of Postoperative Atrial Fibrillation
		22.9	 Conclusion
		References
	23: Enhanced Recovery After Thoracic Surgery
		23.1	 Key Components for Enhanced Recovery After Thoracic Surgery (ERATS)
		23.2	 Implementation of ERATS
		23.3	 Anesthetic Management
		23.4	 Perioperative Multimodal Analgesia
			23.4.1	 Postoperative Management
		23.5	 Conclusion
		References
	24: Postoperative Complications Following Thoracic Surgery
		24.1	 Introduction
		24.2	 Risk Stratification
		24.3	 General Complications
			24.3.1	 Airway Injury
			24.3.2	 Bronchospasm
			24.3.3	 Hemorrhage
			24.3.4	 Atelectasis
			24.3.5	 Deep Vein Thrombosis and Pulmonary Embolism
			24.3.6	 Acute Kidney Injury
			24.3.7	 Injury to Surrounding Structures
				24.3.7.1	 Vocal Cord Palsy
				24.3.7.2	 Phrenic Nerve Injury
				24.3.7.3	 Chylothorax
				24.3.7.4	 Horner’s Syndrome
		24.4	 Specific Complications
			24.4.1	 Respiratory Problems
				24.4.1.1	 Pulmonary Edema
				24.4.1.2	 Air Leak
				24.4.1.3	 Post-pneumonectomy Syndrome
				24.4.1.4	 Lobar Torsion
				24.4.1.5	 Mediastinal Emphysema
				24.4.1.6	 Pleural Effusion and Empyema
				24.4.1.7	 Bronchopleural Fistula
				24.4.1.8	 Pneumonia
			24.4.2	 Cardiac Problems
				24.4.2.1	 Arrhythmia
				24.4.2.2	 Interatrial Shunt
				24.4.2.3	 Cardiac Herniation
				24.4.2.4	 Cardiac Tamponade
			24.4.3	 Neurological Problem
				24.4.3.1	 Cerebral Infarction
		24.5	 Conclusion
		References
	25: Pain Management in Thoracic Surgery
		25.1	 Introduction
		25.2	 Pathogenesis of Post-thoracotomy Pain
		25.3	 Factors Influencing Pain After Thoracotomy
			25.3.1	 Sex
			25.3.2	 Age
			25.3.3	 Preoperative Education
			25.3.4	 Opioid Tolerance
			25.3.5	 Psychological Factors
			25.3.6	 Preemptive Analgesia
			25.3.7	 Surgical Approaches for Thoracic Surgery
				25.3.7.1	 Sternotomy
				25.3.7.2	 Video-Assisted Thoracoscopic Surgery (VATS)
				25.3.7.3	 Open Thoracotomy
					Posterolateral Incision
					Muscle-Sparing Incision
					Anterior Incision
			25.3.8	 Transverse (Clamshell) Sternothoracotomy
		25.4	 Analgesic Modalities
			25.4.1	 Non-opioid Pharmacological Methods
				25.4.1.1	 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
				25.4.1.2	 Acetaminophen
				25.4.1.3	 N-Methyl-d-Aspartate (NMDA) Antagonists
				25.4.1.4	 Gabapentinoids
				25.4.1.5	 α2 Adrenergic Agonists
				25.4.1.6	 Glucocorticoids
			25.4.2	 Opioid-Based Pharmacological Methods
				25.4.2.1	 Patient Controlled Analgesia (PCA)
			25.4.3	 Non-pharmacological Methods
				25.4.3.1	 Cryoanalgesia
				25.4.3.2	 Transcutaneous Nerve Stimulation
			25.4.4	 Regional Techniques
				25.4.4.1	 Local Anesthetic Patch
				25.4.4.2	 Continuous Wound Infiltration Catheter
					Liposomal Bupivacaine
				25.4.4.3	 Interpleural Block
				25.4.4.4	 Erector Spinae Plane Block
				25.4.4.5	 Intrathecal Analgesia
				25.4.4.6	 Intercostal Nerve Block
				25.4.4.7	 Serratus Anterior Plane Block
				25.4.4.8	 Paravertebral Block
					Methods of Performing Paravertebral Blocks
					Landmark Technique
					Under Direct Vision (Fig. 25.12)
						Absolute Contraindications
						Relative Contraindications
						Ultrasound-Guided Methods
				25.4.4.9	 Epidural Analgesia
					Techniques of Thoracic Epidural Catheter Insertion
					Dose and Regimens of Epidural Solution
					Adverse Effects
						Urinary Retention
						Gastric Emptying
						Hypotension
		25.5	 Techniques for Specific Situations
			25.5.1 Sternotomy
			25.5.2 Video-Assisted Surgery
			25.5.3 Open Thoracotomy
			25.5.4 Esophageal Surgery
			25.5.5 Shoulder Pain
		25.6	 Chronic Post-thoracotomy Pain (CPTP)
			25.6.1	 Prevalence of Post-thoracotomy Pain
			25.6.2	 Mechanism of Post-thoracotomy Pain
			25.6.3	 Predisposing Factors for the Development of Post-thoracotomy Pain
			25.6.4	 Signs and Symptoms
			25.6.5	 Management
		25.7	 Conclusion
		References