What is the recommended anesthetic management and fluid management strategy for a patient undergoing pneumonectomy?

Anesthetic Management in Pneumonectomy Including Fluid Management

For patients undergoing pneumonectomy, a restrictive fluid management strategy of 2-6 mL/kg/h with oesophageal Doppler-guided monitoring is strongly recommended to reduce postoperative pulmonary complications, combined with thoracic epidural analgesia or paravertebral block for optimal pain control. 1

Preoperative Assessment

Thorough preoperative evaluation should focus on three key areas:

• Lung mechanical function: Spirometry, flow-volume loops
• Pulmonary parenchymal function: Diffusion capacity, arterial blood gases
• Cardiopulmonary reserve: Exercise testing, VO2 max 2

Risk factors that require special attention:

• Decreased respiratory function (high risk for acute lung injury)
• Geriatric population (increased risk for postoperative arrhythmias)
• History of smoking (cessation recommended preoperatively)
• Malnutrition or hypoalbuminemia 1, 2

Intraoperative Management

Anesthetic Technique

• General anesthesia with lung isolation is essential for optimal surgical exposure
• Use of shorter-acting neuromuscular blocking agents (atracurium, vecuronium) rather than pancuronium to reduce postoperative pulmonary complications 1
• Consider combining general anesthesia with neuraxial blockade (reduces pneumonia risk from 5% to 3%) 1

Ventilation Strategy

• Protective lung ventilation during one-lung ventilation:
  • Low tidal volumes (6 mL/kg)
  • PEEP application
  • Alveolar recruitment maneuvers
  • Low FiO2 (minimum required to maintain adequate oxygenation)
  • Maintain low peak and plateau airway pressures 1, 3

Fluid Management

• Restrictive fluid strategy: 2-6 mL/kg/h of baseline intraoperative fluid 1
• Oesophageal Doppler monitoring for guided fluid therapy:
  • Initial 200 mL crystalloid bolus after induction
  • Maintenance at 3 mL/kg/h
  • Additional boluses based on stroke volume variation
  • Consider norepinephrine for hypotension when fluid responsive parameters are optimized 1

High-volume fluid administration is an independent risk factor for postoperative pulmonary complications, particularly acute lung injury. Patients who develop ALI typically receive significantly higher intraoperative fluid volumes (9.1 mL/kg vs. 7.2 mL/kg) 1.

Postoperative Management

Pain Management

• First-line: Continuous paravertebral block (better safety profile than thoracic epidural) 1
• Alternative: Thoracic epidural analgesia (gold standard for pain control and restoration of pulmonary function) 4
  • Superior to intercostal nerve blocks with IV PCA morphine for pain control and preservation of pulmonary function 4
  • Caution with concurrent VTE prophylaxis due to epidural hemorrhage risk 1
• Short courses of NSAIDs can be added to the regimen 1
• If regional techniques fail, use opioid PCA for the first few postoperative days 1

Respiratory Care

• Early mobilization and walking
• Breathing exercises and incentive spirometry
• Bronchial drainage and coughing techniques with pain management education 1
• Avoid routine use of postoperative NIV or High-Flow Oxygen 1

Chest Drainage

• After most pneumonectomies, the pleural space can be safely closed without drainage
• If chest tube is required, a balanced drainage system is recommended 5

Potential Complications and Prevention

• Acute lung injury: Prevented by protective ventilation and restrictive fluid management
• Postoperative arrhythmias: Consider calcium channel blockers or beta-blockers intraoperatively or immediately postoperatively 1, 2
• Cardiac herniation: Rare but treatable cause of life-threatening hemodynamic instability in early postoperative period 2

Special Considerations

• Pneumonectomy has the highest perioperative risk among common pulmonary resections 2
• Better outcomes are observed in centers with larger surgical volumes 2
• Extrapleural pneumonectomy and sleeve pneumonectomy place increased demands on anesthesiologists 2

By following these evidence-based recommendations, particularly regarding fluid management and pain control strategies, the risk of postoperative pulmonary complications can be significantly reduced, improving overall outcomes for patients undergoing pneumonectomy.