The implementation of Enhanced Recovery After Surgery (ERAS) pathways is thought to
facilitate recovery by diminishing disruption of homeostasis associated with surgery
and streamlining perioperative care. The European Society of Thoracic Surgeons has
recently put forth guidelines for enhanced recovery after lung surgery in light of
emerging evidence of their benefits, such as reductions in pulmonary and cardiac events,
fluid overload, length of stay (LOS), opiate use, and hospital costs [
[1]
]. Strategies for perioperative fluid management have evolved as appreciation for
the deleterious effects of liberal fluid resuscitation has been followed by recognition
of complications associated with restrictive fluid regimens [
- Batchelor T.J.P.
- Rasburn N.J.
- Abdelnour-Berchtold E.
- Brunelli A.
- Cerfolio R.J.
- Gonzalez M.
- et al.
Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced
Recovery After Surgery (ERAS(R)) Society and the European Society of Thoracic Surgeons
(ESTS).
Eur J Cardiothorac Surg. 2019; 55: 91-115
2
,
3
,
4
,
5
]. Optimal fluid management for pulmonary resections remains elusive in patient populations
at risk for interstitial and alveolar oedema due to multifactorial lung injury from
existing pulmonary disease, previous chemoradiotherapy, intraoperative lung manipulation,
one-lung ventilation (OLV), and ischaemia-reperfusion injury [
[1]
]. When such factors are compounded by fluid overload, there is an increased risk
of acute respiratory distress syndrome, atelectasis, pneumonia, empyema and death,
though the role of intraoperative versus postoperative fluid administration remains
incompletely understood [
- Batchelor T.J.P.
- Rasburn N.J.
- Abdelnour-Berchtold E.
- Brunelli A.
- Cerfolio R.J.
- Gonzalez M.
- et al.
Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced
Recovery After Surgery (ERAS(R)) Society and the European Society of Thoracic Surgeons
(ESTS).
Eur J Cardiothorac Surg. 2019; 55: 91-115
[2]
,
[4]
,
[6]
,
[7]
]. The degree of lung injury, which appears to correlate with the extent of lung resection,
is highest after pneumonectomy or extensive resection, followed by lobectomy irrespective
of tumour laterality; even patients who undergo sublobar wedge resections or segmentectomies
have a 4% rate of lung injury [
8
,
9
,
10
]. Moderate intraoperative infusion rates during minimally invasive lung resections
are associated with significantly lower incidences of postoperative pneumonia (24.1%
vs 39–49%) and overall pulmonary complications (25.9% vs 44–51%) relative to more
restrictive and liberal infusion rates, which is consistent with open thoracotomies
[
[3]
,
[11]
]. While the importance of a judicious fluid regimen is apparent, the merits of the
traditional restrictive fluid strategy are debatable in light of concerns for impaired
tissue perfusion, organ dysfunction, and acute kidney injury (AKI) secondary to hypovolaemia
[
[3]
,
[5]
,
12
,
13
,
14
]. Increased awareness of the adverse sequelae of too little or too much fluid has
prompted the search for monitoring devices to guide patient-specific, goal-directed
fluid therapy (GDFT) that can help curtail organ-specific morbidity associated with
pulmonary resections. We reflect on the clinical utility of select devices and suggest
that ultrasound-based technologies, such as oesophageal Doppler and lung ultrasound,
show promise as tools to facilitate euvolaemia with dry lungs during lung resection.
The capabilities of minimally invasive monitors that utilise pulse wave analysis and
transpulmonary thermodilution could also be harnessed during OLV once the threshold
values for their application are better understood. In light of limited available
evidence to date for the application of haemodynamic monitors in lung resection surgery,
we propose the concurrent use of tissue perfusion biomarkers to promote fluid optimisation
and oxygen delivery.Keywords
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Article info
Publication history
Published online: October 12, 2021
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© 2021 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
