Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria. Results Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. Conclusions These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

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Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria. Results Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery). Conclusions These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

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Mucormycosis is a life threatening condition caused by invasion of fungi of the order Mucorales. Gastrointestinal invasion is very rare and often lethal, particularly in disseminated mucormycosis. We present the case of a 26-year-old woman from North Africa with type 2 diabetes who, after a cholecystectomy, developed unexplained septic shock and haematemesis due to gastric necrosis. Computed tomography (CT) revealed a disseminated fungal invasion of the lungs, kidney and paranasal sinuses. A gastrectomy and subsequent amphotericin B treatment resolved her condition. The number of patients with mucormycosis is increasing. Early diagnosis of high risk patients with CT and biopsies from which fungi are directly isolated must be followed by surgery and systemic amphotericin B infusion. Mucormycosis is a life threatening infection caused by fungi of the subphylum Mucoromycotina, order Mucorales. Mucoromycotina are characterised by large, ribbon-like hyphae with only occasional septa (aseptate fungi). These fungi cause mucormycosis, which leads to severe and potentially life threatening infections. Patients at risk of invasive mucormycosis include those with type 2 diabetes or autoimmune disorders, solid organ and hematopoietic stem cell transplant recipients, neonates, users of illicit intravenous drugs and patients with burns, trauma or surgical wounds.1 The symptoms of mucormycosis are varied and depend on the site affected; however, no specific blood test is available. Case HistoryIn the summer of 2010, a 26-year-old woman of North African ethnicity was admitted to our emergency department for abdominal pain, which had developed three days previously, and fever. She complained of upper right quadrant pain with a positive Murphy's sign, tachypnoea and tachycardia. Her blood tests showed increased leucocytes, C-reactive protein and transaminases. Her past medical history revealed type 2 diabetes mellitus. Abdominal ultrasonography identified distended, abnormal gallbladder with lithiasis. She underwent a laparoscopic cholecystectomy for suspected acute cholecystitis.In the early postoperative period, she developed rapid and progressive respiratory failure, and was admitted to the intensive care unit with a diagnosis of severe sepsis. She deteriorated rapidly, developing multiple organ failure with kidney, lung and cardiovascular involvement despite treatment. She required vasoactive support with norepinephrine and dopamine. Blood samples from central and peripheral lines were obtained for culture, and urine was collected for analysis. She was treated with broad spectrum antibiotics and antifungal therapy.On the third postoperative day, her blood results were: white blood cells 33,000/mm 3 , haemoglobin 8g/dl, haematocrit 27.1%, platelets 95,000/mm 3 , creatinine 9.6mg/dl, glucose 151mg/dl, pH 7.22, C-reactive protein 34mg/l and procalcitonin 15ng/ml. She underwent continuous venovenous haemofiltration. On the same day, she had an episode of haematemesis and an oesophagogastroduodenoscopy revealed gastric nec...