Perioperative Fluid Management for Pulmonary Resection Surgery and Esophagectomy

Abstract

Perioperative fluid management is of significant importance during pulmonary resection surgery and esophagectomy. Excessive fluid administration has been consistently shown as a risk factor for lung injury after thoracic procedures. Probable causes of this serious complication include fluid overload, lung lymphatics and pulmonary endothelial damage. Along with new insights regarding the Starling equation and the absence of a third space, current evidence supports a restrictive fluid regimen for patients undergoing pulmonary resection surgery and esophagectomy. Multiple minimally invasive hemodyamic monitoring devices, including pulse pressure/stroke volume variation, esophageal Doppler, and extravascular lung water measurement, were evaluated for optimizing perioperative fluid therapy. Further research regarding the prevention, diagnosis, and treatment of acute lung injury after pulmonary resection and esophagectomy is required.

Volume Management and Resuscitation in Thoracic Surgery

“…Fluid in excess of 2 L total volume administered during pneumonectomy is linked with negative effects on postoperative respiratory outcomes [3,13,15,17], and similar results have been demonstrated with high perioperative fluid loads and lesser pulmonary resections [3,10,16]. In patients with pulmonary fibrosis, higher perioperative fluid volumes and balance are linked to an increased risk of postoperative respiratory compromise after lung resection surgery, a devastating complication [19].…”

“…It has since been recognized that the syndrome may occur after lesser degrees of resection and surgery requiring one-lung ventilation (OLV) without lung resection [5,6]. PPPE has been found to share histological features with acute respiratory distress syndrome (ARDS) [7], is not of cardiogenic origin [3], and the most severe form of PPPE follows a course indistinguishable from ARDS [5]. Accordingly, the condition may be described as post-thoracotomy ARDS.…”

“…The various components of the glycocalyx model and revised Starling's forces are shown. In steady state, net filtration into the interstitium occurs and is subsequently removed by the lymphatic system [3] The EGL has other functions. It regulates blood cellendothelial interaction by its negative charge, and via specific adhesion molecules for leucocytes and platelets.…”

“…Endothelial injury maybe induced by activation of systemic and local inflammatory mediators, related to positive pressure ventilation, ''volutrauma'', oxygen toxicity, ischaemia-reperfusion injury, surgical trauma, and pre-existing lung disease [1,3]. Endothelial cell injury results in disruption of intercellular endothelial cell junctions, cytoskeleton contraction, and cell death, leading to increased permeability of the alveolar-capillary barrier and decreased lung compliance [1].…”

“…Fluid therapy is an integral component of the perioperative management of these complex patients [2], and the risks of fluid overload and tissue edema must be balanced against the risk of hypovolemia and end-organ ischemia [3].…”