Induction, Maintenance, Fluids, and Pressors (Thoracic Anesthesia)


Ketamine deserves stronger consideration as it is a known bronchodilator. Consider IV lidocaine 1-1.5 mg/kg prior to airway manipulation.


Strongly consider volatile anesthetics, as all of them decrease airway reactivity and bronchoconstriction (sevoflurane the most [Rooke GA et al. Anesthesiology 86: 1294, 1997]), and the vast majority of thoracic surgery patients have some sort of airway reactivity. Consider a lidocaine infusion in order to reduce airway reactivity.

Fluid Management

In general, fluid management should be relatively restrictive (to avoid pulmonary edema in the dependent lung). Practitioners should lean towards ionotropes over fluids in treating hypotension. Most authors recommend that 24h fluid intake should not exceed 3L or 20 cc/kg.


Pressors have complex effects on patients undergoing thoracic surgery. On one hand, ionotropes will increase cardiac output. On the other hand, increased cardiac output is accompanied by elevated PA pressures and a reduction in HPV, leading to an increase in shunt fraction and a fall in PaO2 [Slinger P and Scott WAC. Anesthesiology 82: 940, 1995; Russell WJ and James MF. Anaesth Intens Care 32: 644, 2004]. On balance, it appears that ionotropy increases SvO2 only slightly, because improvements in blood flow are negated by a fall in PaO2.