We present a case of endobronchial endometriosis with catamenial hemoptysis. The lesion was diagnosed as endobronchial endometriosis using helical CT, and the patient underwent a subsegmentectomy of the upper part of the lateral basal segment. A histopathologic examination of the resected specimen revealed findings typical of endobronchial endometriosis with intimal hyperplasia within the bronchus. Since the operation, the patient has been asymptomatic for 11 months with no recurrence of hemoptysis.

Advances in the understanding of nitric oxide as a biological mediator and a therapeutic tool continue to accumulate at a rapid rate. This review provides an update on recent developments pertinent to the role of nitric oxide in adult lung disease. After a brief review of basic nitric oxide biochemistry and physiology, the evidence supporting the role of nitric oxide in the regulation of vascular and airway tone in the normal lung is considered. Clinical studies addressing the pathophysiological role of nitric oxide in pulmonary hypertension, airway disease, and lung injury are reviewed, and the application of inhaled nitric oxide therapy is discussed.

Pulmonary edema is a known postoperative complication, but the clinical manifestations and danger levels for fluid administration are not known. We studied (1) 13 postoperative patients (11 adult, 2 pediatric) who developed fatal pulmonary edema, and (2) one contemporaneous year of inpatient operations at two university teaching hospitals to determine the clinical manifestations, causes, epidemiology, and guidelines for fluid administration.

There are a number of conditions that present commonly in patients with cancer that may have a significant effect on the preoperative, intraoperative, and postoperative treatment of these patients. These effects can be broadly categorized into anatomic and physiologic effects and may be examined as direct effects of the tumor or as effects of therapy administered for the tumors. Tumors that cause anatomic effects of importance to perioperative management include head and neck tumors with airway obstruction, mediastinal masses with respiratory compromise, pericardial effusion and cardiac tamponade, and superior vena cava syndrome. Some tumors that cause physiologic effects include pheochromocytomas and carcinoid tumors. Anatomic effects of tumor therapy are important after radiation therapy to the head and neck and after radiation therapy to the abdomen. Tumor therapy has important physiologic effects in such areas as the cardiopulmonary complications of chemotherapy, hematologic effects of chemotherapy, steroid administration, and wound healing. While the list of topics is not exhaustive, this is a useful framework for discussing the effects of tumors and their therapy on the cancer patient, especially in regard to perioperative management. Most importantly, these examples demonstrate the importance of close cooperation among surgeon, anesthesiologist, and referring physician to assure the conduct of surgical procedures on the patient with cancer with maximal safety.

With aging, the heart, kidneys, liver, lungs, and brain lose mass. While not inherently impaired, the reserve capacity of the older individual to compensate for stress, metabolic derangement, and drug metabolism is increasingly limited. Functional disability occurs faster and takes longer to remediate, necessitating early preventive interventions.

The medical care of chronic renal failure patients is often complicated by the comorbid conditions of hypertension and coronary artery disease in the perioperative period. The limitations on solute and water excretion imposed by renal dysfunction increase the susceptibility of this population to both salt deficit and surfeit, as well as hyponatremia and hypernatremia perioperatively. Accurate assessment and successful treatment of these complications in renal failure patients require understanding of the concept of electrolyte-free water, proper utilization of diuretics, and calculated prescription of fluid therapy. The presence of hyperkalemia in the adapted renal failure patient generally indicates a severe reduction in glomerular filtration, such that nonrenal hypokalemic treatments are imperative. IV calcium-based therapy and infusion of insulin with glucose represent the mainstays of immediate therapy, and sodium bicarbonate therapy should be given only when severe acidemia is present. Perioperative aggravation of preexistent hypertension is common. Rebound hypertension attributable to injudicious adjustment of the medical regimen should be diligently searched for first, before any new therapies are recommended. Relief of pain or anxiety may be all that is necessary. Briefly acting calcium channel blocker therapy should not be employed in these cases, and smooth IV control by a variety of agents is preferable, the choice of the agent contingent on the clinical scenario.

Nutrition support plays an important role in the management of nutritional deficiencies in properly selected critically ill patients. A full nutritional assessment allows the calculation of appropriate feeding goals. The route of feeding, enteral or parenteral, is determined by the presence or absence of a functioning intestine and hemodynamic status of the patient. The specific roles of carbohydrates, fats, and protein need to be considered in order to prevent overfeeding and other complications. The efficacy of certain disease-specific enteral formulas has been demonstrated in clinical trials, however, careful cost-benefit analyses are required.

Coronary artery disease (CAD) is common in the surgical population, with up to 50% of postoperative deaths due to cardiac events. Most of these events are ischemic, with some being exacerbations of underlying congestive heart failure (CHF). Recent data indicate that acute perioperative beta-adrenergic blockade can reduce ischemia and ischemic events. Postoperative monitoring should focus on myocardial ischemia, with preparation for rapid treatment using IV therapy. A few studies suggest that elderly patients with known CAD undergoing major procedures might benefit from perioperative treatment guided by information from a pulmonary artery catheter. Postoperative CHF, which is likely to present early after surgery, may need aggressive management with diuretics, vasodilators, and inotropic drugs. Mechanical ventilation should be considered. When the patient develops severe or refractory dysrhythmias, serum magnesium levels should be supplemented and consideration given to IV use of amiodarone. Postoperative hypertension is common and can precipitate ischemia, CHF, and arrhythmias as well as cause bleeding. Newer IV drugs are arterial specific and can lower BP in a smooth and predictable manner. All acute cardiac disorders can be precipitated or exacerbated by inadequate pain control, hypoxemia, and fluid or electrolyte disorders.

Immediate postoperative evaluation of the patient remains a crucial role of the intensivist. Postoperative patients can be divided into the otherwise healthy, chronically ill, and acutely ill for strategizing about care. For chronically ill and acutely ill patients who require ongoing ventilation, ventilator management continues to evolve toward modes that are more interactive with patient needs. Newer modes of ventilation are also being explored to protect the lung against damage attributable to mechanical ventilation. Weaning indexes and associated protocols have become more sophisticated and now allow physicians greater certainty in evaluating patients' readiness for extubation. This article will discuss factors to be considered prior to extubation as well as the latest ventilatory and weaning strategies.

To describe changes in ICU postoperative management strategies utilized for patients undergoing cardiac surgery. The treatment of these patients serves as a useful illustration of the changing patterns of ICU utilization and care associated with contemporary surgery.

Effective analgesia and blockade of the perioperative stress response may improve outcome and accelerate recovery following thoracic surgery. Although different approaches can achieve the same goal, it seems that a multimodal pain management based on the use of synergistic drugs provides better analgesia. The route of administration of the postoperative analgesic drugs is important, and epidural analgesia plays a role in the reduction of pulmonary complications.

A reevaluation of the indications for and alternatives to transfusion of allogeneic blood was precipitated by transfusion-induced HIV. The transfusion trigger has shifted from an optimal hemoglobin level and hematocrit (10/30) to that level of hemoglobin necessary to meet the patient's tissue oxygen demands. This critical level can best be determined by physiologic measurements. A number of autologous blood options can reduce the patient's allogeneic blood needs. Pharmacologic measures to increase hemoglobin levels (erythropoietin) and to decrease blood loss at surgery are discussed as are the potential contributions of blood substitutes to transfusion support of the surgical patient.

An approach to intraoperative fluid management based on a monitored physiologic application of the Starling principles of cardiac function is recommended to individualize therapy to optimize hemodynamic function and tissue perfusion. The complexity of intraoperative fluid administration, beginning with preoperative cardiovascular function followed by innumerable intraoperative considerations, including anesthetic pharmacology, positive pressure ventilation, operative site, and surgical technique may lead to serious intraoperative and postoperative complications. Emphasis must be given to intraoperative fluid shifts resulting in hidden fluid loss and intravascular hypovolemia that must be replaced. Explanations for this fluid redistribution have included tissue trauma, endotoxemia, and proinflammatory cytokines with resultant increased capillary permeability.

The routine practice of monitoring oxygenation, ventilation, circulation, and temperature during surgery is now the standard of care. However, with the possible exception of pulse oximetry and capnography, extensive physiologic monitoring has not been shown to reduce the incidence of adverse anesthetic-related events. Monitors are useful adjuncts, but they alone cannot replace careful observation by a vigilant anesthesiologist.

Cost-effective preoperative evaluation can be approached from a variety of methods, educational strategies, and use of data to modify clinical practice. This article focuses on the proposed organizational and clinical changes in the process of preoperative evaluations, the cost-effective outcomes, and the relative merits these changes provide the physicians, operating room nurses, and center administrators.

Preoperative preparation of the cardiac patient is based on matching the cardiac reserve to the blood flow demands imposed by surgical stress and the underlying disease state. Evaluation must include functional assessment of any coronary artery disease or other organic cardiac disease that may place myocardial tissue at risk of ischemia as demand for cardiac output increases. Monitoring should be individualized based on anticipated problems and the risk assessment of the patient. Preoperative therapy should include maneuvers that reduce congestive heart failure, optimize volume status, and provide adequate cardiac output to deliver oxygen sufficient to meet or exceed demand. Underlying electrical and metabolic abnormalities should be corrected and controlled in the perioperative period. Long-term therapy should be evaluated and modified in the context of the anesthetic and surgical plan. Preventive interventions such as fluid loading and low-dose dopamine should be considered prior to surgery.

Preoperative pulmonary evaluation and preparation involve first identifying patients at risk for complications and then attempting to modify that risk. For most patients without underlying lung disease, a thorough history and physical examination and preoperative instruction in the use of incentive spirometry is sufficient. In patients with known or suspected lung disease, preoperative pulmonary function tests, while unproven as prognostic tools, may reduce risk by aiding in medical management, and in the case of the lung resection candidate, by helping determine very directly his or her viability for the procedure.