a
Check out the timestamps below to help you navigate through the many topics we discussed.
On This Episode:
Thoracic anesthesia is one of the most complex and high-stakes specialties in medicine, where the airway may literally be open on the table, and every breath depends on seamless teamwork.
In this episode of Anesthesia Alchemy, Lynn and Garry welcome Dr. Melissa Puskac, a CRNA and thoracic anesthesia expert, to unpack the challenges and breakthroughs that define this field. From carinal resections and sleeve lobectomies to esophagectomies and mediastinal mass surgeries, Dr. Puskac explains how modern techniques like cross-field ventilation, high-frequency jet ventilation (HFJV), and ECMO are transforming survival and recovery.
You’ll also hear about the risks of airway strictures, recurrent laryngeal nerve injuries, and “spit fistulas,” along with the extraordinary surgical creativity—like neocarinal reconstruction—that makes these procedures possible. It’s a fascinating look into the art and science of anesthesia in some of the most demanding surgeries performed today.
This episode will allow you to:
- Define Goal-Directed Fluid Therapy (GDFT) and explain its role in optimizing perioperative hemodynamics and patient outcomes in anesthetic practice.
- Describe the historical evolution of perioperative fluid management, from liberal fluid strategies to restrictive and goal-directed approaches.
- Explain the Frank–Starling law of the heart and its relevance to fluid responsiveness and stroke volume optimization during anesthesia.
- Differentiate between fluid responsiveness and fluid overload, emphasizing why not all hypotension or low cardiac output should be treated with fluids.
- Discuss key physiologic variables used in GDFT, including stroke volume, cardiac output, preload, afterload, and contractility.
- Review common monitoring technologies used in GDFT, such as arterial waveform analysis, esophageal Doppler, pulse pressure variation, and stroke volume variation.
- Summarize the evidence supporting GDFT, including its impact on postoperative morbidity, length of hospital stay, and recovery in high-risk surgical patients.
- Highlight current clinical guidelines and consensus statements on the use of GDFT in anesthetic and perioperative care.
- Explore practical implementation of GDFT in the operating room, including patient selection, fluid challenges, and integration with vasoactive therapy.
- Identify limitations, controversies, and future directions in GDFT, including applicability in low-risk surgery, spontaneous ventilation, and evolving noninvasive monitoring tools.
Important Links:
"Fluid volume therapy is important for multiple reasons, and we cannot just say, let’s give fluids and see how things work."
- Lynn & Garry
References
Calvo-Vecino. Br J Anaesth 2018; 120:615-616. doi:10.1016/j.bja.2018.01.001. Effect of goal-directed haemodynamic therapy on postoperative complications in low-moderate risk surgical patients
Gao M, Chen M, Dai G, Zhu D and Cai Y (2024) Clinical study: the impact of goal-directed fluid therapy on volume management during enhanced recovery after surgery in gastrointestinal procedures. Acta Biochim. Pol 71:12377. doi: 10.3389/abp.2024.12377
Jalalzadeh H, Hulskes RH, Weenink RP, Wolfhagen N, van Dusseldorp I, Schaad RR, Veelo DP, Hollmann MW, Boermeester MA, de Jonge SW. Systematic review and meta-analysis of goal-directed haemodynamic therapy algorithms during surgery for the prevention of surgical site infection. EClinicalMedicine. 2024 Nov 22;78:102944. doi: 10.1016/j.eclinm.2024.102944. Erratum in: EClinicalMedicine. 2025 May 17;84:103235. doi: 10.1016/j.eclinm.2025.103235. PMID: 39687427; PMCID: PMC11647171.
Zhu AC, Agarwala A, Bao X. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clin Colon Rectal Surg. 2019 Mar;32(2):114-120. doi: 10.1055/s-0038-1676476. Epub 2019 Feb 28. PMID: 30833860; PMCID: PMC6395091.
