Antibiotic dosing during extracorporeal membrane oxygenation: does the system matter? Purpose of review The aims of this review are to discuss the impact of extracorporeal membrane oxygenation (ECMO) on antibiotic pharmacokinetics and how this phenomenon may influence antibiotic dosing requirements in critically ill adult ECMO patients. Recent findings The body of literature describing antibiotic pharmacokinetic and dosing requirements during ECMO support in critically adult patients is currently scarce. However, significant development has recently been made in this research area and more clinical pharmacokinetic data have emerged to inform antibiotic dosing in these patients. Essentially, these clinical data highlight several important points that clinicians need to consider when dosing antibiotics in critically ill adult patients receiving ECMO: physicochemical properties of antibiotics can influence the degree of drug loss/sequestration in the ECMO circuit; earlier pharmacokinetic data, which were largely derived from the neonatal and paediatric population, are certainly useful but cannot be extrapolated to the critically ill adult population; modern ECMO circuitry has minimal adsorption and impact on the pharmacokinetics of most antibiotics; and pharmacokinetic changes in ECMO patients are more reflective of critical illness rather than the ECMO therapy itself. Summary An advanced understanding of the pharmacokinetic alterations in critically ill patients receiving ECMO is essential to provide optimal antibiotic dosing in these complex patients pending robust dosing guidelines. Antibiotic dosing in this patient population should generally align with the recommended dosing strategies for critically ill patients not on ECMO support. Performing therapeutic drug monitoring (TDM) to guide antibiotic dosing in this patient population appears useful. Correspondence to Jason A. Roberts, University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, 4029 QLD, Australia. E-mail: j.roberts2@uq.edu.au Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Postoperative neurocognitive disorders Purpose of review Alterations in cognitive functions are common in the perioperative course. Although often unnoticed by physicians, these alterations might have distinct long-term consequences for the patient with regard to everyday functioning, self-dependency, and quality of life. In recent years, however, perioperative cognition has gained increased interest, both by clinicians and scientists, and knowledge of the preventive measures of postoperative cognitive decline has become mandatory for anesthetists and surgeons. Recent findings This review offers a brief overview of the current state of knowledge concerning perioperative changes in cognition, including its pathophysiology and prevention strategies. Summary Postoperative neurocognitive disorders are frequent complications, especially in elderly patients, with postoperative delirium being its most pronounced and acute postoperative form, predisposing the patient for long-term cognitive impairment. The incidence of postoperative cognitive decline can be reduced by implementing preventive measures during perioperative patient care as recommended by national and international guidelines. Correspondence to Cynthia Olotu, MD, Department of AnaesthesiologyUniversity Medical Center Hamburg, Martini Street 52, 20251 Hamburg, Germany. Tel: +49 40 7410 52415; fax: +49 40 7410 - 44963; e-mail: c.olotu@uke.de Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Right ventricular function during and after thoracic surgery Purpose of review Right ventricular (RV) dysfunction following thoracotomy and pulmonary resection is a known phenomenon but questions remain about its mechanism, risk factors, and clinical significance. Acute RV dysfunction can present intraoperatively and postoperatively, persisting for 2 months after surgery. Recent findings Recently, the pulmonology literature has emphasized pulmonary arterial capacitance, rather than pulmonary vascular resistance, as a marker to predict disease progression and outcome in patients with pulmonary hypertension and heart failure. Diagnostic focus has emerged on the use of cardiac MRI and new echocardiographic parameters to better quantify the presence of RV dysfunction and the role of pulmonary capacitance in its development. Summary In this review, we examine the most recent literature on RV dysfunction following lung resection, including possible mechanisms, time span of RV dysfunction, and available diagnostic modalities. The clinical relevance of these factors on preoperative assessment and risk stratification are presented. Correspondence to Theresa Gelzinis, MD, Associate Professor, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15217, USA. work. Tel: +1 412 647 3260; +1 412 292 656 (home); fax: +1 412 647 6290; e-mail: gelzinista@anes.upmc.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Circulatory support during lung transplantation Purpose of review Lung transplantation can be performed off-pump, with sequential one-lung ventilation, or using mechanical circulatory support (MCS). MCS can either be in the form of cardiopulmonary bypass (CPB) or veno-arterial or veno-venous extracorporeal membrane oxygenation (VA ECMO or VV ECMO). This article reviews the indications, benefits and limitations of these different techniques and evaluates their effect on outcomes. Recent findings Recently, there has been a shift toward intraoperative ECMO support and away from CPB. The first results of this strategy are promising. The use of intraoperative ECMO with the possibility of prolongation of MCS into the postoperative period has been shown to lead to improved survival when compared with lung transplants not receiving ECMO. Recipients of organs from extended criteria donors show encouraging survival rates when the lungs are reperfused using MCS. A recent metaanalysis comparing ECMO versus CPB showed favourable outcomes supporting the use of ECMO despite not finding a difference in mortality between the two methods. Summary The trend toward ECMO and away from cardiopulmonary bypass is backed up with good survival rates. However, to date, there has not been a randomized controlled trial to further guide the choice of MCS strategy for lung transplantation. Correspondence to Florian Falter, Department of Anaesthesia, Royal Papworth Hospital, Papworth Road, Cambridge, CB2 0AY, UK. Tel: +44 1223 6380000; e-mail: florian.falter@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

How to communicate between surgeon and intensivist? Purpose of review Communication and teamwork are essential to enhance the quality of care, especially in operating rooms and ICUs. In these settings, the effective interprofessional collaboration between surgeons and intensivists impacts patients’ outcome. This review discusses current opinions and evidence for improving communication strategies and the relationship between surgeons and intensivists/anesthesiologist. Recent findings Effective teamwork has been demonstrated to improve patient outcome and foster healthier relationships between professionals. With the expansion of new medical superspecialist disciplines and the latest medical developments, patient care has been put through a progressive fragmentation, rather than a holistic approach. Operating theaters and ICU are the common fields where surgeons and anesthesiologists/intensivists work. However, communication challenges may frequently arise. Therefore, effective communication, relational coordination, and team situation awareness are considered to affect quality of teamwork in three different phases of the patient-centered care process: preoperatively, intraoperatively, and postoperatively. Summary Although limited, current evidence suggests to improve communication and teamwork in patient perioperative care. Further research is needed to strengthen the surgeon–intensivist relationship and to deliver high-quality patient care. Correspondence to Cesare Gregoretti, Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, via del vespro 129, 90127 Palermo, Italy. E-mail: c.gregoretti@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Ex-vivo lung perfusion Purpose of review Ex-vivo lung perfusion (EVLP) has been developed to expand the donor pool for lung transplantation recipients. The role of EVLP in organ preservation, evaluation and potential reconditioning is reviewed. Recent findings EVLP has been shown to significantly increase the utilization of donor lungs for transplantation. Evidence suggests that patient outcomes from EVLP lungs are comparable to standard procurement technique. Novel strategies are being developed to treat and recondition injured donor lungs. EVLP may also prove to be a tool for translational research of lung diseases. Summary EVLP has been shown to be an effective system to expand donor pool for lung transplantation without detriment to recipients. Future potential ex-vivo developments may further improve patient outcomes as well as increasing availability of donor organs. Correspondence to Jacobo Moreno Garijo, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada. Tel.: +1 416 340 5164;. e-mail: jacobo.moreno@uhn.ca Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Anesthetic management of lung transplantation: impact of presenting disease Purpose of review Recent literature has described the emerging role of anesthesiologists as key members of the lung transplantation team and the impact of anesthetic management on outcomes. This review examines the impact of presenting cause of end-stage lung disease (ESLD) on anesthetic management. Recent findings The four primary causes of ESLD are suppurative, obstructive, or restrictive processes, and pulmonary hypertension. Our recent review of perioperative literature revealed new data regarding preoperative risk stratification, intraoperative management, and postoperative use of extracorporeal membrane oxygenation (ECMO) support. Major studies specifically about anesthetic management are lacking; however, the principles studied are readily applicable to the design of a perioperative care plan. The most compelling data have resulted in a revolutionary change in terms of intraoperative support and postoperative planning for pulmonary hypertension patients. Historically treated with cardiopulmonary bypass, significant data have been reported describing the successful use of ECMO both as an intraoperative support with superior outcomes, as well as postoperative support for improved stability during biventricular remodeling postgraft implantation. Summary The application of these updated findings should assist anesthesiologists as they develop internal protocols and external guidelines to integrate within multidisciplinary teams caring for the lung transplant patient. Correspondence to Archer Kilbourne Martin, MD, Department of Anesthesiology and Perioperative Medicine, Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA. Tel.: +1 904 956 3004;. e-mail: Martin.Archer@Mayo.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Fascial plane blocks in thoracic surgery: a new era or plain painful? Purpose of review The demand for well-tolerated, effective, and opioid reducing pain management has become imperative in thoracic surgery. With the recent movement away from neuraxial analgesia for thoracic surgical patients, great interest in alternative analgesic techniques of the chest wall has developed. Several fascial plane blocks exist for pain management of the lateral chest wall and we present an up-to-date review of these popular new blocks. Recent findings The pectoralis and serratus anterior plane blocks may offer effective analgesia of the lateral chest wall for thoracic surgical patients. The erector spinae plane block may offer more extensive analgesic coverage but requires further investigation. Summary Fascial plane blocks hold the potential for well-tolerated and effective analgesia for thoracic surgical patients as part of a multimodal regimen of pain relief. However, many questions remain regarding block characteristics. As the literature matures, more formal recommendations will be made but quality trials are needed to provide this guidance. Correspondence to Donn Marciniak, MD. E-mail: marcind@ccf.org Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

From the ICU to the operating room: how to manage the patient? Purpose of review To outline key points for perioperative ICU optimization of nutrition, airway management, blood product preparation and transfusion, antibiotic prophylaxis and transport. Recent findings Optimization entails glycemic control for all, with specific attention to type-1 diabetic patients. Transport-related adverse events may be averted with surgery in the ICU. If moving the patient is unavoidable, transport guidelines should be followed and hemodynamic optimization, airway control, and stabilization of mechanical ventilation ensured before transport. Preinduction preparation includes assessment of the airway and high-flow oxygen to prolong apneic oxygenation. Postintubation, a protective positive ventilation strategy, should be employed. Ideal transfusion thresholds are 7 g/dl for hemodynamically stable adult patients, 8 g/dl in orthopedic/cardiac surgery/cardiovascular disease and higher in specific disease states. Antimicrobial prophylaxis within 120 min of incision prevents most surgical site infections. Antibiotic therapy depends on the antibiotics being received in the ICU, the time elapsed since ICU admission, local epidemiology and the type of surgery. Tailored antimicrobial regimens may be continued periprocedurally. If more than 70% of the nutritional requirement cannot be met enterally, parenteral nutrition should be initiated within 5–7 days of surgery or earlier if the patient is malnourished. Summary ICU patients who require surgery may benefit from appropriate perioperative management. Correspondence to Professor Sharon Einav, MSc, MD, Director, Surgical Intensive Care Unit, Shaare Zedek Medical Centre, Affiliated with the Hebrew University, POB 3235, Jerusalem 91031, Israel. Tel: +972 2 6666664; fax: +972 2 6555144; e-mail: einav_s@szmc.org.il Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.