I.V. fluid therapy does not result in the extracellular volume distribution expected from Starling’s original model of semi-permeable capillaries subject to hydrostatic and oncotic pressure gradients within the extracellular fluid. Fluid therapy to support the circulation relies on applying a physiological paradigm that better explains clinical and research observations. The revised Starling equation based on recent research considers the contributions of the endothelial glycocalyx layer (EGL), the endothelial basement membrane, and the extracellular matrix. The characteristics of capillaries in various tissues are reviewed and some clinical corollaries considered. The oncotic pressure difference across the EGL opposes, but does not reverse, the filtration rate (the ‘no absorption’ rule) and is an important feature of the revised paradigm and highlights the limitations of attempting to prevent or treat oedema by transfusing colloids. Filtered fluid returns to the circulation as lymph. The EGL excludes larger molecules and occupies a substantial volume of the intravascular space and therefore requires a new interpretation of dilution studies of blood volume and the speculation that protection or restoration of the EGL might be an important therapeutic goal. An explanation for the phenomenon of context sensitivity of fluid volume kinetics is offered, and the proposal that crystalloid resuscitation from low capillary pressures is rational. Any potential advantage of plasma or plasma substitutes over crystalloids for volume expansion only manifests itself at higher capillary pressures.

Hemoptysis after cardiopulmonary bypass (CPB) occasionally occurs, and has varying clinical
significance based upon amount of bleeding. Hemoptysis resulting in a clot and airway
obstruction is an extremely rare event found almost exclusively in the intensive care unit. We
describe a unique case of hemoptysis resulting in bronchial impaction from a clot requiring an
emergent return to CPB during valve replacement surgery. We used a rigid bronchoscope,
without an endotracheal tube, to facilitate airway patency in a patient with diffuse airway
bleeding after bronchial disimpaction to separate from CPB.

Objective. The authors sought to provide a snapshot of contemporary thoracic anesthetic practice in the United Kingdom and Ireland.
Design. An online survey.
Setting. United Kingdom.
Participants. An invitation to participate was e-mailed to all members of the Association of Cardiothoracic Anaesthetists.
Measurements and Main Results
A total of 132 responses were received; 2 were excluded because they did not originate from the United Kingdom. Values are number (percent).
Anesthetic Technique. The majority of respondents (109, 85%) maintain anesthesia with a volatile anesthetic agent, with a lesser proportion (20, 15%) reporting use of a total intravenous anesthetic technique. The majority of respondents (78, 61%) favor pressure control ventilation over volume control (50, 39%); just under half (57, 45%) report the routine use of positive end-expiratory pressure (median = 5 cmH2O [interquartile range (IQR), 4-5]). Fifty-two (40%) respondents report ventilating to a target tidal volume (median = 6 mL/kg [IQR, 5-7]). Most (114, 89%) respondents routinely ventilate with an FIO2 less than 1.0. Thoracic epidural blockade (TEB) is favored by nearly two thirds of respondents (80, 62%) compared with paravertebral block (39, 30%) and other analgesic techniques (10, 8%). Anesthesiologists favoring TEB are significantly less likely to prescribe systemic opioids (17, 21% v 39, 100% [p < 0.001]). Proponents of TEB are significantly more likely to “routinely” use vasopressor infusions both intra- and postoperatively (16, 20% v 0, 0% [p = 0.003] and 28, 35% v 4, 11% [p =0.013], respectively). Most respondents (127, 98%) report a double-lumen tube as their first choice. Many (82, 64%) report “rarely” using bronchial blockers.
Conclusions.
The authors hope this survey both provides interest and serves as a useful resource reflecting the current practice of thoracic anesthesia.

Tidal volumes have tremendously decreased over the last decades
from <15 ml kg
1 to w6 mlkg
1 actual body weight. Guidelines,
widely agreed and used, exist for patients with acute lung injury or
acute respiratory distress syndrome (ARDS). However, it is questionable
if data created in patients with acute lung injury or ARDS
from ventilation on intensive care units can be transferred to
healthy patients undergoing surgery. Consensus criteria regarding
this topic are still missing because only a few randomised
controlled trials have been performed to date, focussing on the use
of the best intra-operative tidal volume. The same problem has
been observed regarding the application of positive end-expiratory
pressure (PEEP) and intra-operative lung recruitment.
This article provides an overviewof the current literature addressing
the size of tidal volume, the use of PEEP and the application of the
open-lung concept in patients without acute lung injury or ARDS.
Pathophysiological aspects of mechanical ventilation are elucidated.

HYPOXEMIA DURING one-lung ventilation (OLV) for video-assisted thoracoscopic surgery (VATS) is a difficult problem for the anesthesiologist to manage. The standard therapy recommended for this problem is the application of continuous positive airway pressure (CPAP) to the nonventilated lung. However, CPAP interferes with surgical exposure in the hemithorax. A novel technique to treat hypoxemia in this context using fiberoptic bronchoscopic segmental oxygen insufflation and recruitment that does not impede surgery is described.

We report the case of a terminally ill cancer patient with recurrent pericardial and bilateral pleural effusions who was scheduled for video-assisted thoracoscopic surgery. The operation was performed with the patient awake under epidural anaesthesia. The patient’s cough reflex in response to lung manipulation was successfully minimised by the inhalation of aerosolised lidocaine. Video-assisted thoracic surgery requires the exclusion of a lung from ventilation. In order to support one-lung spontaneous ventilation in this high-risk patient, we successfully used non-invasive bilevel positive airway pressure ventilation via a facemask. Based on this preliminary experience, we think that critically ill patients scheduled for palliative surgery can be successfully managed with the combination of minimally invasive surgical techniques and neuraxial block with non-invasive lung ventilation.

Authors: Iwata, M.; Inoue, S.; Kawaguchi, M.; Takahama, M.; Tojo, T.; Taniguchi, S.; Furuya, H.
Keywords: one-lung ventilation; sevoflurane; propofol; lung surgery; jugular bulb venous oxygen saturation
Abstract (English): Objective: During one-lung ventilation (OLV), systemic oxygenation can be compromised. In such a scenario, if anesthetic techniques were used that adversely affected cerebral oxygen balance, the risk for impaired cerebral oxygen balance may be increased. In this study, jugular bulb venous oxygen saturation (SjO2) during OLV under sevoflurane- or propofol-based anesthesia for lung surgery was investigated. Design: Prospective clinical study. Setting: University hospital. Participants: Fifty-two adult patients scheduled for elective thoracic procedures in the lateral position. Interventions: Patients were randomly allocated to either the sevoflurane or propofol group (n = 26). General anesthesia was maintained with sevoflurane or propofol combined with epidural anesthesia. Measurements and Main Results: Arterial and jugular bulb blood samples were measured before OLV, 15 minutes after OLV, 30 minutes after OLV, and 15 minutes after the termination of OLV. SjO2 values in both sevoflurane and propofol groups significantly declined during OLV (p < 0.05). SjO2 values in the sevoflurane group were higher than in the propofol group, although SaO2 values were similar (p < 0.05). Regarding the incidence of SjO2 <50% (cerebral oxygen desaturation), there were significant differences between the sevoflurane group and the propofol group during both normally ventilated conditions (0% v 7.7%, p < 0.05, relative risk [RR]: not applicable) and OLV (1.9% v 26.9%, p < 0.05, RR = 14; 95% confidence interval [CI] 1.91-103). Significant increase in the incidence of SjO2 <50% during OLV was also observed only in the propofol group (from 7.7% to 26.9%, p < 0.05, RR = 3.5; 95% CI 1.29-12.4). Conclusion: Cerebral oxygen desaturation was more frequently detected during OLV under propofol- versus sevoflurane-based anesthesia. Cerebral oxygen balance during OLV for lung surgery was less impaired under sevoflurane-based anesthesia compared with propofol; however, the clinical outcome or implications for cognitive function need to be determined.

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Authors
Dyszkiewicz W. Pawlak K. Gasiorowski L.
Institution
Department of Thoracic Surgery, K. Marcinkowski University of Medical Sciences, Ul. Szamarzewskiego 62, Poznan, Poland.
Title
Early post-pneumonectomy complications in the elderly.
Source
European Journal of Cardio-Thoracic Surgery. 17(3):246-50, 2000 Mar.
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Abstract
OBJECTIVE: The surgical treatment of non-small cell lung cancer (NSCLC) in elderly patients presents a serious challenge to thoracic surgeons. As there is considerable divergence of opinion about both the mortality and morbidity rates, it is important to set guidelines for proper patient selection. METHODS: Early post-operative complications in 42 patients aged over 70 years who had undergone pneumonectomy because of NSCLC (Group I) were analyzed. The control group (Group II) consisted of 48 patients, also aged over 70 years, but who had undergone lobectomy or wedge resections. In both groups, the pre-operative conditions and 30-day morbidity and mortality were evaluated. RESULTS: Postoperative complications occurred significantly more frequently in pneumonectomy patients (78.5%) than in Group II (58%). Transient or long-standing arrhythmias were noted in 20 patients (47.6%) from Group I and in 17 (35.4%) from Group II. Pulmonary complications occurred in 17 patients (40.4%)!
from Group I and 16 (33.3%) from Group II. The most important factors contributing to post-operative complications in pneumonectomy patients were performance status (WHO), chronic obstructive pulmonary disease (COPD) and elevated level of blood urea nitrogen (BUN). The highest impact on early mortality in pneumonectomy patients was exerted by COPD, arterial hypertension, formation of broncho-pleural fistula (BPF), the need for re-thoracotomy and high level of BUN. CONCLUSIONS: (1) Pneumonectomy in patients over the age of 70 carries a considerable risk of severe post-operative complications and death, when compared to patients with less extensive pulmonary resections. (2) Elderly patients with impaired Performance Status (WHO 2 or more) and co-existing arterial hypertension, COPD and elevated level of BUN should be considered for pneumonectomy very carefully and cautiously.