Mehran R, Martin L, Baker C ,et al. Pain management in an enhanced recovery pathway after thoracic surgical procedures. Ann Thorac Surg 102: e595-6, 2016

This manuscript briefly outlines a mutlimodal approach to post operative pain after open and VATS thoracic surgery. One important aspect of the multimodal thetapy is the use of liposomal bupivacaine for intercostal blocks and subcutaneous infiltration.

Analgesia p.slinger 7:20 AM Comments Off on Mehran R, Martin L, Baker C ,et al. Pain management in an enhanced recovery pathway after thoracic surgical procedures. Ann Thorac Surg 102: e595-6, 2016

Blank RS, Colquhoun DA, Durieux ME, et al. Management of one-lung ventilation, impact of tidal volumes on complications after thoracic surgery

Background: The use of lung-protective ventilation (LPV) strategies may minimize iatrogenic lung injury in surgical patients. However, the identification of an ideal LPV strategy, particularly during one-lung ventilation (OLV), remains elusive. This study examines the role of ventilator management during OLV and its impact on clinical outcomes.

Methods: Data were retrospectively collected from the hospital electronic medical record and the Society of Thoracic Surgery database for subjects undergoing thoracic surgery with OLV between 2012 and 2014. Mean tidal volume (VT) during two-lung ventilation and OLV and ventilator driving pressure ([DELTA]P) (plateau pressure – positive end-expiratory pressure [PEEP]) were analyzed for the 1,019 cases that met the inclusion criteria. Associations between ventilator parameters and clinical outcomes were examined by multivariate linear regression.

Results: After the initiation of OLV, 73.3, 43.3, 18.8, and 7.2% of patients received VT greater than 5, 6, 7, and 8 ml/kg predicted body weight, respectively. One hundred and eighty-four primary and 288 secondary outcome events were recorded. In multivariate logistic regression modeling, VT was inversely related to the incidence of respiratory complications (odds ratio, 0.837; 95% CI, 0.729 to 0.958), while [DELTA]P predicted the development of major morbidity when modeled with VT (odds ratio, 1.034; 95% CI, 1.001 to 1.068).

Conclusions: Low VT per se (i.e., in the absence of sufficient PEEP) has not been unambiguously demonstrated to be beneficial. The authors found that a large proportion of patients continue to receive high VT during OLV and that VT was inversely related to the incidence of respiratory complications and major postoperative morbidity. While low (physiologically appropriate) VT is an important component of an LPV strategy for surgical patients during OLV, current evidence suggests that, without adequate PEEP, low VT does not prevent postoperative respiratory complications. Thus, use of physiologic VT may represent a necessary, but not independently sufficient, component of LPV.

One-lung Ventilation p.slinger 6:29 AM Comments Off on Blank RS, Colquhoun DA, Durieux ME, et al. Management of one-lung ventilation, impact of tidal volumes on complications after thoracic surgery

Ahn HJ, Kim JA, Lee AR, et al. The risk of acute kidney injury from fluid restriction and hydroxyethel starch in thoracic surgery. Anesth AAnalg 2016, 122: 186-93

BACKGROUND: Fluid is restricted in thoracic surgery to reduce acute lung injury, and hydroxyethyl starches (HES) are often administered to reduce fluid amount. This strategy may contribute to the development of acute kidney injury (AKI). We evaluated the incidence, risk factors, and prognosis of AKI in thoracic surgery. We especially focused on whether fluid restriction/HES administration increased AKI.

METHODS: This is a retrospective study of patients undergoing thoracic surgery in a tertiary care academic center. Postoperative AKI was diagnosed within 72 hours after surgery based on the Acute Kidney Injury Network criteria. Demographic, intraoperative, and postoperative data were compared between non-AKI and AKI groups. Logistic regression was used to model the association between risk factors and AKI.

RESULTS: Final analysis included 1442 patients. Of these, 74 patients developed AKI (5.1%). Crystalloid restriction (<=3 mL·kg-1·h-1) was unrelated to AKI, regardless of preoperative renal functions (odds ratio [OR], 0.5; 95% confidence interval [CI] 0.2–1.4). AKI occurred more often when HES were administered to the patients with decreased renal function (OR, 7.6; 95% CI, 1.5–58.1) or having >2 risk factors with normal renal function (OR, 7.2; 95% CI, 3.6–14.1). Multivariate analysis revealed several risk factors: angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, open thoracotomy, pneumonectomy/esophagectomy, diabetes mellitus, cerebrovascular disease, low albumin level, and decreased renal function.

CONCLUSIONS: Fluid restriction neither increased nor was a risk factor for AKI. HES should be administered with caution in high-risk patients undergoing thoracic surgery.

General p.slinger 2:13 PM Comments Off on Ahn HJ, Kim JA, Lee AR, et al. The risk of acute kidney injury from fluid restriction and hydroxyethel starch in thoracic surgery. Anesth AAnalg 2016, 122: 186-93

Posterior intercostal block with liposomal bupivacaine: an alternative to thoracic epidural analgesia.Rice,D.C.; Cata,J.P.; Mena,G.E.; et al. Ann Thorac Surg 2015, 99: 1953-60

Abstract
BACKGROUND:
Pain relief using regional neuroaxial blockade is standard care for patients undergoing major thoracic surgery. Thoracic epidural analgesia (TEA) provides effective postoperative analgesia but has unwanted side effects, including hypotension, urinary retention, nausea, and vomiting, and is highly operator dependent. Single-shot intercostal nerve and paravertebral blockade have not been widely used because of the short duration of action of most local anesthetics; however, the recent availability of liposomal bupivacaine (LipoB) offers the potential to provide prolonged blockade of intercostal nerves (72 to 96 hours). We hypothesized that a five-level unilateral posterior intercostal nerve block using LipoB would provide effective analgesia for patients undergoing thoracic surgery.
METHODS:
We identified patients who underwent lung resection using intraoperative LipoB posterior intercostal nerve blockade and retrospectively compared them with a group of patients who had TEA and who were matched for age, sex, type of surgery, and surgical approach. We analyzed perioperative morbidity, pain scores and narcotic requirements.
RESULTS:
There were 54 patients in each group. Mean hospital stay was 3.5 days and 4.5 days (p = 0.004) for LipoB group and TEA group, respectively. There were no significant differences in perioperative complications, postoperative pain scores, or in narcotic utilization between LipoB group and TEA group. No acute toxicity related to LipoB was observed.
CONCLUSIONS:
Posterior intercostal nerve blockade using LipoB is safe and provides effective analgesia for patients undergoing thoracic surgery. It may be considered as a suitable alternative to TEA.

Analgesia p.slinger 9:03 AM Comments Off on Posterior intercostal block with liposomal bupivacaine: an alternative to thoracic epidural analgesia.Rice,D.C.; Cata,J.P.; Mena,G.E.; et al. Ann Thorac Surg 2015, 99: 1953-60

A Comparison of the Efficacy and Adverse Effects of Double-Lumen Endobronchial Tubes and Bronchial Blockers in Thoracic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Clayton-Smith A, Bennett K, Alston RP, et al. J Cardiothorac Vasc Anesth 2015, 29: 955-66

Objective: To compare the efficacy and adverse effects of
using bronchial blockers (BBs) and double-lumen endobronchial
tubes (DLTs).
Design: Systematic review and meta-analysis of randomized
controlled trials (RCTs) comparing BBs and DLTs.
Setting: Hospital units undertaking thoracic surgery
Participants: Patients undergoing thoracic surgery requiring
lung isolation.
Interventions: BBs and DLTs.
Measurements and Main Results: A systematic literature
search was conducted for RCTs comparing BBs and DLTs
using Google Scholar, Ovid Medline, and Cochrane library
databases up to October 2013. Inclusion criteria were RCTs
comparing BBs and DLTs, intubation carried out by qualified
anesthesiologists or trainee specialists, outcome measures
relating to either efficacy or adverse effects. Studies that
were inaccessible in English were excluded. MantelHaenszel
fixed-effect meta-analysis of recurring outcome
measures was performed using RevMan 5 software. The
search produced 39 RCTs published between 1996 and 2013.
DLTs were quicker to place (mean difference: 51 seconds,
95% confidence intervals [CI] 8-94 seconds; p ¼ 0.02) and
less likely to be incorrectly positioned (odds ratio [OR] 2.70;
95% CI 1.18-6.18, p ¼ 0.02) than BBs. BBs were associated
with fewer patients having a postoperative sore throat (OR
0.39, 95% CI: 0.23-0.68, p ¼ 0.0009), less hoarseness (OR:
0.43,95%, CI 0.24-0.75, p ¼ 0.003), and fewer airway injuries
(OR 0.40, 95% CI 0.21-0.75, p ¼ 0.005) than DLTs.
Conclusion: While BBs are associated with a lower incidence
of airway injury and a lower severity of injury, DLTs
can be placed quicker and more reliably.
& 2015 Elsevier Inc. All rights reserved.
KEY WORDS: bronchial blocker, double-lumen endobronchial
tube, lung isolation, one-lung ventilation, thoracic surgery,
efficacy, adverse effects

Lung Isolation p.slinger 2:54 PM Comments Off on A Comparison of the Efficacy and Adverse Effects of Double-Lumen Endobronchial Tubes and Bronchial Blockers in Thoracic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Clayton-Smith A, Bennett K, Alston RP, et al. J Cardiothorac Vasc Anesth 2015, 29: 955-66

The implications of a tracheal bronchus on one-lung ventilation and bronchoscopy in a patient undergoing thoracic surgery: a case report. Can J Anesth 2015, 62: 399-402

Purpose
Due to its anatomical complexity, a tracheal bronchus has important clinical implications for one-lung ventilation (OLV). We present a case of successful OLV in a patient with a high a type I (i.e., high take-off) tracheal bronchus. This anomaly presented unusual fibreoptic bronchoscopic (FOB) views that were difficult to discern from the normal carinal bifurcation.
Clinical features
A 35-yr-old male presented for posterior basal segmentectomy of the left lower lobe under video-assisted thoracoscopy. The preoperative chest radiography was reported as normal, but a computed tomography scan of the chest revealed a right upper lobe tracheal bronchus. The inlet of the tracheal bronchus was located high above the carina, and the distal trachea had significant narrowing. Because the main trachea was divided into a tracheal bronchus and a distal trachea with similar diameters and with an acute angle of divergence, FOB views of the tracheal bronchus take-off appeared similar to the normal carinal bifurcation. Moreover, the actual carina had an atypical appearance with the main bronchi shifted laterally and a blunted carinal ridge. As a result of this atypical tracheobronchial anatomy, we used an Arndt endobronchial blocker system instead of a double-lumen tube (DLT) for right-sided OLV. One-lung ventilation was satisfactory throughout the uncomplicated operation.
Conclusion
Careful preoperative assessment of tracheobronchial anatomy is imperative in order to choose an appropriate method of OLV and prevent potential complications. In a type I tracheal bronchus with a narrowed distal trachea, a bronchial blocker may have advantages over the conventional DLT in achieving OLV.

Lung Isolation p.slinger 1:25 PM Comments Off on The implications of a tracheal bronchus on one-lung ventilation and bronchoscopy in a patient undergoing thoracic surgery: a case report. Can J Anesth 2015, 62: 399-402

How long is a transurethral catheter necessary in patients undergoing thoracotomy and receiveing thoracic epidural analgesia? Literature review. Zaouter C, Ouattara A. J Cardiothoracic and Vasc Anesth 2015, 29(2): 496-501

Conclusions: “…the present review claimed that transurethral catheter could be discontinued safely on the day after surgery”

Analgesia p.slinger 10:56 AM Comments Off on How long is a transurethral catheter necessary in patients undergoing thoracotomy and receiveing thoracic epidural analgesia? Literature review. Zaouter C, Ouattara A. J Cardiothoracic and Vasc Anesth 2015, 29(2): 496-501

The Use of Preoperative B-type Natriuretic Peptide as a Predictor of Atrial Fibrillation after Thoracic Surgery: Systemic Review and Meta-Analysis. Simmers D, et al. J Cardiothorac Vasc Anesth 2015, 29(2): 389-95

Objective
To determine whether elevated preoperative B-type natriuretic peptide (NP) measurements are an independent predictor of atrial fibrillation (AF) in patients having thoracic surgery.
Design
Systematic review and meta-analysis.
Setting
In-hospital and 30 days after thoracic surgery.
Participants
The 742 patients who participated in the 5 observational studies.
Interventions
None.
Measurements and Main Results
EMBASE, OVID Health Star, Ovid Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ProQuest Dissertations and Theses A&I databases were searched for all studies of noncardiac thoracic surgery patients in whom a preoperative NP was measured up to 1 month before surgery, and that measured the incidence of postoperative AF. Studies were included regardless of their language, sample size, publication status, or study design. Study quality was evaluated using the Newcastle Ottowa Scale.
The combined incidence of postoperative AF was 14.5% (n = 108/742), and the NP thresholds used to predict AF varied among studies. An elevated preoperative NP measurement was associated with an OR of 3.13 (95% CI 1.38-7.12; I2 = 87%) for postoperative AF, with the sensitivity analysis reporting an OR of 9.51 (95% CI 4.66-19.40; I2 = 0).
Conclusion
Patients with an elevated preoperative NP measurement are at an increased risk of postoperative AF. There may be value in incorporating NP measurement into existing AF risk prediction models.

Complications p.slinger 10:45 AM Comments Off on The Use of Preoperative B-type Natriuretic Peptide as a Predictor of Atrial Fibrillation after Thoracic Surgery: Systemic Review and Meta-Analysis. Simmers D, et al. J Cardiothorac Vasc Anesth 2015, 29(2): 389-95

Lumb A, Slinger P. Hypoxic pulmonary vasoconstriction, physiology and anesthetic implications. Anesthesiology 2015, 122: 932-46

Sorry, but this post is not available in English

One-lung Ventilation p.slinger 1:56 PM Comments Off on Lumb A, Slinger P. Hypoxic pulmonary vasoconstriction, physiology and anesthetic implications. Anesthesiology 2015, 122: 932-46

Intravenous lidocaine decreases tumor necrosis factor alpha expression both locally and systemically in pigs undergoing lung resection surgery. Garutti, I, et al. Anesth Analg 2014, 119: 815-28

BACKGROUND: Lung resection surgery is associated with an inflammatory reaction. The use
of 1-lung ventilation (OLV) seems to increase the likelihood of this reaction. Different prophylactic
and therapeutic measures have been investigated to prevent lung injury secondary to OLV.
Lidocaine, a commonly used local anesthetic drug, has antiinflammatory activity. Our main goal
in this study was to investigate the effect of IV lidocaine on tumor necrosis factor α (TNF-α) lung
expression during lung resection surgery with OLV.
METHODS: Eighteen pigs underwent left caudal lobectomy. The animals were divided into 3
groups: control, lidocaine, and sham. All animals received general anesthesia. In addition, animals
in the lidocaine group received a continuous IV infusion of lidocaine during surgery (1.5
mg/kg/h). Animals in the sham group only underwent thoracotomy. Samples of bronchoalveolar
lavage (BAL) fluid and plasma were collected before initiation of OLV, at the end of OLV, at the
end of surgery, and 24 hours after surgery. Lung biopsy specimens were collected from the left
caudal lobe (baseline) before surgery and from the mediastinal lobe and the left cranial lobe
24 hours after surgery. Samples were flash-frozen and stored to measure levels of the following
inflammatory markers: interleukin (IL) 1β, IL-2, IL-10, TNF-α, nuclear factor κB, monocyte chemoattractant
protein-1, inducible nitric oxide synthase, and endothelial nitric oxide synthase.
Markers of apoptosis (caspase 3, caspase 9, Bad, Bax, and Bcl-2) were also measured. In addition,
levels of metalloproteinases and nitric oxide metabolites were determined in BAL fluid and
in plasma samples. A nonparametric test was used to examine statistical significance.
RESULTS: OLV caused lung damage with increased TNF-α expression in BAL, plasma, and lung
samples. Other inflammatory (IL-1β, nuclear factor κB, monocyte chemoattractant protein-1)
and apoptosis (caspase 3, caspase 9, and BAX) markers were also increased. With the use
of IV lidocaine there was a significant decrease in the levels of TNF-α in the same samples
compared with the control group. Lidocaine administration also reduced the inflammatory and
apoptotic changes observed in the control group. Hemodynamic values, blood gas values, and
airway pressure were similar in all groups.
CONCLUSIONS: Our results suggest that lidocaine can prevent OLV-induced lung injury through
reduced expression of proinflammatory cytokines and lung apoptosis. Administration of lidocaine
may help to prevent lung injury during lung surgery with OLV. (Anesth Analg 2014;119:815–28)

One-lung Ventilation p.slinger 4:56 PM Comments Off on Intravenous lidocaine decreases tumor necrosis factor alpha expression both locally and systemically in pigs undergoing lung resection surgery. Garutti, I, et al. Anesth Analg 2014, 119: 815-28

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