Garutti I, Puente-Maestu L, Laso J, et al. Comparison of gas exchange after lung resection with a Boussignac CPAP or Venturi mask. Br J Anaesth 112: 929-35, 2014

Background Postoperative continuous positive airway pressure (CPAP) can improve lung function. The aim of our study was to assess the efficacy of prophylactic CPAP on the Pa O 2 /FI O 2 ratio measured the day after surgery in patients undergoing lung resection surgery (LRS).
Methods The study population comprised 110 patients undergoing LRS. On arrival in the postanaesthesia care unit (PACU), patients were randomized to receive CPAP at 5–7 cm H2O during the first 6 h after surgery (CPAP group) or supplemental oxygen through a Venturi mask (Venturi group). The Pa O 2 /FI O 2 ratio was measured on arrival in the PACU, 7 h after admission, and the day after surgery. The Pa O 2 /FI O 2 ratio is the primary endpoint of our study. We also analysed the chest radiograph and assessed the postoperative course. We then analysed the impact of ventilatory management in the PACU depending on the respiratory risk of the patient.
Results Baseline characteristics were similar in both groups. Patients who received CPAP had significantly higher Pa O 2 /FI O 2 at 24 h after surgery compared with patients managed conventionally (Venturi group) (48.6±14 vs 42.3±12, P=0.031), but there were no differences at 7 h. On subgroup analysis, we found that the benefits of CPAP were greater in higher risk patients. The incidence of postoperative pulmonary complications and stay in the PACU and hospital were similar in both groups.
Conclusions In patients undergoing LRS, prophylactic CPAP during the first 6 h after surgery with a pressure of 5–7 cm H2O improved the Pa O 2 /FI O 2 ratio at 24 h. This effect was more evident in patients with increased risk of postoperative pulmonary complications.

Complications p.slinger 3:07 PM Comments Off on Garutti I, Puente-Maestu L, Laso J, et al. Comparison of gas exchange after lung resection with a Boussignac CPAP or Venturi mask. Br J Anaesth 112: 929-35, 2014

Verhage RJJ, Boone J, Rijkers GT, et al. Reduced local immune response with continuous positive airway pressure during one-lung ventialtion for oesophagectomy, Br. J Anaesth 2014, advanced online access Feb. 11, 2014

Background. Transthoracic oesophagectomy requires prolonged one-lung ventilation causing
systemic and local inflammatory responses. Application of continuous positive airway
pressure (CPAP) to the collapsed lung potentially reduces pulmonary damage, hypoxia, and
consequent inflammation. This randomized controlled trial studied the influence of CPAP
applied to the collapsed right lung during thoracoscopic oesophagectomy on local and
systemic inflammatory response.
Methods. Broncho-alveolar lavage fluid (BALF) fromthe right collapsedandleft ventilated lung
and serum samples were obtained during surgery from 30 patients undergoing
thoracolaparoscopic oesophagectomy for cancer who were randomized for one-lung
ventilation with or without CPAP applied to the collapsed right lung. Concentrations of
cytokines and chemokines, in BALF and serum, were determined with Luminex.
Results. Patients fromthe control (no CPAP) group had significantly increased concentrations of
interleukin (IL)-1a, IL-1b, IL-10, tumour necrosis factor-alpha, macrophage inflammatory
protein (MIP)-1a, pulmonary and activation-regulated chemokine (PARC), and IL-8 in the
collapsed (right) lung when compared with patients from the CPAP group (P,0.05). The
ventilated (left) lung of the control group showed increased concentrations of monocyte
chemoattractant protein (MCP)-1 and MIP-1a (P,0.05). Serum concentrations of cytokines
and chemokines increased during surgery, but did not differ between the control and CPAP
groups.
Conclusions. A significantly lower local immune response was observed during one-lung
ventilation when CPAP was applied to the collapsed lung. The findings suggest a beneficial
effect of CPAP on the collapsed lung during oesophagectomy with one-lung ventilation

One-lung Ventilation p.slinger 12:26 PM Comments Off on Verhage RJJ, Boone J, Rijkers GT, et al. Reduced local immune response with continuous positive airway pressure during one-lung ventialtion for oesophagectomy, Br. J Anaesth 2014, advanced online access Feb. 11, 2014

Phenylephrine infusion improves blood flow to the stomach during oesophagectomy in the presence of a thoracic epidural analgesia. Pathak D, et al. Eur J Cardiothorac Surg 2013, 44: 130-3

OBJECTIVES Gastric tube necrosis is a major cause of mortality after oesophagectomy. The construction of the gastric tube used for oesophageal reconstruction involves a division of several arteries leading to a reduction in the blood supply at the fundus, which is used for the oesophageal anastomosis. This study was undertaken to determine the effect of thoracic epidural anaesthesia and intravenous phenylephrine on haemodynamics and blood flow in the tubularized stomach.

METHODS Ten patients undergoing an oesophagectomy were prospectively studied. Pulmonary artery catheters were used to measure haemodynamic changes, and laser Doppler flow probes were used to measure gastric blood flow. The effects of an intraoperative thoracic epidural and subsequent intravenous phenylephrine infusion were documented.

RESULTS The administration of a thoracic epidural bolus of bupivacaine 0.25% at 0.1 ml kg resulted in a significant reduction in flux at the anastomotic end of the newly formed gastric tube from a median of 57–41 perfusion units (P = 0.003). A subsequent intravenous phenylephrine infusion titrated to restore mean arterial pressure significantly increased the flux at the anastomotic end from a median of 41–66 perfusion units (P = 0.009).

CONCLUSIONS An intravenous phenylephrine infusion can reverse the epidural bolus-induced reduction in blood flow at the anastomotic end of the newly formed gastric tube.

Analgesia p.slinger 3:50 PM Comments Off on Phenylephrine infusion improves blood flow to the stomach during oesophagectomy in the presence of a thoracic epidural analgesia. Pathak D, et al. Eur J Cardiothorac Surg 2013, 44: 130-3

Intravenous versus inhalation anaesthesia for one-lung ventilation.Modolo, SP Norma. Modolo, Marilia P. Marton, Marcos A. Volpato, Enilze. Monteiro Arantes, Vinicius. do Nascimento Junior, Paulo. El Dib, Regina P. Cochrane Anaesthesia Group Cochrane Database of Systematic Reviews. 7, 2013.

AB Background This is an update of a Cochrane Review first published in The Cochrane Library, Issue 2, 2008. Objectives The objective of this review was to evaluate the effectiveness and safety of intravenous versus inhalation anaesthesia for one-lung ventilation. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL); The Cochrane Library (2012, Issue 11); MEDLINE (1966 to November 2012); EMBASE (1980 to November 2012); Literatura Latino-Americana e do Caribe em Ciencias da Saude (LILACS, 1982 to November 2012) and ISI web of Science (1945 to November 2012), reference lists of identified trials and bibliographies of published reviews. We also contacted researchers in the field. No language restrictions were applied. The date of the most recent search was 19 November 2012. The original search was performed in June 2006. Selection criteria We included randomized controlled trials and quasi-randomized controlled trials of intravenous (e.g. propofol) versus inhalation (e.g. isoflurane, sevoflurane, desflurane) anaesthesia for one-lung ventilation in both surgical and intensive care participants. We excluded studies of participants who had only one lung (i.e. pneumonectomy or congenital absence of one lung). Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Main results We included in this updated review 20 studies that enrolled 850 participants, all of which assessed surgical participants[FULLWIDTH HYPHEN-MINUS]no studies investigated one-lung ventilation performed outside the operating theatre. No evidence indicated that the drug used to maintain anaesthesia during one-lung ventilation affected participant outcomes. The methodological quality of the included studies was difficult to assess as it was reported poorly, so the predominant classification of bias was ‘unclear’. Authors’ conclusions Very little evidence from randomized controlled trials suggests differences in participant outcomes with anaesthesia maintained by intravenous versus inhalational anaesthesia during one-lung ventilation. If researchers believe that the type of drug used to maintain anaesthesia during one-lung ventilation is important, they should design randomized controlled trials with appropriate participant outcomes, rather than report temporary fluctuations in physiological variables.

General &One-lung Ventilation p.slinger 2:22 PM Comments Off on Intravenous versus inhalation anaesthesia for one-lung ventilation.Modolo, SP Norma. Modolo, Marilia P. Marton, Marcos A. Volpato, Enilze. Monteiro Arantes, Vinicius. do Nascimento Junior, Paulo. El Dib, Regina P. Cochrane Anaesthesia Group Cochrane Database of Systematic Reviews. 7, 2013.

Preoperative Pulmonary Rehabilitation Versus Chest Physical Therapy in Patients Undergoing Lung Cancer Resection: A Pilot Randomized Controlled Trial. Morano MT, et al. Arch Phys Med Rehab, 2013, 94: 53-8

Abstract
Objective: To evaluate the effect of 4 weeks of pulmonary rehabilitation (PR) versus chest physical therapy (CPT) on the preoperative functional
capacity and postoperative respiratory morbidity of patients undergoing lung cancer resection.
Design: Randomized single-blinded study.
Setting: A teaching hospital.
Participants: Patients undergoing lung cancer resection (N=24).
Interventions: Patients were randomly assigned to receive PR (strength and endurance training) versus CPT (breathing exercises for lung
expansion). Both groups received educational classes.
Main Outcome Measures: Functional parameters assessed before and after 4 weeks of PR or CPT (phase 1), and pulmonary complications
assessed after lung cancer resection (phase 2).
Results: Twelve patients were randomly assigned to the PR arm and 12 to the CPT arm. Three patients in the CPT arm were not submitted to lung
resection because of inoperable cancer. During phase 1 evaluation, most functional parameters in the PR group improved from baseline to 1
month: forced vital capacity (FVC) (1.47L [1.27-2.33L] vs 1.71L [1.65-2.80L], respectively; P=.02); percentage of predicted FVC (FVC%;
62.5% [49%-71%] vs 76% [65%-79.7%], respectively; P<.05); 6-minute walk test (425.585.3m vs 47586.5m, respectively; P<.05); maximal inspiratory pressure (9045.9cmH2O vs 117.536.5cmH2O, respectively; P<.05); and maximal expiratory pressure (79.717.1cmH2O vs 92.921.4cmH2O, respectively; P<.05). During phase 2 evaluation, the PR group had a lower incidence of postoperative respiratory morbidity (P=.01), a shorter length of postoperative stay (12.23.6d vs 7.84.8d, respectively; P=.04), and required a chest tube for fewer days (7.42.6d vs 4.52.9d, respectively; P=.03) compared with the CPT arm. Conclusions: These findings suggest that 4 weeks of PR before lung cancer resection improves preoperative functional capacity and decreases the postoperative respiratory morbidity. Archives of Physical Medicine and Rehabilitation 2013;94:53-8

Preoperative Assessment p.slinger 8:20 AM Comments Off on Preoperative Pulmonary Rehabilitation Versus Chest Physical Therapy in Patients Undergoing Lung Cancer Resection: A Pilot Randomized Controlled Trial. Morano MT, et al. Arch Phys Med Rehab, 2013, 94: 53-8

Lung transplantation on cardiopulmonary support: Venoarterial extracorporeal membrane oxygenation outperformed cardiopulmonary bypass. Ius F, Kuehn C, Tudorache I, et al. The Journal of Thoracic and Cardiovascular Surgery (December 2012), 144 (6), pg. 1510-1516

Objectives
Patients requiring extracorporeal cardiorespiratory support during lung transplantation can be treated with conventional cardiopulmonary bypass (CPB) or venoarterial extracorporeal membrane oxygenation (ECMO). In a retrospective analysis, we compared the postoperative course and outcomes of patients treated using these approaches.
Methods
Between August 2008 and September 2011, 92 consecutive patients underwent lung transplantation with extracorporeal support (CPB group, n = 46; and, since February 2010, ECMO group, n = 46) at our institution. We evaluated survival, secondary organ failure, bleeding complications, and the need for blood and platelet transfusions in these 2 patient populations.
Results
Intraoperatively, the CPB group required more packed red blood cell transfusions (12 ± 11 vs 7 ± 9 U; P = .01) and platelet concentrates (2.5 ± 1.6 vs 1.5 ± 1 U; P < .01) than the ECMO group. In-hospital mortality (39% vs 13%; P = .004), the need for hemodialysis (48% vs 13%; P < .01), and new postoperative ECMO support (26% vs 4%; P < .01) were greater in the CPB group than in the ECMO group, respectively. After propensity score analysis, multivariate analysis identified retransplantation (odds ratio, 7; 95% confidence interval, 1-43; P = .034) and transplantation with CPB support (odds ratio, 4.9; 95% confidence interval, 1.2-20; P = .026) as independent risk factors for in-hospital mortality. The survival rate at 3, 9, and 12 months was 70%, 59%, and 56% in the CPB group and 87%, 81%, and 81% in the ECMO group (P = .004). Conclusions Intraoperative ECMO allows for better periprocedural management and reduced postoperative complications and confers a survival benefit compared with CPB, mainly because of lower in-hospital mortality. It is now the standard of care in our lung transplantation program.

Lung Transplantation p.slinger 12:52 PM Comments Off on Lung transplantation on cardiopulmonary support: Venoarterial extracorporeal membrane oxygenation outperformed cardiopulmonary bypass. Ius F, Kuehn C, Tudorache I, et al. The Journal of Thoracic and Cardiovascular Surgery (December 2012), 144 (6), pg. 1510-1516

Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy. Woodcock TE, Woodcock TM. Br J Anesth 2012, 108 : 384-94

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.

General p.slinger 2:47 PM Comments Off on Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy. Woodcock TE, Woodcock TM. Br J Anesth 2012, 108 : 384-94

Ishikawa S, Greisdale DEG, Lohser J. Acute kidney injury after lung resection surgery: incidence and perioperative risk factors. Anesth Analg 2012, 114: 1256-62

Abstract
BACKGROUND: Postoperative acute kidney injury (AKI) is associated with increased perioperative morbidity and mortality in a variety of surgical settings, but has not been well studied after lung resection surgery. In the present study, we defined the incidence of postoperative AKI, identified risk factors, and clarified the relationship between postoperative AKI and outcome in patients undergoing lung resection surgery.

METHODS: A retrospective, observational study of patients who underwent lung resection surgery between January 2006 and March 2010 in a tertiary care academic center was conducted. Postoperative AKI was diagnosed within 72 hours after surgery based on the Acute Kidney Injury Network creatinine criteria. Logistic regression was used to model the association between perioperative factors and the risk of AKI within 72 hours after surgery. The relationship between postoperative AKI and patient outcome including mortality, days in hospital, and the requirement of reintubation was investigated.

RESULTS: A total of 1129 patients (pneumonectomy n = 71, bilobectomy n = 30, lobectomy n = 580, segmentectomy n = 35, wedge resection/bullectomy n = 413) were included in the final analysis. Patients were an average of 61 years (SD 15) and 50% were female. AKI was diagnosed in 67 patients (5.9%) based on Acute Kidney Injury Network criteria (stage 1, n = 59; stage 2, n = 8; and stage 3, n = 0) within 72 hours after surgery, and only 1 patient required renal replacement therapy. Multivariate analysis demonstrated an independent association between postoperative AKI and hypertension (adjusted odds ratio [OR] 2.0, 95% confidence interval [CI]: 1.1-3.8), peripheral vascular disease (OR 4.4, 95% CI: 1.8-10), estimated glomerular filtration rate (OR 0.8, 95% CI: 0.69-0.93), preoperative use of angiotensin II receptor blockers (OR 2.2, 95% CI: 1.1-4.4), intraoperative hydroxyethyl starch administration (OR 1.5, 95% CI: 1.1-2.1), and thoracoscopic (versus open) procedures (OR 0.37, 95% CI: 0.15-0.90). Development of AKI was associated with increased rates of tracheal reintubation (12% vs 2%, P < 0.001), postoperative mechanical ventilation (15% vs 3%, P < 0.001), and prolonged hospital length of stay (10 vs 8 days, P < 0.001). There was no difference in mortality between the 2 groups (3% vs 1%, P = 0.12). CONCLUSIONS: Preoperative risk factors for AKI after lung resection surgery overlap with those established for other surgical procedures. Perioperative management seems to influence the risk of AKI after lung resection; in particular, the use of synthetic colloids may increase the risk, whereas thoracoscopic procedures may decrease the risk of AKI. Early postoperative AKI is associated with respiratory complications and prolonged hospitalization.

Complications p.slinger 2:33 PM Comments Off on Ishikawa S, Greisdale DEG, Lohser J. Acute kidney injury after lung resection surgery: incidence and perioperative risk factors. Anesth Analg 2012, 114: 1256-62

Separation from CPB with a rigid bronchoscope airway after hemoptysis and bronchial impaction with clot. Neuberger PJ, Galloway AC, Zervos MD, Kanchuger MS. Anesth Analg 2012, 114: 89-82

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.

General p.slinger 6:14 PM Comments Off on Separation from CPB with a rigid bronchoscope airway after hemoptysis and bronchial impaction with clot. Neuberger PJ, Galloway AC, Zervos MD, Kanchuger MS. Anesth Analg 2012, 114: 89-82

Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. Unzueta C, Tusman G, Suarez-Shipmann F, et al. Br J Anesth epub Dec. 26, 2011

Background. This study was conducted to determine whether an alveolar recruitment
strategy (ARS) applied during two-lung ventilation (TLV) just before starting one-lung
ventilation (OLV) improves ventilatory efficiency.
Methods. Subjects were randomly allocated to two groups: (i) control group: ventilation with
tidal volume (VT) of 8 or 6 ml kg21 for TLV and OLV, respectively, and (ii) ARS group: same
ventilatory pattern with ARS consisting of 10 consecutive breaths at a plateau pressure of
40 and 20 cm H2O PEEP applied immediately before and after OLV. Volumetric capnography
and arterial blood samples were recorded 5 min (baseline) and 20 min into TLV, at 20 and
40 min during OLV, and finally 10 min after re-establishing TLV.
Results. Twenty subjects were included in each group. In all subjects, the airway
component of dead space remained constant during the study. Compared with baseline,
the alveolar dead space ratio (VDalv/VTalv) increased throughout the protocol in the
control but decreased in the ARS group. Differences in VDalv/VTalv between groups were
significant (P,0.001). Except for baseline, all PaO2 values in kPa (SD) were higher in the
ARS than in the control group (P,0.001), respectively [70 (7) and 55 (9); 33 (9) and 24
(10); 33 (8) and 22 (10); 70 (7) and 55 (10)].
Conclusions. Recruitment of both lungs before instituting OLV not only decreased alveolar
dead space but also improved arterial oxygenation and the efficiency of ventilation.
Keywords: lung, atelectasis; lung, gas exchange; surgery, thoracic; ventilation, dead space;
ventilation, one-lung ventilation

One-lung Ventilation p.slinger 2:15 PM Comments Off on Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. Unzueta C, Tusman G, Suarez-Shipmann F, et al. Br J Anesth epub Dec. 26, 2011

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