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.

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.

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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