Abstract

One-lung ventilation is routinely used to facilitate exposure for thoracic surgical procedures and can be achieved via several lung isolation techniques. The optimal method for lung isolation depends on a number of factors that include (1) the indication for lung isolation, (2) anatomic features of the upper and lower airway, (3) availability of equipment and devices, and (4) the anesthesiologist’s proficiency and preferences. Though double-lumen endobronchial tubes (DLTs) are most commonly utilized to achieve lung isolation, the use of endobronchial blockers offer advantages in patients with challenging airway anatomy. Anesthesiologists should be familiar with existing alternatives to the DLT for lung isolation and alternative techniques for DLT placement in the patient with a difficult airway. Newer technologies such as videolaryngoscopy with or without adjunctive fiberoptic bronchoscopy may facilitate intubation and lung isolation in difficult airway management.

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.

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.

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.

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.

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

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.

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

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.

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