Objective: Lung injury induced by one-lung ventilation is rare, but it is acondition that may result in high mortality. This study evaluates the effects ofone-lung ventilation and occlusion time on collapsed and contralateral lungs.Methods: Sprague-Dawley rats were allocated randomly into 7 groups consisting of6 animals each: sham; O1, 1 hour of occlusion/2 hours of re-expansion; C1, 3 hoursof mechanical ventilation control; O2, 2 hours of occlusion/2 hours of re-expansion;C2, 4 hours of mechanical ventilation control; O3, 3 hours of occlusion/2 hours ofre-expansion; and C3, 5 hours of mechanical ventilation control groups. In theocclusion groups, the left lung was collapsed by bronchial occlusion. Malondialdehydeactivity was determined in the blood, and myeloperoxidase and malondialdehydeactivity was determined in the collapsed and contralateral lungs. Lung tissueswere also examined histopathologically.Results: Malondialdehyde and myeloperoxidase levels rose as occlusion durationincreased. This increase was greater in the occlusion groups than that in their owncontrol groups. Increases were significant in the O2 compared with the O1 groups(P .005). Histologically, tissue damage increased as occlusion time rose injury incollapsed and contralateral lungs. Injury was greater in the occlusion groups thaninjury in their own control groups (P .005).Conclusions: Our findings show that biochemical and histopathologic injury occurin collapsed and contralateral lungs in one-lung ventilation, and this injury increasesas occlusion time rises. We believe that occlusion and occlusion time-related injuryshould be borne in mind in the clinic under conditions requiring the application of one-lung ventilation.

Kuzkov, Vsevolod V. MD, PhD; Suborov, Evgeny V. MD; Kirov, Mikhail Y. MD, PhD; Kuklin, Vladimir N. MD, PhD; Sobhkhez, Mehrdad MSci; Johnsen, Solveig MD; Waerhaug, Kristine MD; Bjertnaes, Lars J. MD, PhD

Institution From the Department of Anesthesiology, Institute of Clinical Medicine, University of Tromso, Tromso, Norway (VVK, EVS, MYK, VNK, MS, SJ, KW, LJB); and the Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russian Federation (VVK, EVS, MYK).

Abstract Objective: To compare the single thermodilution and the thermal-dye dilution techniques with postmortem gravimetry for assessment of changes in extravascular lung water after pneumonectomy and to explore the evolution of edema after injurious ventilation of the left lung.

Design: Experimental study.

Setting: University laboratory.

Subjects: A total of 30 sheep weighing 35.6 +/- 4.6 kg. The study included two parts: a pneumonectomy study (n = 18) and an injurious ventilation study (n = 12).

Methods: Sheep were anesthetized and mechanically ventilated with an Fio2 of 0.5, tidal volume of 6 mL/kg, and positive end-expiratory pressure of 2 cm H2O. In the pneumonectomy study, sheep were assigned to right-sided pneumonectomy (n = 7), left-sided pneumonectomy (n = 7), or lateral thoracotomy only (sham operation, n = 4). In the injurious ventilation study, right-sided pneumonectomy was followed by ventilation with a tidal volume of 12 mL/kg and positive end-expiratory pressure of 0 cm H2O (n = 6) or by ventilation with a tidal volume of 6 mL/kg and positive end-expiratory pressure of 2 cm H2O for 4 hrs (n = 6). Volumetric variables, including extravascular lung water index (EVLWI), were measured with single thermodilution (STD; EVLWISTD) and thermal-dye dilution (TDD; EVLWITDD) techniques. We monitored pulmonary hemodynamics and respiratory variables. After the sheep were killed, EVLWI was determined for each lung by gravimetry (EVLWIG).

Results: In total, the study yielded strong correlations of EVLWISTD and EVLWITDD with EVLWIG (n = 30; r = .83 and .94, respectively; p < .0001). After pneumonectomy, both the left- and the right-sided pneumonectomy groups displayed significant decreases in EVLWISTD and EVLWITDD. The injuriously ventilated sheep demonstrated significant increases in EVLWI that were detected by both techniques. The mean biases (+/-2 sd) compared with EVLWIG were 3.0 +/- 2.6 mL/kg for EVLWISTD and 0.4 +/- 1.6 mL/kg for EVLWITDD. Conclusions: After pneumonectomy and injurious ventilation of the left lung, TDD and STD displayed changes in extravascular lung water with acceptable accuracy when compared with postmortem gravimetry. Ventilator-induced lung injury seems to be a crucial mechanism of pulmonary edema after pneumonectomy.

Authors: Solak, O.; Metin, M.; Esme, H.; Solak, O.; Yaman, M.; Pekcolaklar, A.; Gurses, A.; Kavuncu, V.
Eur J Cardio-Thorac Surg 32: 9-12, 2007
Keywords: Chronic post-thoracotomy pain; Neuropathic pain; Gabapentin; Wound pain
Abstract (English): Background: Chronic post-thoracotomy pain (CPTP) consists of different types of pain. Some characteristics of CPTP are the same as those of recognized neuropathic pain syndromes. Objective: We aimed to determine the safety and efficacy of gabapentin (GP) in comparison to naproxen sodium (NS) in patients with CPTP. Methods: Forty consecutive patients with CPTP after posterolateral/lateral thoracotomy were prospectively evaluated. Twenty patients were given GP and another 20 were given NS treatment. Visual Analogue Scale (VAS) and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scorings were performed pretreatment (day 0) and on the 15th, 30th, 45th and 60th days. Adverse events were questioned. The mean ages were 45.7+/-14.9 and 49.8+/-15.2 years and the mean durations of pain were 3.8+/-0.9 and 3.8+/-1.1 months, respectively. Results: The mean pretreatment VAS scores (VAS0) were 6.4+/-0.6 and 6.8+/-0.6, the mean pretreatment LANSS scores (LANSS0) were 18.85+/-1.6 and 20.75+/-2.6 in GP and NS groups, respectively (p>0.05). Minor adverse events which did not mandate discontinuation of treatment were observed in seven patients (35%) in the GP and in four patients (20%) in the NS group. The number of patients with a VAS score <5 at the latest follow-up (VAS60<5) was 17 (85%) and 3 (15%) in GP and NS groups, respectively (p<0.001). Seventeen patients (85%) in the GP and 0 patients (0%) in the NS group had a LANSS score <12 at the latest follow-up. Conclusion: Gabapentin is safe and effective in the treatment of CPTP with minimal side effects and a high patient compliance. These results should be supported with multidisciplinary studies with larger sample sizes and longer follow-ups.

Ozcan PE. Senturk M. Sungur Ulke Z. Toker A. Dilege S. Ozden E. Camci E.
Institution
Department of Anaesthesiology, Istanbul Medical Faculty, Istanbul University, Capa 34093, Istanbul, Turkey.
Title
Effects of thoracic epidural anaesthesia on pulmonary venous admixture and oxygenation during one-lung ventilation.
Source
Acta Anaesthesiologica Scandinavica. 51(8):1117-22, 2007 Sep.

Abstract
BACKGROUND: In this clinical randomized study, the effects of four anaesthesia techniques during one-lung ventilation [total intravenous anesthesia (TIVA) with or without thoracic epidural anaesthesia (TEA) (G-TIVA-TEA and G-TIVA), isoflurane anaesthesia with or without TEA (G-ISO-TEA and G-ISO)] on pulmonary venous admixture (Qs/Qt) and oxygenation (OLV) were investigated. METHODS: In 100 patients (four groups, 25 patients in each) undergoing thoracotomy, a thoracic epidural catheter was inserted pre-operatively. In G-TIVA-TEA and G-ISO-TEA, bupivacaine 0.1% + 0.1 mg/ml morphine was administered intra-operatively (10 ml of first bolus + 7 ml/h infusion). Propofol infusion or isoflurane concentration was adjusted to keep a bispectral index (BIS) of between 40 and 50 in all groups. FiO(2) was 0.8 during OLV and 0.5 before and after OLV. Partial arterial and central venous oxygen pressures (PaO(2) and PvO(2)), arterial and venous oxygen saturations and Qs/Qt values were recorded before, during and after OLV. RESULTS: During OLV, PaO(2) was significantly higher and Qs/QT significantly lower in G-TIVA-TEA and G-TIVA compared with G-ISO-TEA and G-ISO (PaO2: 188 +/- 36; 201 +/- 39; 159 +/- 33; 173 +/- 42 mmHg, respectively; Qs/Qt: 31.2 +/- 7.4; 28.2 +/- 7; 36.7 +/- 7.1; 33.7 +/- 7.7%, respectively). No statistical changes were observed in patients with TEA compared with without TEA in any measurement. CONCLUSION: During OLV, TEA does not significantly affect the oxygenation and Qs/Qt and can be used safely regardless of whether TIVA or inhalation techniques are used.

Objectives: This study was designed to evaluate the effectiveness of low-volume interscalene brachial plexus block for post-thoracotomy ipsilateral shoulder pain and to compare it with nonsteroidal anti-inflammatory drug treatment. Design: Prospective nonblinded study. Setting: University hospital. Participants: Sixty adult patients. Intervention: Patients who underwent elective thoracic surgery under combined epidural and general anesthesia, and after surgery were free of incisional pain but complaining of shoulder pain, were included in the study. They were selected in a sequential manner and placed into 2 groups of 30 patients each. Group 1 had a low-volume interscalene brachial plexus block, using 10 mL of bupivacaine 0.5%. Group 2 had an intramuscular injection of diclofenac sodium, 75 mg. Measurements and Main Results: Pain was measured during their stay in the postanesthesia care unit (PACU) by using a visual analog score (VAS). Opioids were administered when pain relief was incomplete. Pain intensity was re-estimated the next morning and patient satisfaction was scored. VAS was found to be significantly lower in the low-volume interscalene block group than in the diclofenac group at 30 minutes after treatment and when leaving PACU (p < 0.001 for both). Patients in the interscalene block group stayed longer in the PACU (p = 0.019), and significantly fewer required rescue opioids (p = 0.03). There was no significant difference between the groups in patient satisfaction with the pain treatment. Conclusions: The authors concluded that low-volume interscalene brachial plexus block is a superior treatment for post-thoracotomy shoulder pain compared with diclofenac injection, although it requires a slightly longer stay in the PACU. J Cardiothorac Vasc Anesth 21: 554-7, 2007

Scholten, Kevin J. MD; Kulkarni, Vivek MD; Brodsky, Jay B. MD
A patient with a prior left pneumonectomy required surgical drainage of a right upper lobe aspergilloma. A left double-lumen endobronchial tube was placed in the right bronchus intermedius, isolating the right upper lobe while allowing ventilation of the right middle and lower lobes.
Anesthesia & Analgesia. 105(2):330-331, August 2007.

krakow-vats-10607.pdfVATS Anesthesia

Spaggiari, Lorenzoa; Scanagatta, Paoloa. Curr Opinion Oncol. Volume 19(2), March 2007, p 84–91
Purpose of review: The aim of this review is to analyze recent evidence for optimal treatment of elderly patients with non-small cell lung cancer, focusing on surgery, and possibly to foresee the future strategies to apply in these patients.

Recent findings: Surgery in elderly patients affected by non-small cell lung cancer is safe and feasible when careful preoperative respiratory and cardiac studies have been carried out and the disease has been properly staged. The surgical treatment is not to be denied in elderly patients due to age per se, but when a major contraindication to surgery has been recognized. Long term survival for elderly patients with early stage lung cancer treated by anatomical pulmonary resection is comparable to the survival rate of younger patients. Pneumonectomy, extended surgical procedure or preoperative induction chemotherapy are major risk factors for an increased postoperative morbidity and mortality rate. When co-morbidities are present or a patient is 80 years or older, there is evidence that a non-anatomical resection can be performed without affecting long-term results.

Summary: Due to the aging of the general population, elderly patients will become a large percentage of the cases of non-small cell lung cancer to be treated. Implementing preoperative cardiologic studies and redefining selective respiratory criteria specifically could dramatically improve results.

mcgill-lung-injury-507.pdfLung Protection

buffalo-lung-isol-507.pdflecture slides