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Unzueta, M Carmen MD, PhD; Casas, J Ignacio MD; Moral, M Victoria MD.
Anesth Analg. 2007 May;104(5):1029-33

From the Department of Anesthesiology, Hospital de Sant Pau, Barcelona, Spain.
Accepted for publication January 15, 2007.
Supported by Departmental resources.
Address correspondence to M. Carmen Unzueta, Sant Antonio Ma Claret 167, Barcelona 08025, Spain. Address e-mail to mcunzueta@telefonica.net.
Abstract
BACKGROUND: Pressure-controlled ventilation (PCV) has been suggested as a tool to improve oxygenation during one-lung ventilation (OLV) for patients undergoing thoracic surgery. In this study we investigated whether PCV results in improved arterial oxygenation compared with volume-controlled ventilation (VCV) during OLV.

METHODS: Fifty-eight patients with good preoperative pulmonary function scheduled for thoracic surgery were prospectively randomized into two groups. Those in group A underwent OLV initially with VCV for 30 min followed by PCV for a similar period of time. Those in group B underwent OLV initially with PCV for 30 min followed by VCV for a similar duration. Airway pressures and arterial blood gases were obtained during OLV at the end of each ventilatory mode.

RESULTS: There were no differences during OLV in arterial oxygenation between VCV (Pao2, 206.1 ± 62.4 mm Hg) and PCV (Pao2, 202.1 ± 56.4 mm Hg; P = 0.534). Peak airway pressure was lower with PCV than with VCV (24.43 ± 3.42 cm H2O vs. 34.16 ± 5.21 cm H2O; P < 0.001). CONCLUSIONS: The use of PCV during OLV does not lead to improved oxygenation during OLV compared with VCV for patients with good preoperative pulmonary function, but PCV did lead to lower peak airway pressures. Further study is needed for patients with severe obstructive or restrictive pulmonary disease.

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R. G. Davies1, P. S. Myles1,2,3,* and J. M. Graham4
1Department of Anaesthesia and Pain Management, Alfred Hospital Commercial Road, Melbourne, Victoria 3004, Australia
2Academic Board of Anaesthesia and Perioperative Medicine, Monash University Victoria 3800, Australia
3Centre for Clinical Research Excellence Canberra, Australia
4Department of Anaesthesia, Austin Hospital Heidelberg, Australia

*Corresponding author: Department of Anaesthesia and Pain Management, The Alfred Hospital, PO Box 315, Melbourne, VIC, 3004, Australia. E-mail: p.myles@alfred.org.au

Epidural analgesia is considered by many to be the best method of pain relief after major surgery. It is used routinely in many thoracic surgery centres. Although effective, side-effects include hypotension, urinary retention, incomplete (or failed) block, and, in rare cases, paraplegia. Paravertebral block (PVB) is an alternative technique that may offer comparable analgesic effectiveness and a better side-effect profile. We undertook a systematic review and meta-analysis of all relevant randomized trials comparing PVB with epidural analgesia in thoracic surgery. Data were abstracted and verified by both authors. Studies were tested for heterogeneity, and meta-analyses were done with random effects or fixed effects models. Weighted mean difference (WMD) was used for numerical outcomes and odds ratio (OR) for dichotomous outcomes, both with 95% CI.

We identified 10 trials that had enrolled 520 thoracic surgery patients. All of the trials were small (n<130) and none were blinded. There was no significant difference between PVB and epidural groups for pain scores at 4–8, 24 or 48 h, WMD 0.37 (95% CI: –0.5, 121), 0.05 (–0.6, 0.7), –0.04 (–0.4, 0.3), respectively. Pulmonary complications occurred less often with PVB, OR 0.36 (0.14, 0.92). Urinary retention, OR 0.23 (0.10, 0.51), nausea and vomiting, OR 0.47 (0.24, 0.53), and hypotension, OR 0.23 (0.11, 0.48), were less common with PVB. Rates of failed block were lower in the PVB group, OR 0.28 (0.2, 0.6). PVB and epidural analgesia provide comparable pain relief after thoracic surgery, but PVB has a better side-effect profile and is associated with a reduction in pulmonary complications. PVB can be recommended for major thoracic surgery.

Authors
Schmid RA. Stammberger U. Hillinger S. Vogt PR. Amman FW. Russi EW. Weder W.
Institution
Department of Surgery, University Hospital, Zurich, Switzerland.
Title
Lung volume reduction surgery combined with cardiac interventions.
Source
European Journal of Cardio-Thoracic Surgery. 15(5):585-91, 1999 May.
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Abstract
OBJECTIVE: Postoperative course and functional outcome were evaluated in patients who underwent lung volume reduction surgery (LVRS) or in combination with valve replacement (VR), percutaneous transluminal coronary angioplasty (PTCA), placement of a stent, or coronary artery bypass grafting (CABG). METHODS: Patients with severe bronchial obstruction and hyperinflation due to pulmonary emphysema were evaluated for lung volume reduction surgery. Cardiac disorders were screened by history and physical examination and assessed by coronary angiography. Nine patients were accepted for LVRS in combination with an intervention for coronary artery disease (CAD). In addition, three patients with valve disease and severe emphysema were accepted for valve replacement (two aortic-, one mitral valve) only in combination with LVRS. Functional results over the first 6 months were analysed. RESULTS: Pulmonary function testing demonstrates a significant improvement in postoperative FEV1 in pa!
tients who underwent LVRS combined with an intervention for CAD. This was reflected in reduction of overinflation (residual volume/total lung capacity (RV/TLC)), and improvement in the 12-min walking distance and dyspnea. Median hospital stay was 15 days (10-33). One patient in the CAD group died due to pulmonary edema on day 2 postoperatively. One of the three patients who underwent valve replacement and LVRS died on day 14 postoperatively following intestinal infarction. Both survivors improved in pulmonary function, dyspnea score and exercise capacity. Complications in all 12 patients included pneumothorax (n = 2), hematothorax (n = 1) and urosepsis (n = 1). CONCLUSION: Functional improvement after LVRS in patients with CAD is equal to patients without CAD. Mortality in patients who underwent LVRS after PTCA or CABG was comparable to patients without CAD. LVRS enables valve replacement in selected patients with severe emphysema otherwise inoperable.

Title:Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia
Authors:Karagoz,H.Y.; Sonmez,B.; Bakkaloglu,B.
Journal : Annals of Thoracic Surgery 70: 91-6, 2000
BACKGROUND: Over the past several years, considerable experience has accumulated in performing coronary anastomoses on the beating heart, and various aspects of minimally invasive approaches have been simplified. In an attempt to further simplify and decrease the “invasiveness” of this procedure, performing this operation without endotracheal general anesthesia was deemed feasible in certain subsets of patients. METHODS: Between October 1998 and June 1999, 5 patients underwent coronary artery bypass grafting without endotracheal general anesthesia, using high thoracic epidural block to construct extension grafts with a short segment of radial artery, between the in situ left or right internal thoracic arteries and the left anterior descending (n = 4) or right coronary arteries (n = 1). There were 2 female and 3 male patients, with a mean age of 67.4 +/- 8.3 years. RESULTS: The perioperative course of the patients was uneventful. There was no perioperative morbidity or mortality. No patient was converted to general anesthesia or to conventional operation. Control angiograms revealed patent anastomoses in all patients. In 1 patient, spasm of the radial artery graft was observed that was relieved 3 weeks later spontaneously. Mean length of hospital stay was 2.2 +/- 0.4 days. All patients were symptom free and returned to normal daily life at the first postoperative month. CONCLUSIONS: Our initial experience confirms the feasibility of performing coronary bypass grafting in the conscious patient without endotracheal general anesthesia

Title:Efficacy and tolerance of a new silicone stent for the treatment of benign tracheal stenosis: preliminary results
Authors:Vergnon,J.M.; Costes,F.; Polio,J.C.
Journal: Chest 118: 422-6, 2000
Abstract:In inoperable patients with tracheal stenosis who are treated using silicone stents, stent migration occurs in 18.6% of cases. To decrease the migration rate, a new silicone stent with narrow central and larger distal parts is desribed. This study analyzes the stability and tolerance of this new stent. DESIGN: Preliminary prospective study conducted in two French university hospitals. PATIENTS: Thirteen inoperable patients with benign complex tracheal stenosis due to intubation or tracheotomy. INTERVENTIONS: Tracheal stent insertion was performed under general anesthesia with a rigid bronchoscope. The patients were followed up clinically up to stent removal, which was planned at 18 months. RESULTS: Stent insertion or removal was very simple and did not differ from other silicone stents. No migration occurred after a mean follow-up of 22.8 months. Minimal granuloma formation occurred in only one patient (7.7%). Sputum retention remained similar to that with other silicone stents and could be improved by a smoother internal wall. Stents have been removed in seven patients after a mean duration of 19.6 months, with a complete stenosis cure in four cases. CONCLUSION: This new stent combines the stability of the metallic stents and the tolerance and easy removal of straight silicone stents. This allows a prolonged use in order to obtain curative action