Author
Ciriaco P. Mazzone P. Canneto B. Zannini P
Institution
Division of Thoracic Surgery, University of Milan, Scientific Institute H.S. Raffaele, Via Olgettina 60, 20132, Milan, Italy
Title
Supraventricular arrhythmia following lung resection for non-small cell lung cancer and its treatment with amiodarone.
Source
European Journal of Cardio-Thoracic Surgery, 18(1):12-16, 2000 July 1.
Abstract
Objective: From January 1998 to February 1999, 160 patients undergoing lung resection for non-small cell lung cancer were studied to define factors that increase the risk of postoperative supraventricular arrhythmia (SA) and to assess the effectiveness of amiodarone as an antiarrhythmic drug. Methods: All patients were monitored intraoperatively and postoperatively up to day 3. Onset of SA was documented with ECG. Amiodarone was administered to those who developed SA with a loading dose of 5 mg/kg in 30 min and a maintenance dose of 15 mg/kg in 24 h. Results: Mean age was 64 years (range 27-83 years). There were nine wedge resections, six segmentectomies, 127 lobectomies and 18 pneumonectomies. Twenty-two patients (13%) had SA, all of which were atrial fibrillations. The incidence of supraventricular arrhythmia with pneumonectomy and lobectomy was 33 and 12%, respectively (P=0.02). None of the patients who had a minor resection developed SA. The peak incidence of onset of SA!
occurred on postoperative day 2 and lasted from 1 to 12 days (average 3.4 days). Sinus rhythm was achieved with amiodarone in 20 patients (90.9%) with no side effects. Two patients received electrical cardioversion because hemodynamically unstable. Mean preoperative pO(2) and pCO(2) were lower in patients with SA: pO(2) 80.8 vs. 85 mmHg (P=0.04); pCO(2) 35.5 vs. 38 mmHg (P=0.01). Patients with concomitant cardiopulmonary diseases presented an odds ratio for postoperative arrhythmia of 12.4 (confidence interval 4.5-34.1) (P<0.0001). Conclusion: Concomitant cardiopulmonary diseases, lower pO(2), pCO(2) and extent of surgery increase the risk of postoperative SA after lung resection for non-small cell lung cancer. Cardiac monitoring in patients at risk is recommended. Amiodarone was both safe and effective in establishing and maintaining sinus rhythm.

Authors
Dyszkiewicz W. Pawlak K. Gasiorowski L.
Institution
Department of Thoracic Surgery, K. Marcinkowski University of Medical Sciences, Ul. Szamarzewskiego 62, Poznan, Poland.
Title
Early post-pneumonectomy complications in the elderly.
Source
European Journal of Cardio-Thoracic Surgery. 17(3):246-50, 2000 Mar.
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Abstract
OBJECTIVE: The surgical treatment of non-small cell lung cancer (NSCLC) in elderly patients presents a serious challenge to thoracic surgeons. As there is considerable divergence of opinion about both the mortality and morbidity rates, it is important to set guidelines for proper patient selection. METHODS: Early post-operative complications in 42 patients aged over 70 years who had undergone pneumonectomy because of NSCLC (Group I) were analyzed. The control group (Group II) consisted of 48 patients, also aged over 70 years, but who had undergone lobectomy or wedge resections. In both groups, the pre-operative conditions and 30-day morbidity and mortality were evaluated. RESULTS: Postoperative complications occurred significantly more frequently in pneumonectomy patients (78.5%) than in Group II (58%). Transient or long-standing arrhythmias were noted in 20 patients (47.6%) from Group I and in 17 (35.4%) from Group II. Pulmonary complications occurred in 17 patients (40.4%)!
from Group I and 16 (33.3%) from Group II. The most important factors contributing to post-operative complications in pneumonectomy patients were performance status (WHO), chronic obstructive pulmonary disease (COPD) and elevated level of blood urea nitrogen (BUN). The highest impact on early mortality in pneumonectomy patients was exerted by COPD, arterial hypertension, formation of broncho-pleural fistula (BPF), the need for re-thoracotomy and high level of BUN. CONCLUSIONS: (1) Pneumonectomy in patients over the age of 70 carries a considerable risk of severe post-operative complications and death, when compared to patients with less extensive pulmonary resections. (2) Elderly patients with impaired Performance Status (WHO 2 or more) and co-existing arterial hypertension, COPD and elevated level of BUN should be considered for pneumonectomy very carefully and cautiously.

Author
Leonard IE. Myles PS
Institution
Department of Anaesthesia and Pain Management, Alfred Hospital, Melbourne, Victoria.
Title
Target-controlled intravenous anaesthesia with bispectral index monitoring for thoracotomy in a patient with severely impaired left ventricular function.
Source
Anaesthesia & Intensive Care, 28(3):318-321, 2000 June.
Abstract
The anaesthetic management of an elderly patient with severely impaired left ventricular function undergoing thoracotomy and lobectomy is described. Total intravenous anaesthesia (TIVA) with remifentanil and target-controlled infusion of propofol titrated according to the bispectral index (BIS) was used, with thoracic epidural anaesthesia commenced at the end of surgery providing postoperative analgesia. Avoidance of intraoperative epidural local anaesthetics and careful titration and dose reduction of propofol using the BIS was associated with excellent haemodynamic stability. The rapid offset of action of remifentanil and low-dose propofol facilitated early recovery and tracheal extubation. The BIS was a valuable monitor in optimal titration of TIVA.

Title:Reexpansion pulmonary edema after VATS successfully treated with continuous positive airway pressure
Authors:Iqbal,M.; Multz,A.S.; Rossoff,L.J.; Lackner,R.P.
Journal: Annals of Thoracic Surgery 70:669-71, 2000
Abstract:Reexpansion pulmonary edema is a well-described complication of treatment for pleural effusion and pneumothorax. It is very rarely described in association with anesthesia and video-assisted thoracoscopic surgery. The etiology is unclear but several mechanisms have been proposed.A case of reexpansion pulmonary edema after video-assisted thoracoscopic surgery treated successfully with continuous positive airway pressure is described

Title: Variability of a Thoracic Paraveretbral Block: Are we ignoring the Endothoracic Fascia?
Authors: Karmakar MK,Chung DC
Journal:Reg Anesth Pain Med 25: 325-7,2000

Letter. The variability which is reported in the spread of local anesthetics in the paravertebral space may depend on whether the injection is superficial or deep to the endothoracic fascia which divides the paravertebral space into two compartments.Due to attachments of this fascia to ribs and the vertebral bodies, injection into the subendothoracic compartment would be expected to spread more easily to other dermatomes and contralaterally. The thinness of this fascia ( 250 um) would make it difficult to identify during either open or percutaneous paravertebral block.

uthors
Richardson J. Sabanathan S. Jones J. Shah RD. Cheema S. Mearns AJ.
Institution
Department of Anaesthetics, Bradford Royal Infirmary, UK.
Title
A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.
Source
British Journal of Anaesthesia. 83(3):387-92, 1999 Sep.
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Abstract
Both epidural and paravertebral blocks are effective in controlling post-thoracotomy pain, but comparison of preoperative and balanced techniques, measuring pulmonary function and stress responses, has not been undertaken previously. We studied 100 adult patients, premedicated with morphine and diclofenac, allocated randomly to receive thoracic epidural bupivacaine or thoracic paravertebral bupivacaine as preoperative bolus doses followed by continuous infusions. All patients also received diclofenac and patient-controlled morphine. Significantly lower visual analogue pain scores at rest and on coughing were found in the paravertebral group and patient-controlled morphine requirements were less. Pulmonary function was significantly better preserved in the paravertebral group who had higher oxygen saturations and less postoperative respiratory morbidity. There was a significant increase in plasma concentrations of cortisol from baseline in both the epidural and paravertebral !
groups and in plasma glucose concentrations in the epidural group, but no significant change from baseline in plasma glucose in the paravertebral group. Areas under the plasma concentration vs time curves for cortisol and glucose were significantly lower in the paravertebral groups. Side effects, especially nausea, vomiting and hypotension, were troublesome only in the epidural group. We conclude that with these regimens, paravertebral block was superior to epidural bupivacaine.

Authors
Bimston DN. McGee JP. Liptay MJ. Fry WA.
Institution
Department of Surgery, Evanston Hospital, Ill, USA.
Title
Continuous paravertebral extrapleural infusion for post-thoracotomy pain management.
Source
Surgery. 126(4):650-6; discussion 656-7, 1999 Oct.
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Abstract
BACKGROUND: Continuous thoracic epidural analgesia is considered by many the gold standard for post-thoracotomy pain control but is associated with its own complications. In this study we compare continuous paravertebral extrapleural to epidural infusion for post-thoracotomy pain control. METHODS: In a prospective fashion, 50 patients were randomized to receive either paravertebral or epidural infusion for post-thoracotomy pain control. The anesthesia department placed epidurals, and the operative surgeon placed unilateral paravertebral catheters. Patients were evaluated for analgesic efficacy and postoperative complications. RESULTS: We found that both methods of analgesia provide adequate postoperative pain control. Epidural infusion demonstrated an improved efficacy early in the postoperative course but provided statistically similar analgesia to paravertebral by postoperative day 2. Neither group demonstrated a greater number of pain-related complications. Narcotic-induc!
ed complications such as pruritus, nausea/vomiting, and postural hypotension/mental status changes/respiratory depression were seen with statistically similar frequency in both epidural and paravertebral arms. Urinary retention, however, was noted to be significantly more frequent in patients with epidural catheters. Drug toxicity was not observed with either epidural or paravertebral infusion. CONCLUSIONS: We recommend continuous paravertebral infusion as an improved method of post-thoracotomy analgesia that can be placed and managed by the surgeon.

Author
Karagoz HY. Sonmez B. Bakkaloglu B. Kurtoglu M. Erdinc M. Turkeli A. Bayazit K
Institution
Department of Cardiovascular Surgery, Guven Hospital, Ankara, Turkey. karagoz@tr-net.net.tr
Title
Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia.
Source
Annals of Thoracic Surgery, 70(1)1-96, 2000 July.
Abstract
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. Continue Reading »

The majority of studies of Nitric Oxide (NO) during one-lung ventilation over the past five years have shown that NO does not cause a significant increase in the mean PaO2. One recent study(1) shows that among patients with hypoxemia (defined here as PaO2/FiO2 <100) there was an increase in mean arterial oxygenation with NO 40ppm. Examining the data shows that a small minority of hypoxemic patients (approximately 25%)will have a clinically useful increase in PaO2 with NO. Examining the data of previous studies(2) it can be seen in other studies that a few patients with borderline hypoxemia will have an increase in PaO2 with NO. Although this does not make NO a useful therapy for hypoxemia during one-lung ventilation it does raise the possibility that it may be possible to identify the minority of patients who respond to NO. Continue Reading »

A previous study suggested that PaO2 during one-lung ventilation (OLV) was decreased when thoracic epidural anesthesia (TEA) was used in combination with general anesthesia compared to general anesthesia alone(1). A recent study suggests that TEA increases PaO2 during OLV(2). The most likely explanation for these opposite conclusions is that TEA has little direct effect on shunt and PaO2 during OLV. The differences are more likely related to changes in cardiac output and PvO2 related to differing anesthetic managment in the two studies. Continue Reading »

There has been a concern that thoracic epidural analgesia with local anesthetics could decrease lung mechanical function due to effects on the chest wall. A recent study shows that analgesic doses of local anesthetics in thoracic epidurals do not cause a reduction of lung mechanics in a group of patients with severe COPD. Continue Reading »