Anesthesia For Thoracic Surgery Research Articles

Establishment and validation of a predictive nomogram for polyuria during general anesthesia in thoracic surgery

BackgroundTo develop and evaluate a predictive nomogram for polyuria during general anesthesia in thoracic surgery.MethodsA retrospective study was designed and performed. The whole dataset was used to develop the predictive nomogram and used a stepwise algorithm to screen variables. The stepwise algorithm was based on Akaike’s information criterion (AIC). Multivariable logistic regression analysis was used to develop the nomogram. The receiver operating characteristic (ROC) curve was used to evaluate the model’s discrimination ability. The Hosmer–Lemeshow (HL) test was performed to check if the model was well calibrated. Decision curve analysis (DCA) was performed to measure the nomogram’s clinical usefulness and net benefits. P < 0.05 was considered to indicate statistical significance.ResultsThe sample included 529 subjects who had undergone thoracic surgery. Fentanyl use, gender, the difference between mean arterial pressure at admission and before the operation, operation type, total amount of fluids and blood products transfused, blood loss, vasopressor, and cisatracurium use were identified as predictors and incorporated into the nomogram. The nomogram showed good discrimination ability on the receiver operating characteristic curve (0.6937) and is well calibrated using the Hosmer–Lemeshow test. Decision curve analysis demonstrated that the nomogram was clinically useful.ConclusionsIndividualized and precise prediction of intraoperative polyuria allows for better anesthesia management and early prevention optimization.

Evaluation of the Combined Effect of the Local Effect of Epidural Anesthesia with General Anesthesia in Thoracic Surgery

Evaluation of the Combined Effect of the Local Effect of Epidural Anesthesia with General Anesthesia in Thoracic Surgery

Intravenous infusion of lidocaine as a component of opioid-free anesthesia in thoracic surgery: prospective randomized single-center observational study

BACKGROUND: The possibility of reducing doses of narcotic analgesics during the perioperative period is widely discussed in modern scientific literature. This direction is called opioid-free anesthesia and is used in abdominal surgery, oncology, gynecology, and other areas. Publications on the use of opioid-free anesthesia in thoracic surgery are scarce.&#x0D; OBJECTIVE: To evaluate the analgesic effectiveness of intravenous lidocaine infusion as a component of anesthesia in thoracic surgery.&#x0D; MATERIALS AND METHODS: Ninety patients who underwent open lobectomy or pneumonectomy were examined. Depending on the analgesic component, patients were divided into three groups: group 1 (n=30) received intravenous infusion of lidocaine, group 2 (n=30) received epidural block, and group 3 (n=30) had fentanyl infusion. Blood pressure, heart rate, cortisol, and blood serum glycemia levels were measured. The intensity of postoperative pain syndrome and the need for promedol, tramadol, and sanitation fibrobronchoscopy were assessed. Arterial hypotension and frequency of postoperative nausea and vomiting were recorded. The length of stay of the patients in the intensive care unit and hospital was recorded.&#x0D; RESULTS: Cortisol levels did not differ between groups (p=0.26). The glucose level in the epidural block group was significantly lower than that in other groups (p=0.011). A significant increase in mean blood pressure and heart rate was observed in the opioid analgesia group (p 0.001). The lowest severity of pain 6 h after surgery was observed in the epidural blockade and lidocaine groups (p 0.001). Perioperative hypotension was more common in the epidural analgesia group (p=0.045). The incidence of postoperative nausea and vomiting was higher in the opioid anesthesia group (p=0.004). In the fentanyl infusion group, sanitary fibrobronchoscopy was more often required to eliminate atelectasis (p=0.039). The number of bed days spent in the ICU was significantly higher in the opioid analgesic group (p=0.002); however, no significant differences were noted between the groups regarding the number of days spent in the hospital (p=0.228).&#x0D; CONCLUSION: Opioid-free anesthesia based on intravenous lidocaine infusion, as a component of anesthetic management in thoracic surgery, provides sufficient perioperative stability of hemodynamic and neuroendocrine status, has a pronounced analgesic effect, with less opioid consumption on the first day after surgery, and helps reduce the length of stay in the intensive care unit and hospital.

Oxygen-sensing pathways and the pulmonary circulation.

The unique property of the pulmonary circulation to constrict in response to hypoxia, rather than dilate, brings advantages in both health and disease. Hypoxic pulmonary vasoconstriction (HPV) acts to optimise ventilation-perfusion matching - this is important clinically both in focal disease (such as pneumonia) and in one-lung ventilation during anaesthesia for thoracic surgery. However, during global hypoxia such as that encountered at high altitude, generalised pulmonary vasoconstriction can lead to pulmonary hypertension. There is now a growing body of evidence that links the hypoxia-inducible factor (HIF) pathway and pulmonary vascular tone - in both acute and chronic settings. Genetic and pharmacological alterations to all key components of this pathway (VHL - von Hippel-Lindau ubiquitin E3 ligase; PHD2 - prolyl hydroxylase domain protein 2; HIF1 and HIF2) have clear effects on the pulmonary circulation, particularly in hypoxia. Furthermore, knowledge of the molecular biology of the prolyl hydroxylase enzymes has led to an extensive and ongoing body of research into the importance of iron in both HPV and pulmonary hypertension. This review will explore these relationships in more detail and discuss future avenues of research.

Cardiac protective properties of lidocaine as adjuvant component of general anesthesia in thoracic surgery for cancer

<h3></h3> Выполнение торакальных операций помимо технической сложности подобного типа вмешательств характеризуется высоким анестезиологическим риском, который определяется функциональными резервами больного и наличием сопутствующих онкологическому процессу заболеваний. Диагностика инфаркта миокарда в ранние сроки после операции затруднена ввиду использования системной анальгетической терапии и смазанности клинической картины данного состояния, поэтому все большее число международных профессиональных медицинских сообществ рекомендуют для оценки периоперационного сердечно-сосудистого риска, в том числе в некардиальной хирургии, использовать лабораторные маркеры усиления нагрузки на миокард с определением выброса соответствующих биологически активных веществ. <h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Проанализировать перспективы внутривенного введения лидокаина в качестве средства адъювантной кардиопротекции во время анестезии и операции у больных раком легкого с сопутствующей сердечно-сосудистой патологией, руководствуясь динамикой уровня N-терминального мозгового натрийуретического белка (NT-proBNP) и клинической картиной в раннем послеоперационном периоде. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> <i></i> В исследование включены 30 пациентов в возрасте от 55 до 79 лет с установленным диагнозом локализованного немелкоклеточного рака легкого, имевшие сердечно-сосудистую патологию, которым выполнена операция в объеме сегментэктомии либо лобэктомии. Случайным образом пациенты разделены на две группы: группу лидокаина (пациенты интраоперационно получали лидокаин внутривенно болюсно + через инфузомат) и группу контроля. Оценка NT-proBNP проведена до момента кожного разреза, а также в 1-е и на 3-и послеоперационные сутки. <h3>РЕЗУЛЬТАТЫ</h3> <i></i> Сравнительный анализ не показал различий в уровнях NT-proBNP исходно и в 1-е сутки после операции (<i>p</i>=0,065 и <i>p</i>=0,237 соответственно). Существенные, статистически значимые, различия уровней NT-proBNP получены на 3-и сутки послеоперационного периода. В группе контроля этот показатель примерно в 2,3 раза выше (<i>p</i>=0,004).<i></i> Вместе с тем выявлена прямая связь между уровнем NT-proBNP в 1-е сутки после операции и минимальным и максимальным значениями частоты сердечных сокращений интраоперационно (<i>p</i>=0,02). Клинически признаки ишемии миокарда не зафиксированы. У одного пациента группы контроля развился послеоперационный делирий. <h3>ЗАКЛЮЧЕНИЕ</h3> На основании результатов проведенного исследования можно рекомендовать внутривенное введение лидокаина в качестве адъювантного средства анестезии при торакальных операциях для кардиопротекции у онкологических пациентов с сердечно-сосудистой патологией. Однако требуются дальнейшие проспективные исследования с увеличением объема выборки больных и строгим соответствием критериям отбора пациентов.

Opioid Free Anesthesia in Thoracic Surgery: A Systematic Review and Meta Analysis.

Introduction: Recent studies showed that balanced opioid-free anesthesia is feasible and desirable in several surgical settings. However, in thoracic surgery, scientific evidence is still lacking. Thus, we conducted the first systematic review and meta-analysis of opioid-free anesthesia in this field. Methods: The primary outcome was the occurrence of any complication. Secondary outcomes were the length of hospital stay, recovery room length of stay, postoperative pain at 24 and 48 h, and morphine equivalent consumption at 48 h. Results: Out of 375 potentially relevant articles, 6 studies (1 randomized controlled trial and 5 observational cohort studies) counting a total of 904 patients were included. Opioid-free anesthesia compared to opioid-based anesthesia, was associated with a lower rate of any complication (74 of 175 [42%] vs. 200 of 294 [68%]; RR = 0.76; 95% CI, 0.65−0.89; p < 0.001; I2 = 0%), lower 48 h morphine equivalent consumption (MD −14.5 [−29.17/−0.22]; p = 0.05; I2 = 95%) and lower pain at 48 h (MD −1.95 [−3.6/0.3]; p = 0.02, I = 98%). Conclusions: Opioid-free anesthesia in thoracic surgery is associated with lower postoperative complications, and less opioid demand with better postoperative analgesia at 48 h compared to opioid-based anesthesia.

Postoperative Analgesia in Cases Not Indicated for Epidural Anesthesia in Thoracic Surgery：A Retrospective Study

呼吸器外科手術において硬膜外ブロックは術後鎮痛に優れているが，抗凝固薬内服症例の増加等により相対的禁忌症例が増えている．そのため，硬膜外ブロックに代わる方法としてマルチモーダル鎮痛が必要であり，当院では末梢神経ブロックやオピオイド全身投与，もしくはその併用が行われている．本研究では，当院で呼吸器外科手術を受けた硬膜外ブロック相対的禁忌症例の術後鎮痛法について，末梢神経ブロック単独群と静注フェンタニル併用群に分けて，術後の鎮痛効果と有害事象について比較検討した．併用群は単独群に比べ術後早期の鎮痛効果に優れていた．有害事象においては2群間で有意な差は見られなかった．

Clinical and Experimental Study on the Application of One-lung Ventilation Anesthesia in Thoracic Surgery

Clinical and Experimental Study on the Application of One-lung Ventilation Anesthesia in Thoracic Surgery

Spectral Entropy Monitoring Accelerates the Emergence from Sevoflurane Anesthesia in Thoracic Surgery: A Randomized Controlled Trial.

The clinical efficacy of spectral entropy monitoring in improving postoperative recovery remains unclear. This trial aimed to investigate the impact of M-Entropy (GE Healthcare, Helsinki, Finland) guidance on emergence from anesthesia and postoperative delirium in thoracic surgery. Adult patients undergoing video-assisted thoracoscopic surgery for lung resection at a medical center were randomly allocated into the M-Entropy guidance group (n = 39) and the control group (n = 37). In the M-Entropy guidance group, sevoflurane anesthesia was titrated to maintain response and state entropy values between 40 and 60 intraoperatively. In the control group, the dosing of sevoflurane was adjusted based on clinical judgment and vital signs. The primary outcome was time to spontaneous eye opening. M-Entropy guidance significantly reduced the time proportion of deep anesthesia (entropy value <40) during surgery, mean difference: −21.5% (95% confidence interval (CI): −32.7 to −10.3) for response entropy and −24.2% (−36.3 to −12.2) for state entropy. M-Entropy guidance significantly shortened time to spontaneous eye opening compared to clinical signs, mean difference: −154 s (95% CI: −259 to −49). In addition, patients of the M-Entropy group had a lower rate of emergence agitation (absolute risk reduction: 0.166, 95% CI: 0.005–0.328) and delirium (0.245, 0.093–0.396) at the postanesthesia care unit. M-Entropy-guided anesthesia hastened awakening and potentially prevented emergence agitation and delirium after thoracic surgery. These results may provide an implication for facilitating postoperative recovery and reducing the complications associated with delayed emergence and delirium.

Prediction of Left Double-Lumen Tube Size by Measurement of Cricoid Cartilage Transverse Diameter by Ultrasound and CT Multi-Planar Reconstruction

Background: Currently, there is no uniform standard for selecting the left double lumen tubes (LDLT). Advantages, such as safety and convenience of the ultrasonic technology, and measurement accuracy, make it more widely applied in the clinical anesthesia, and computed tomography (CT) multi-planar reconstruction (MPR) technology will certainly provide a more accurate measurement. For better application for thoracic surgery choice LDLT, relieving the injury to patients, and reducing the complications, this study will compare the two approaches.Methods: The first part, 120 cases of patients were selected according to the height and gender; recording the patient's optimum LDLT and measurement the transverse diameter of the cricoid cartilage (TD-C) by ultrasound and CT MPR, and then obtained the TD-C range measurement by ultrasound and CT MPR corresponding to different types of LDLT. The second part, total of 102 patients were divided into the ultrasound group and the CT MPR group. In the ultrasound group, TD-C was measured by ultrasound, the corresponding size for intubation was selected based on the conclusions derived from the first part. In the CT MPR group, TD-C was measured by CT MPR, the corresponding size of LDLT based on the conclusions derived from the first part.Results: In the first part, 120 patients were no significant difference in the basic characteristics (P > 0.05). The accuracy of selecting the LDLT by conventional experience, namely height and gender was 58.3%. Ultrasonic measurement TD-C range was as follows: 32 Fr <15.88, 35 Fr: 15.88–16.80, 37 Fr: 16.75–17.81, and 39 Fr > 17.80. CT MPR measurement TD-C range was as follows: 32 Fr <15.74, 35 Fr: 15.74–16.65, 37 Fr: 16.56–17.68, and 39 Fr > 17.65. In the second part, there was no significant difference in the basic characteristics between the two groups (P > 0.05). The accuracy of intubation in the ultrasound group was 90.2% and the corresponding in the CT MPR group was 94.1% (P > 0.05).Conclusions: The accuracy of selecting the LDLT based on TD-C is significantly higher than conventional experience; it can significantly reduce the post-operative complications and there was no statistical significance in the accuracy of LDLT selected for TD-C measurement by ultrasound vs. CT, and both of them could be safely used for the evaluation before intubation under anesthesia in thoracic surgery.

Anesthesia for thoracic surgery in infants and children.

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part\xa01: preadmission and preoperative care

IntroductionAnesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care.MethodsA multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria.ResultsRecommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery).ConclusionsThese recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Anesthesia in Thoracic Surgery: Changes of Paradigms

Anesthesia in Thoracic Surgery: Changes of Paradigms

Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care

IntroductionAnesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients.MethodsA multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria.ResultsRecommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis.ConclusionsThese recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

PROFESSOR’S S. A. SHALAEV 80TH ANNIVERSARY

Sergey Alekseevich Shalaev (born 1939) - surgeon, doctor of medical sciences (1984), professor (1986), honored doctor of the Russian Federation (1995), colonel of medical service (1980). Head of the department of thoracic (hospital) surgery from 1988 to 1994. Priority research in the field of surgery of lung cancer, purulent-destructive diseases of the lungs and pleura, injuries and injuries of the chest and chest cavity, resuscitation and anesthesia in thoracic surgery and pulmonology (1 figure, bibliography: 8 refs).

Opioid-free Anesthesia in Thoracic Surgery

Opioid-free Anesthesia in Thoracic Surgery

Principles and Practice of Anesthesia for Thoracic Surgery, 2nd ed

Principles and Practice of Anesthesia for Thoracic Surgery, 2nd ed

Orotracheal intubation guided with a vivasight single lumen tube in unanticipated difficult airway

Introduction The management of an unanticipated difficult airway is a challenge for any anesthesiologist. Over the years, devices have been developed to improve intubation in cases of difficulty. Methods We present the case of a patient with an unanticipated difficult airway, who was intubated during the first attempt thanks to the use of a VivaSight tube. The consent for the publication of this case was obtained by the patient. He is a 57-year-old man, who underwent a programmed left upper lobectomy. Predictors of airway assessment performed in preanesthesia classified the patient as low risk. The initial plan included the use of a VivaSight SL tube and a bronchial blocker for left lung collapse under direct vision during surgery. Results The patient underwent general anesthesia. After 2 minutes of induction and verify that the ventilation could be carried out without problem, a direct laryngoscopy was performed. A spheroidal tumor adhered to the epiglottis was visualized (figure 1), turning the patient into a Cormack-Lehane III grade. Because we had prepared a VivaSight single lumen endotracheal tube for intubation, we chose to perform intubation guided by the video of the camera integrated in the VivaSight tube. The intubation sequence can be seen in the images of figure 1. The result was an intubation of less than a minute in duration and without incidents during the first attempt. Discussion VivaSight is a special tracheal tube, which has a built-in direct vision camera. It is used mostly in anesthesia for thoracic surgery. There are 2 models: double lumen and single lumen. The single lumen can usually be used together with bronchial blockers without requiring a fiber optic bronchoscope. The main advantages described with the use of these devices are the visualization of the correct position of the tube and the visualization of the correct position of the bronchial blocker2. Other authors have shown that the use of the VivaSight tube decreases intubation time and number of attempts with respect to video laryngoscopy in emergencies3. In the case that we have described, the camera of the tube allowed us to perform an intubation in a case of unanticipated difficult airway. Therefore, we think that the VivaSight tube should be an option to consider in the cases of patients with anticipated or known difficult airway in thoracic surgery. However, it is necessary to develop prospective studies that provide more evidence.

Patient perspectives of ‘one stop shop’ preassessment

Introduction We decided to explore the patient perspective of our new ‘one stop shop’ cardiothoracic surgery pre-assessment service, in which the patient sees the surgeon, specialist nurse and anaesthetist in one hospital visit. The service aims to improve patient experience by reducing the number of preoperative hospital visits, and facilitate the move of all elective patients to day of surgery admission. Identification of anaesthetic concerns in advance of admission and discussion ofEnhanced Recovery following surgery were anticipated clinical advantages. As part of the service, we give a written leaflet (1) and introduced online information videos for patients to access at home following their ‘one stop shop’ preassessment. Methods In April 2019, a year following service implementation, we surveyed 30 post-operative inpatients by use of a bedside questionnaire. All patients had attended our pre-assessment clinic before their surgery. Results We visited 16 Cardiac and 14 Thoracic patients. 100% of patients felt they received enough information to feel adequately prepared for surgery. 88% (14/16) cardiac patients received the leaflet 'Anaesthesia for Heart Surgery'(1), with 86% (12/14) finding it useful. 30% (9/30) accessed our online videos. Feedback was positive. 24% (5/21) of non-viewers, were unaware of them, but of these, only one accessed other online information. The average time spent in hospital for the ‘one stop shop’ was 5 hours 22 minutes (median 5 hours IQR 2.25 hours). 97% (29/30) felt this was acceptable and did not wish to have separate visits to the hospital. Patients found it helpful to have their partner with them, and found it ‘overall a good experience’. Staff were rated as friendly, supportive and reassuring. Suggested areas to improve upon included: appointment duration with surgeon, diagrammatic explanation of their surgery and the timing of anaesthetic appointments. Discussion Patients appear to rate our 'one stop shop' highly, and favour the reduction in number of hospital visits despite the long day. We need to highlight the availability of our online videos, signposting patients towards them during their visit to the “one stop shop” more clearly. Production of a written patient information leaflet on anaesthesia for thoracic surgery is needed.

Airway management in anesthesia for thoracic surgery: a "real life" observational study.

One-lung ventilation (OLV) in thoracic anesthesia is required to provide good surgical exposure. OLV is commonly achieved through a double lumen tube (DLT) or a bronchial blocker (BB). Malposition is a relevant issue related to these devices use. No prospective studies with adequately large sample size have been performed to evaluate the malposition rate of DLTs and BBs. A total of 2,127 patients requiring OLV during thoracic surgery were enrolled. The aim of this multicenter prospective observational study performed across 26 academic and community hospitals is to evaluate intraoperative malposition rate of DLTs and BBs. We also aim to assess: which device is the most used to achieve OLV, the frequency of bronchoscope (BRO) use, the incidence rate of desaturation during OLV and the role of other factors that can correlate to this event, and incidence of difficult airway. Malposition rate for DLTs was 14%, for BBs 33%. DLTs were used in 95% of patients and BBs in 5%. Mean positioning time was shorter for DLT than BB (156±230 vs. 321±290 s). BRO was used in 54% of patients to check the correct positioning of the DLT. Desaturation occurred in 20% of all cases during OLV achieved through a DLT. Predicting factors of desaturation were dislocation (OR 2.03) and big size of DLT (OR 1.15). BRO use (OR 0.69) and left surgical side (OR 0.41) proved to be protective factors. Difficult airway prevalence was 16%; 10.8% predicted and 5.2% unpredicted. DLT has a low malpositioning rate and is the preferred device to achieve OLV. BRO use recorded was unexpectedly low. The possibility of encountering a difficult airway is frequent, with an overall prevalence of 16%. Risk factors of desaturation are malposition and increased size of DLT. Left procedures and BRO use could lead to fewer episodes of desaturation.