Cardiopulmonary Reserve Research Articles

Anesthetic Considerations for Transcarotid Artery Revascularization: Experience and Review of Forty Cases From a Single Medical Center.

Transcarotid artery revascularization (TCAR) procedure is a novel hybrid surgical modality in treating carotid stenosis. Understanding the various steps of the TCAR and the unique challenges involved in the anesthetic management is essential for the successful conduct of anesthesia. In this article, we discuss the overview of the key issues relevant to the anesthetic management and strategies from our experience. We present the data on anesthetic management and outcomes of 40 patients who underwent TCAR procedure at our institute between June 2018 and February 2020. Electronic medical records were retrospectively reviewed and relevant demographic, clinical, and laboratory data were collected. All our patients had general anesthesia with an endotracheal tube utilizing standard American Society of Anesthesiology (ASA) monitoring along with intra-arterial blood pressure monitoring and cerebral oximetry.The mean age of our patients was 73.6 ± 7.58 years. Fifteen (37.5 %) patients had significant co-morbidities, thus classified as ASA 4 and 10 (25%) patients were on at least three antihypertensives (beta-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, loop diuretics, thiazides). Thirty-four (85%) patients were considered to have symptomatic carotid stenosis which was the predominant indication for the TCAR procedure. Patients who had episodes of transient ischemic attack (TIA) or a cerebrovascular accident (CVA) documented by a computerized tomography (CT) scan of the brain and/or residual weakness are considered symptomatic. Thirty-six (90%) of our patients received a bolus dose of 0.2 - 0.4 mg of glycopyrrolate for maintaining heart rate of around 70 beats per minute (BPM) and 38 (95%) received phenylephrine infusion during the carotid clamp to maintain blood pressure between 140 and 160 mm Hg systolic or at patients’ baseline. Twenty-one (52.5%) patients needed antihypertensives such as hydralazine ( 10-20 mg) or beta-blockers such as labetalol (10-20 mg) at the time of emergence from anesthesia to mitigate hemodynamic response during extubation. The mean blood loss was 74 ml ± 33.19 ml, and none of our patients received blood transfusion during the perioperative period. The mean duration of anesthesia was 202.6 ± 27.85 minutes, and the mean length of hospital stay was 1.5 ± 0.97 days.A thorough preoperative examination with specific attention to the preoperative neurological deficits and cardiopulmonary reserve is important for the meticulous management of intraoperative hemodynamics. Intraoperative administration of glycopyrrolate and the use of vasopressors to maintain optimal hemodynamics to ensure cerebral perfusion during the perioperative period should be considered. The anesthetic goals of carotid revascularization (TCAR) are perioperative hemodynamic stability and early evaluation of neurological status in the immediate postoperative period.

Congestive Heart Failure Predicts Major Complications and Increased Length of Stay in Lower Extremity Pedicled Flap Reconstruction.

Congestive heart failure affects 6.2 million people in the United States. Patients have a decreased cardiopulmonary reserve and often suffer from peripheral edema, important considerations in lower extremity reconstructive surgery. In this study, the authors sought to determine the impact of congestive heart failure on postoperative outcomes following lower extremity pedicled flap reconstruction using a national multi-institutional database. The authors isolated all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent lower extremity pedicled flap reconstruction from 2010 to 2016. Preoperative, intraoperative, and postoperative variables were compared between patients with and without congestive heart failure. Multivariable regressions were performed to determine the independent effect of congestive heart failure on postoperative outcomes. The authors identified 1895 patients who underwent lower extremity pedicled flap reconstruction, of whom 34 suffered from congestive heart failure. No significant difference was observed between patients with versus without congestive heart failure in postoperative wound complications (superficial wound infection, deep wound infection, and wound dehiscence), renal failure, or readmission. On multivariable analysis, congestive heart failure was independently associated with increased cardiopulmonary complications (i.e., myocardial infarction, cardiac arrest, pneumonia, reintubation, and failed ventilator weaning) (OR, 3.92; 95 percent CI, 1.53 to 9.12), septic events (OR, 4.65; 95 percent CI, 2.05 to 10.02), and length of hospital stay (β, 0.37; 95 percent CI, 0.01 to 0.72). In patients undergoing lower extremity pedicled flap reconstruction, congestive heart failure independently predicts a four-fold increase in postoperative sepsis and cardiopulmonary complications and a significantly increased length of hospital stay. The authors' findings highlight the need for heightened perioperative vigilance and medical optimization in this high-risk population. Risk, II.

Exercise cardiac MRI unmasks cardiac dysfunction in childhood and adolescent cancer survivors with reduced cardiopulmonary fitness

Abstract Background Young cancer survivors are at increased risk of impaired cardiopulmonary fitness (VO2peak) and heart failure. Assessment of exercise cardiac reserve may reveal sub-clinical abnormalities that better explain impairments in fitness and long term heart failure risk. Purpose To investigate the presence of impaired VO2peak in pediatric cancer survivors with increased risk of heart failure, and to assess its relationship with resting cardiac function and cardiac reserve Methods Twenty pediatric cancer survivors (aged 8–24 years) treated with anthracycline chemotherapy underwent cardiopulmonary exercise testing to quantify VO2peak, with a value <85% of predicted defined as impaired VO2peak. Resting cardiac function was assessed using 3-dimensional echocardiography, with cardiac reserve quantified from resting and peak exercise heart rate (HR), stroke volume index (SVi) and cardiac index (CI) using exercise cardiac magnetic resonance imaging. Results 12 of 20 survivors (60%) had impaired VO2peak (97±14% vs. 70±16% of age and gender predicted). There were no differences in echocardiographic or CMR measurements of resting cardiac function between survivors with normal or impaired VO2peak. However, those with reduced VO2peak had diminished cardiac reserve, with a lesser increase in CI (Fig. 1A) and SVi (Fig. 1B) during exercise (Interaction P=0.001 for both), whilst the HR response was similar (Fig. 1C; P=0.71). Conclusions Resting measures of cardiac function are insensitive to significant cardiac dysfunction amongst pediatric cancer survivors with reduced VO2peak. Measures of cardiopulmonary fitness and cardiac reserve may aid in early identification of survivors with heightened risk of long-term heart failure. Figure 1 Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): National Heart Foundation

The role of robotic segmentectomy for non-small cell lung cancer

Segmentectomy may be applied to all segments; superior segmentectomies (lower lobe superior segments for both lungs), lingulectomies (two segments forming lingulas of upper left lobe) and basal segmentectomies (segments other than superior segment for both lungs). In lung segment resections; segmentectomy has an equivalent morbidity, recurrence and survival rate compared to lobectomy, in patients with stage I lung cancer, tumors smaller than 2 cm and within the segmental anatomical limits. Segmentectomy also contributes more to preserving lung function and exercise capacity than lobectomy. In tumor resection; especially in patients with advanced age, insufficient performance or insufficient cardiopulmonary reserve, 2 cm in diameter and acceptable segmental margins may be provided. Limited long-term results show oncological results of robotic approach similar to open and VATS approaches. Robotic approach facilitates surgery with more intuitive movements, greater flexibility and high definition, three-dimensional vision. However, high cost and lack of touch sense are main disadvantages of robotic surgery. New studies are needed to assess quality of life, morbidity, oncological results and cost effectiveness. However, considering development of technology in our age and fact that many surgical robot brands will be released in the near future, it is predicted that disadvantages of robotic surgery will be minimized in the near future. This article reviews experience of segmentectomy in non-small cell lung cancer and discusses benefits and limitations of robotic segmentectomy.

Standard and extended sleeve resections of the tracheobronchial tree.

Anatomic resections with bronchial and/or vascular resections and reconstruction, so called sleeve resections were originally performed in patients with impaired cardio-pulmonary reserves. Nowadays, sleeve resections are established surgical procedures of first choice for tracheobronchial pathologies, whenever anatomically and oncologically feasible. Experienced thoracic surgeons have a broad surgical armentarium to avoid a pneumonectomy and the morbidity and mortality associated with it. Sleeve resections are associated with better outcomes in all aspects. Thus, sleeve resection is not an alternative for pneumonectomy and vice versa. In this review article we set out to provide a contemporary overview on this topic.

Two chair test: a substitute of 6 min walk test appear cardiopulmonary reserve specific

BackgroundA simple and efficient exercise test possible in a small space is welcome to supplement 6 min walk test (6MWT) that demands a 100 feet corridor to perform.MethodsThe proposed two...

Ventilatory support during whole-body row training improves oxygen uptake efficiency in patients with high-level spinal cord injury: A pilot study

High-level spinal cord injury (SCI) is characterized by profound respiratory compromise. One consequence is a limitation of whole-body exercise-based rehabilitation, reducing its cardioprotective effect. We investigated the use of ventilatory support during training on cardiorespiratory response to exercise.Nine subjects with high-level SCI (T3-C4) were included in this double-blind sham-controlled study. All had training adaptations plateauing for more than 6 months before enrolling in the study. After performing baseline assessment, participants were randomly assigned to continue training with non-invasive ventilation (NIV: n = 6: IPAP = 20 ± 2, EPAP: 3 cmH2O) or sham (n = 3: IPAP = 5, EPAP: 3 cmH2O) for 3 months and performed again maximal exercise tests. We compared the oxygen uptake efficiency slope (OUES, the rate of increases in VO2 in relation to increasing VE) before and after training.Training with NIV increased OUES both compared to baseline (4.1 ± 1.1 vs. 3.4 ± 1.0, i.e. +20 ± 12%, p < 0.05) and Sham (p = 0.01), representing an increase in ability to uptake oxygen for a given ventilation. This result was sustained without NIV during the test, suggesting improved cardiopulmonary reserve. Best responders were the youngest whose characteristics were very similar to sham participants. In addition, NIV tended to increase weekly rowing distance by 24% (p = 0.09, versus 10% in sham).Our results are very suggestive of a positive effect of ventilatory support during whole-body exercise in high-level SCI. Training adaptations found are of great importance since this sub-population of patients have the greatest need for exercise-based cardio-protection.

Prehabilitation With High Intensity Inverval Training Before Major Abdominal Surgery

PURPOSE: Improving cardiopulmonary reserve, or peak oxygen consumption (VO2peak) measured during cardiopulmonary exercise testing (CPET), may reduce complications after surgery. This feasibility study determined the effectiveness of a supervised, preoperative High Intensity Interval Training (HIIT) program in increasing VO2peak by 2ml/kg/min. Clinical outcomes were documented to determine the endpoint most sensitive to improved fitness. METHODS: In this prospective study, participants aged 50-85 undergoing major abdominal surgery were randomised to standard care or 14 sessions of HIIT over 4-6 weeks. HIIT sessions involved approximately thirty minutes of stationary cycling (5 warm-up, 20 interval training, 5 cool-down). Interval training alternated 1 minute of high and low intensity pedalling, with the goal of reaching 90% maximum heart rate during the session. Clinical outcomes included complications, postoperative morbidity survey, length of stay, and Short Form-36 quality of life questionnaire (SF-36). RESULTS: Of 63 participants, 46 completed both CPETs and 51 completed clinical follow-up. On per protocol analysis, mean VO2peak increased 14%, from 20.3-23.2ml/kg/min in the exercise group and 0.7%, from 21.8-22.0 ml/kg/min in the control group. Change in VO2peak was 2.87 vs. 0.14 ml/kg/min (p<.001). Exercisers increased peak work rate by 25 watts. Although there were no significant differences in the clinical outcomes, those most responsive to improved fitness with exercise were: the total number of postoperative complications (0.64 in exercisers vs. 1.16 in controls per patient, p=.07) and the physical component score of the SF-36 (p=.07), with the greatest difference six weeks after surgery indicating a quicker postoperative recovery. CONCLUSION: There was a significant improvement in VO2peak and peak work rate with preoperative HIIT. We also noted a trend towards fewer postoperative complications and a more rapid recovery after surgery. Preoperative HIIT results in a clinically important improvement in cardiopulmonary reserve for patients undergoing abdominal surgery.

Proposed Modifications in the 6-Minute Walk Test for Potential Application in Patients With Mild COVID-19: A Step to Optimize Triage Guidelines.

Proposed Modifications in the 6-Minute Walk Test for Potential Application in Patients With Mild COVID-19: A Step to Optimize Triage Guidelines.

Prehabilitation Telemedicine in Neoadjuvant Surgical Oncology Patients During the Novel COVID-19 Coronavirus Pandemic

Prehabilitation Telemedicine in Neoadjuvant Surgical Oncology Patients During the Novel COVID-19 Coronavirus Pandemic

A feasibility study to investigate the utility of a home-based exercise intervention during and after neo-adjuvant chemotherapy for oesophago-gastric cancer\u2014the ChemoFit study protocol

BackgroundTreatment of locally advanced oesophago-gastric adenocarcinoma usually entails neo-adjuvant chemotherapy (NAC) and surgery. Surgery is associated with high morbidity and mortality. Cardiopulmonary reserve of patients having major surgery is related to postoperative outcomes. Complications are associated with poorer quality of life and may affect prognosis. Preventing complications may be beneficial to both of these and have cost implications. Prehabilitation may improve recovery from surgery by increasing a patients’ fitness before surgery. Designing a potentially cost and resource effective regimen which improves cardiopulmonary reserve may have a beneficial impact on patient outcomes after surgery.MethodsThe ChemoFit study is a non-randomised, single-arm and single-centre pilot study designed to investigate the feasibility of a home-based prehabilitation exercise intervention for patients receiving neoadjuvant treatment prior to oesophago-gastric surgery. Forty patients will be recruited at a single high-volume centre. The simple, home-based exercise intervention involves patients increasing their daily step-count during and after NAC and in the weeks leading up to surgical resection of the cancer. Additionally, quality of life assessments (QLQ-C30 and QLQ-OG25), oncological treatment delivery and participant perceptions of the study assessed by focus groups and questionnaires will be performed. The primary outcomes are to assess feasibility of the exercise intervention. The secondary outcomes will evaluate changes in cardiopulmonary reserve, sarcopenia and fat composition.DiscussionIt is anticipated that during an important teachable moment, the diagnosis and treatment of cancer, our patients will be open to the possibility of improving their fitness during chemotherapy and before major cancer surgery. It is possible that the negative impact of NAC on cardiopulmonary fitness could be prevented by implementing a home-based prehabilitation programme during and after NAC, prior to surgery for oesophago-gastric adenocarcinoma.Trial registrationThis study has been approved by the Health Research Authority (REC 18/WA/0427). Newcastle upon Tyne Hospitals NHS Foundation Trust (NUTH) will act as the study sponsor and the work is funded by a grant awarded by The Jon Moulton Charitable Foundation, supported by a research post funded by the Sir Bobby Robson Foundation. Trial registration: Clinicaltrials.gov, NCT04194463. Registered 11th December 2019—retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04194463.

Rehabilitation of Individuals with Limb Loss due to Trauma

To provide a comprehensive overview of care and rehabilitation of those with traumatic limb loss, from preoperative to lifelong care. Comprehensive care including peer support and monitoring for the development of secondary conditions which compound disability is essential after traumatic amputation. Conditions that commonly develop after traumatic limb loss include heterotopic ossification, intact limb knee osteoarthritis, low back pain, and reduction in cardiopulmonary reserve. Optimal care for people after traumatic limb loss requires a multidisciplinary team to provide perioperative and lifelong care. In addition to ensuring optimal rehabilitation based on the individual’s vocational and avocational goals, current function, concomitant injuries, and amputation level, their psychological recovery must not be overlooked. To optimize quality of life and independence, lifelong follow-up with a physiatrist is essential to care for complications and secondary conditions, as well as to promote an active lifestyle.

Is lung stereotactic ablative radiotherapy safe after pneumonectomy?-a systematic review.

Patients treated with surgery for lung cancer are at risk of second primary lung cancers (SPLCs), which when localized, may be amenable to radical treatment. Treatment options, however, are limited due to reduced cardiopulmonary reserve and competing mortality risks. The aim of this study was to perform a systematic review of publications examining treatment planning considerations, clinical outcomes, and toxicity rates of stereotactic ablative radiotherapy (SABR) in patients who have previously undergone pneumonectomy. A systematic review of the literature was conducted in accordance with PRISMA guidelines using PubMed and EMBASE from inception to July 2018. Articles were limited to those published in the English language. Non-review articles with patients who received exclusively lung SABR post-pneumonectomy were included. Two reviewers independently performed abstract and full-text review, with discrepancies settled by a third reviewer. Of the 215 articles identified by the initial search, 6 articles comprising 53 patients who received lung SABR post-pneumonectomy met inclusion criteria. The mean age was 68, and most patients were male (73.7%). The mean time to pneumonectomy was 6.5 years. The mean biologically effective dose was 115 Gy, and the most common dose fractionation schemes were 54 Gy in 3 fractions, 48 Gy in 4 fractions, and 50 Gy in 5 fractions. The mean follow-up was 25.4 months. The mean 1-year overall survival and 2-year local control rates were 80.6% and 89.4%. Grade 3 or higher toxicity was reported in 13.2% of patients. SABR appears to be a safe and feasible option for SPLCs in patients with prior pneumonectomy. Multi-institutional and/or prospective studies would be helpful to determine the true risk and appropriateness of SABR in this high-risk patient population.

Perioperative management in thoracic surgery

Thoracic surgery has undergone significant advances in recent years related to anesthetic and surgical techniques and the prevention and management of complications related to the procedure. This has allowed improvements in patient clinical outcomes in surgeries of this kind. Despite the above, thoracic surgery, especially related to pulmonary resection, is not without risk, and is associated to considerable morbidity and mortality. Fast track or enhanced recovery after anesthesia protocols, minimally invasive surgery, and intraoperative anesthetic management improve the prognosis and safety of thoracic surgery. Patients in the postoperative period of major thoracic surgery require intensive surveillance, especially the first 24–72h after surgery. Admission to the ICU is especially recommended in those patients with comorbidities, a reduced cardiopulmonary reserve, extensive lung resections, and those requiring support due to life-threatening organ failure. During the postoperative period, intensive cardiorespiratory monitoring, proper management of thoracic drainage, aggressive pain control (multimodal analgesia and regional anesthetic techniques), nausea and multimodal rehabilitation are key elements for avoiding adverse events. Medical complications include respiratory failure, arrhythmias, respiratory infections, atelectasis and thromboembolic lung disease. The most frequent surgical complications are hemothorax, chylothorax, bronchopleural fistula and prolonged air leakage. The multidisciplinary management of these patients throughout the perioperative period is essential in order to ensure the best surgical outcomes.

Anticoagulant treatment for subsegmental pulmonary embolism.

Acute pulmonary embolism (PE) is a common cause of death, accounting for 50,000 to 200,000 deaths annually. It is the third most common cause of mortality among the cardiovascular diseases, after coronary artery disease and stroke. The advent of multi-detector computed tomographic pulmonary angiography (CTPA) has allowed better assessment of PE regarding visualisation of the peripheral pulmonary arteries, increasing its rate of diagnosis. More cases of peripheral PEs, such as isolated subsegmental PE (SSPE) and incidental PE, have thereby been identified. These two conditions are usually found in patients with few or none of the classic PE symptoms such as haemoptysis or pleuritic pain, acute dyspnoea or circulatory collapse. However, in patients with reduced cardiopulmonary reserve, classic PE symptoms can be found with isolated SSPEs. Incidental SSPE is found casually in asymptomatic patients, usually by diagnostic imaging performed for other reasons (for example routine CT for cancer staging in oncology patients). Traditionally, all PEs are anticoagulated in a similar manner independent of their location, or number and size of the thrombi. It has been suggested that many patients with SSPE may be treated without benefit, increasing adverse events by a possible unnecessary use of anticoagulants. Patients with isolated SSPE, or incidental PE, may have a more benign clinical presentation compared to those with proximal PEs. However, the clinical significance in patients, and their prognosis, needs to be studied to evaluate whether anticoagulation therapy is required. This is the second update of the Cochrane systematic review published in 2014. To assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 November 2019. We also undertook reference checking to identify additional studies. We included randomised controlled trials of anticoagulation therapy versus control in patients with SSPE or incidental SSPE. Two review authors inspected all citations identified to ensure reliable assessment. If relevant studies were identified, we planned for two review authors to independently extract data and to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. We did not identify any studies that met the inclusion criteria. There is no evidence from randomised controlled trials to assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. Well-conducted research is required before informed practice decisions can be made.

BLOOD TRANSFUSION IN CARDIAC SURGERY- NEED TO FOLLOW BASICS!

More and more data is coming in recent times about hazards of blood transfusion. In a landmark TRICC1 trial Euvolemic patients in the intensive care unit (ICU) with Hb&lt;9 g/dl were randomized to a restrictive transfusion strategy for transfusion of PRBCs (transfused if Hb&lt;7 g/dl to maintain Hb between 7 and 9 g/dl) or a liberal strategy (transfused if Hb&lt;10 g/dl to maintain Hb 10-12 g/dl). Mortality was similar in both groups, indicating that liberal transfusions were not beneficial. An Updated Report by the American Society of AnaesthesiologistsTask Force on Perioperative Blood Management tells us restrictive red blood cell transfusion strategy may be safely used to reduce transfusion administration. It further states that The determination of whether hemoglobin concentrations between 6 and 10 g/dl justify or require red blood cell transfusion should be based on potential or actual on going bleeding (rate and magnitude), intravascular volume status, signs of organ ischemia, and adequacy of cardiopulmonary reserve. Should we extrapolate these guidelines in Cardiac surgery? TRACS2 trial concluded that among patients undergoing cardiac surgery, the use of a restrictive perioperative transfusion strategy compared with a more liberal strategy resulted in noninferior rates of the combined outcome of 30-day all-cause mortality and severe morbidity.They advocated use of restrictive strategy, but 5 years later, the authors 3concluded that A restrictive transfusion threshold after cardiac surgery was not superior to a liberal threshold with respect to morbidity or health care costs. With this conflicting evidence, by which way anaesthesiologist to go?

Comparison of Orotracheal versus Nasotracheal Fiberoptic Intubation Using Hemodynamic Parameters in Patients with Anticipated Difficult Airway.

Background:Both nasal and oral routes can be used for fiberoptic intubation. Often it leads to hemodynamic disturbances, which may have a significant effect in patients with limited cardiopulmonary reserve as well as with cerebrovascular diseases.Aims:The aim of the study was to evaluate whether there is a clinically relevant difference between the circulatory responses to oral and nasal fiberoptic intubation.Settings and Design:This was a prospective, randomized, and comparative study.Materials and Methods:In this study, a total of 90 patients with the American Society of Anesthesiologist physical status I and II of either sex in the age group of 18–60 years and having anticipated difficult airway (DA) posted for elective surgery under general anesthesia were randomly allocated into two groups. Patients underwent fiberoptic intubation via either oral or nasal route under sevoflurane anesthesia with bispectral index guidance. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), time taken to intubation, and need of maneuver were measured.Statistical Analysis Used:All the analyses were carried out on SPSS 16.0 version (Inc., Chicago, USA). Mean and standard deviation were calculated. The test of analysis between two groups was done by unpaired t-test.Results:Demographic and DA characteristics were similar in both the groups. Significantly (P < 0.01) lesser alteration in HR, SBP, DBP, and MAP was seen in oral fiberoptic intubation when compared to nasal fiberoptic intubation in the early phase of postintubation. Time taken to intubation was also significantly (P < 0.01) lesser in the oral route compared to the nasal route.Conclusions:Oral fiberoptic intubation causes less hemodynamic alteration and takes less time in comparison to nasal fiberoptic intubation.

Velocity Transfer Function In The Right Pulmonary Artery And Impaired Cardiopulmonary Reserve In COPD.

Velocity Transfer Function In The Right Pulmonary Artery And Impaired Cardiopulmonary Reserve In COPD.

P138 IMPACT OF NEOADJUVANT FLOT CHEMOTHERAPY ON CARDIORESPIRATORY RESERVE OF PATIENTS WITH OESOPHAGOGASTRIC ADENOCARCINOMA

Abstract Introduction Neoadjuvant chemotherapy is known to have a deleterious effect on the cardiorespiratory reserve of patients with oesophagogastric cancer[1,2]. A low anaerobic threshold is associated with increased morbidity after major surgery[3] The effect that FLOT (5FU, leucovorin, oxaliplatin, docetakel) chemotherapy has upon cardiopulmonary reserve has not been reported. This work aims to quantify this effect. Methods Cardiopulmonary exercise testing (CPET) was completed in 18 consecutive patients with oesophagogastric cancer who received FLOT chemotherapy. CPET pre-chemotherapy and 4-5weeks post-chemotherapy measured the ventilatory anaerobic threshold (AT) and peak oxygen uptake (Vo2p). Ventilatory equivalents for CO2 (Ve/VCO2) and total ventilation (Ve) were reported. The group mean change in these objective measurements of cardiopulmonary reserve was compared before and after FLOT. Results Between October 2018 and January 2019 eighteen patients (median age 58.1 years, 16/18 male) were tested before and after FLOT. In 14 patients (78%) a decline in AT and VO2p was demonstrated. A mean decrease in AT of 2.1 mlkg-1min-1 (14.9 Vs 12.8 mlkg-1min-1, p=0.02) and VO2p of 2.3 mlkg-1min-1 (20.6 vs 18.3 mlkg-1min-1, p=0.01) was seen after FLOT. Ve/VCO2 and Ve were unchanged. Conclusion Patients receiving FLOT chemotherapy demonstrate a clinically significant decrease in cardiorespiratory reserve. This appears to be similar to that observed in patients who have previously received neoadjuvant ECX (MAGIC regimen) [1,2,4]. Further investigation into the clinical impact of this observation is required.

Anesthetic management of geriatric patients.

The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.