Length Of Postoperative Ventilation Research Articles

Double-lung versus heart-lung transplantation for end-stage cardiopulmonary disease: a systematic review and meta-analysis.

We compared posttransplant outcomes following double-lung transplantation (DLTx) and heart-lung transplantation (HLTx), based on a search of PubMed, Cochrane Library, and Embase, from inception to March 8, 2022, for studies that report outcomes of these procedures. We then performed a meta-analysis of baseline characteristics and posttransplant outcomes. Subgroup analyses were implemented according to indication, publication year, and center. This study was registered on PROSPERO (number CRD42020223493). Ten studies were included in this meta-analysis, involving 1230 DLTx patients and 1022 HLTx patients. The DLTx group was characterized by older donors (P = 0.04) and a longer allograft ischemia time (P < 0.001) than the HLTx group. The two groups had comparable 1-year, 3-year, 5-year, 10-year survival rates (all P > 0.05), with similar results identified in subgroup analyses. We found no significant differences in 1-year, 5-year, and 10-year chronic lung allograft dysfunction (CLAD)-free survival, length of intensive care unit stay and hospital stay, length of postoperative ventilation, in-hospital mortality, or surgical complications between the groups (all P > 0.05). Thus, DLTx provides similar posttransplant survival to HLTx for end-stage cardiopulmonary disease. These two procedures have a comparable risk of CLAD and other posttransplant outcomes.

Slide Tracheoplasty for Congenital Tracheal Stenosis Repair: A Systematic Review and Meta-Analysis.

Congenital tracheal stenosis (CTS) is a rare but life-threatening condition in children. At present, slide tracheoplasty has been advocated as the preferred technique for most cases of CTS. However, the morbidity and mortality subsequent to slide tracheoplasty need further elaboration. Therefore, a meta-analysis was performed on the outcomes of slide tracheoplasty in children with CTS. Systematic review and meta-analysis. Electronic databases, including PubMed, Embase, and Cochrane Library CENTRAL, were systematically searched for the period from January 1990 to March 2021 for literature that reported clinical outcomes of slide tracheoplasty for children with CTS. Meta-regression and subgroup analyses were performed to determine the risk factors for in-hospital mortality and airway reinterventions. A total of 25 studies involving 577 patients were included. For children with CTS, in-hospital and overall mortality after slide tracheoplasty was 6.1% (95%CI=4.2%-8.0%) and 9.7% (95%CI=7.3%-12.1%), respectively. The incidence of airway reinterventions was 23.0% (95%CI=15.6%-30.5%). The length of postoperative ventilation and hospital stay was 6.8 days (95%CI=5.1-8.4 days) and 19.2 days (95%CI=15.8-22.7 days), respectively. Postoperative complications occurred in 46.6% (95%CI=35.8%-57.4%) of all patients. Meta-regression analysis showed that a higher proportion of the recently published studies reported significantly better in-hospital survival (coefficient -0.011, P=.021). In conclusion, in-hospital mortality after slide tracheoplasty is 6.1%, and the incidence of airway reinterventions is 23.0%. In-hospital mortality after slide tracheoplasty has decreased chronologically. NA Laryngoscope, 132:1532-1541, 2022.

Novel Suture Technique for Slide Tracheoplasty for the Treatment of Long-Segment Tracheal Stenosis

Long-segment tracheal stenosis is a rare, life-threatening condition. Slide tracheoplasty is the surgical treatment of choice but is associated with significant morbidity and mortality. We examined our institutional outcomes utilizing a running, everting horizontal mattress suture technique. From August 2012 to January 2019, 7 infants and children underwent slide tracheoplasty with a single surgeon utilizing a running, everting horizontal mattress suture technique. Demographics and patient clinical data were obtained through chart review, and a retrospective analysis was performed. Median age was 7 months (range, 4 days-19 months) and median weight was 5.5 kg (range, 2.8-9.4). All patients underwent slide tracheoplasty using a running, everting horizontal mattress suture technique. One patient died on postoperative day 45 of multisystem organ failure, unrelated to his patent airway. Length of postoperative ventilation in survivors was 7 days (range, 0-20 days). Average follow-up was 3 years. There were no instances of significant postoperative airway stenosis, anastomotic leak, granulation tissue formation, or figure-of eight deformity. A running, everting horizontal mattress suture technique is safe and efficacious for slide tracheoplasty, prevents figure-of-eight deformity, and may decrease the incidence of tracheal stenosis, airway granulation tissue formation, and anastomotic leak.

Does Traumatic Donor Cause of Death Influence Outcome after Lung Transplantation? A Single-Centre Analysis.

Background Owing to the shortage of donor organs in lung transplantation (LuTX), liberalization of donor selection criteria has been proposed. However, some studies suggested that donor traumatic brain damage might influence posttransplantation allograft function. This article aimed to investigate the association of donor cause of death (DCD) and outcome after LuTX. Methods A retrospective analysis of 186 consecutive double LuTXs at our institution from January 2000 to December 2008 was performed. DCD was categorized into traumatic brain injury (TBI) and nontraumatic brain injury (NTBI). In addition, NTBI was sub classified as spontaneous intracerebral bleeding (B), hypoxic brain damage (H), and intracerebral neoplasia (N). Results DCD was classified as TBI in 50 patients (26.9%) and NTBI in 136 patients (73.1%): B in 112 patients (60.2%), H in 21 patients (11.3%), and N in 3 patients (1.6%). Young male donors predominated in group TBI (mean age 36.0 ± 14.5 vs. 42.8 ± 10.7, p < 0.01; 29 males in the TBI group [58.0%] vs. 48 males in the NTBI group [35.3%], p < 0.01). Groups of DCD did not differ significantly by recipient age or gender, recipient diagnosis, donor ventilation time, or paO2/FiO2 before harvesting. TBI donors received significantly more blood (3.4 ± 3.8 vs. 1.8 ± 1.9, p = 0.03). A chest trauma was evident only in group T (n = 7 [3.7%] vs. 0 [0%], p < 0.001). Mode of donor death did not affect the following indices of graft function: length of postoperative ventilation, paO2/FiO2 ratio up to 48 hours, and lung function up to 36 months. One- and three-year survival was comparable with 84.4 and 70.4% for TBI donors versus 89.4% and 69.2% for NTBI donors. Five-year survival tended to be lower in the TBI group but did not reach statistical significance (43.4 vs. 53.9%). Conclusion This study indicates that traumatic DCD does not affect outcome after LuTX. These results can be achieved with an ideal donor management combined with an individual case-to-case evaluation by an experienced LuTX surgeon.

Automated Alerting and Recommendations for the Management of Patients With Preexisting Hypoxia and Potential Acute Lung Injury

Blum, James M.*; Stentz, Michael J.*; Maile, Michael D.*; Jewell, Elizabeth*; Raghavendran, Krishnan†; Engoren, Milo*; Ehrenfeld, Jesse M.‡ Author Information

Automated Alerting and Recommendations for the Management of Patients with Preexisting Hypoxia and Potential Acute Lung Injury

Acute lung injury (ALI) is associated with high mortality. Low tidal volume (Vt) ventilation has been shown to reduce mortality in ALI patients in the intensive care unit. Anesthesiologists do not routinely provide lung-protective ventilation strategies to patients with ALI in the operating room. The authors hypothesized that an alert, recommending lung-protective ventilation regarding patients with potential ALI, would result in lower Vt administration. The authors conducted a randomized controlled trial on anesthesia providers caring for patients with potential ALI. Patients with an average or last collected ratio of partial pressure of arterial oxygen to inspired fraction of oxygen less than 300 were randomized to providers being sent an alert with a recommended Vt of 6 cc/kg predicted body weight or conventional care. Primary outcomes were Vt/kg predicted body weight administered to patients. Secondary outcomes included ventilator parameters, length of postoperative ventilation, and death. The primary outcome was a clinically significant reduction in mean Vt from 508-458 cc (P = 0.033), with a reduction in Vt when measured in cc/kg predicted body weight from 8 to 7.2 cc/kg predicted body weight (P = 0.040). There were no statistically significant changes in other outcomes or adverse events associated with either arm. Automated alerts generated for patients at risk of having ALI resulted in a statistically significant reduction in Vt administered when compared with a control group. Further research is required to determine whether a reduction in Vt results in decreased mortality and/or postoperative duration of mechanical ventilation.

Risk Factors for Bronchopleural Fistula After Right Pneumonectomy: Does Eliminating the Stump Diverticulum Provide Protection?

Bronchopleural fistula (BPF) remains an important source of morbidity and mortality after right pneumonectomy. We reviewed our 18-year institutional experience with right pneumonectomy to identify risks factors for BPF. From 1992 to 2010, a total of 145 patients who underwent right pneumonectomy were identified from an institutional database. Median age was 56 years. Most patients (66.2%) underwent surgery for non-small cell lung cancer. Sixty-seven patients (46.2%) received either chemotherapy or radiotherapy before surgery. Medical records were reviewed for 14 variables potentially predictive for BPF, including two airway closure techniques (standard bronchial closure and carinal closure). Variables predictive of BPF by univariate analysis were entered into a logistic regression model. The overall mortality rate was 13.1% (n=19), with 15.9 and 10.5% mortality in the bronchial closure and carinal closure groups, respectively (P=0.33). The overall BPF rate was 7.6% (n=11), with a 3.9% (3 of 76) rate in the carinal closure group compared to 11.6% (8 of 69) in the bronchial closure group (P=0.08). Seven of eight bronchial closure patients who developed BPF required operative repair. Only one of three patients who developed BPF after carinal closure did not spontaneously heal after open drainage. Multivariate analysis identified preoperative radiation dose (P=0.042) and bronchial closure (P=0.041) as independent risk factors for BPF, while the length of postoperative ventilation before development of BPF approached significance (P=0.057). In our experience, higher preoperative radiation doses are a risk factor for BPF after right pneumonectomy, while carinal closure exerts a protective effect.

Use of donors who have suffered cardiopulmonary arrest and resuscitation in lung transplantation☆

Shortage of donors is one of the major limitations in lung transplantation (LuTX) and an aggressive expansion of criteria for donor selection has been proposed. This study evaluates the outcome of recipients of pulmonary grafts coming from resuscitated donors when compared with recipients of non-resuscitated donors. We retrospectively analyzed the donor and recipient charts of all double LuTX performed at our institution between 2000 and 2008 with regard to the performance of donor-cardiopulmonary resuscitation (CPR). Out of 186 eligible transplants, 22 patients (11.8%) received lungs from donors who have suffered cardiac arrest (CA) and subsequent CPR. Mean duration of CPR was 15.2 ± 11.3 min. Terminal laboratory profiles of CPR donors and non-CPR donors were similar as were ventilation time and paO(2)/FiO(2) ratio before organ harvesting or chest X-ray. CPR-donor status did not affect the following indices of graft function: length of postoperative ventilation, paO(2)/FiO(2) ratio up to 48 h and lung function up to 60 months. Length of intensive care and hospital stay, need for inotropic support and 30-day mortality were not significantly different for the transplantation of CPR or no-CPR donor lungs. One- and 3-year survival rates were comparable as well with 84.4% and 66.3% for CPR donors versus 88.5% and 69.8% no-CPR donors. This study indicates that transplantation of lungs from resuscitated donors may not affect outcome after LuTX. Therefore, donor history of CA should not automatically preclude LuTX.

Arterial blood gas management during cardiopulmonary bypass.

This study sought to investigate the effects of α-stat and pH stat regimens on cardiac outcome during moderate hypothermic cardiopulmonary bypass. 100 patients undergoing elective coronary artery bypass grafting (CABG) were randomly assigned with respect to the target value for PaCO(2) during cardiopulmonary bypass (CPB) into 2 groups. In 50 patients the target PaCO(2) was 40 mmHg, measured at a standard electrode temperature of 37°C while in the other 50 patients the target PaCO(2) was 40 mmHg, corrected to the patients nasopharyngeal temperature (lowest value reached: 32±0.5°C). There were no significant differences between groups with regards to cardiac outcome such as appearance of new 'Q' waves on the electrocardiogram, postoperative creatinine kinase-MB fraction, systemic vascular resistance (SVR), cardiac index (Cl), need for inotropic or intra-aortic balloon pump support and the length of postoperative ventilation or intensive care unit stay. These findings support the hypothesis that CO(2) management during CPB at moderate hypothermia has no clinically significant effect on cardiac outcome.

An audit of cardiac surgery in patients aged over 70 years

With an increasingly aged population, the number of patients requiring treatment for cardiovascular diseases will rise. Previous expectations of cardiac surgery in the over-seventies have been poor, with surgery being very much a last resort. We decided to test whether this was appropriate, and to determine whether the priority of surgery affected the outcome. Three hundred and six patients over the age of 70 were operated on in our unit in a 4 1/2-year period, 210 as elective operations and 96 as emergencies. Eighty-nine per cent were in NYHA class III-IV pre-operatively and half had other significant medical problems. Most (46%) underwent coronary artery surgery. The methods used were identical to those used for the younger patients in both operative approach and post-operative management. The overall mortality was 6.9%; 1.9% for elective procedures and 16.7% for emergencies (12.3% when catastrophic pathologies are excluded). However, the morbidity was not significantly different between the two groups and the length of post-operative ventilation and hospital stay were likewise not significantly different. Follow-up of the survivors showed no late deaths, and 87% were in NYHA class I and II. Of the others, 25 have required additional hospital admissions for associated cardiac problems. One required another invasive procedure (a PTCA), but none has required further surgery. The findings of low mortality for elective cardiac surgery in this age group are in agreement with other reports. If early referral prevents emergency surgery, it should be avidly pursued, in view of the improved outcome for elective surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Transhiatal esophagectomy for carcinoma of the esophagus and cardia. Experience with 160 cases.

We reviewed our experience from 1979 to 1990 with 160 cases of transhiatal esophagectomy for carcinoma of the lower esophagus and cardia to evaluate trends in patient selection, management, and outcome. Patients treated in the past 6 years (n = 110) and those treated before 1985 (n = 50) were similar in terms of age and sex distribution, medical history, and weight loss. The majority of tumors seen were adenocarcinoma, with patients in the latter group having significantly lower stages. Significant decreases in anesthetic time, units of blood transfusions, chest tube insertions, length of postoperative ventilation, incidence of postoperative pneumonia, and length of hospital stay were seen during the past 6 years. Wound infections increased significantly during the same period. The decrease in the 30-day mortality rate from 6% to 0.9% was not significant. Survival rates did not differ between groups, with overall rates of 62%, 40%, and 21% at 1, 2, and 5 years, respectively.

A Randomized Study of Carbon Dioxide Management during Hypothermic Cardiopulmonary Bypass

Eighty-six patients undergoing coronary artery bypass graft (n = 63) or intracardiac (n = 23) surgery were randomly assigned with respect to the target value for PaCO2 during cardiopulmonary bypass. In 44 patients the target PaCO2 was 40 mmHg, measured at the standard electrode temperature of 37 degrees C, while in 42 patients the target PaCO2 was 40 mmHg, corrected to the patient's rectal temperature (lowest value reached: mean 30.1, SD 1.9 degrees C). Other salient features of bypass management include use of bubble oxygenators without arterial filtration, flows of 1.8-2.4 l.min-1.m-2, mean hematocrit of 23%, and mean arterial blood pressure of approximately 70 mmHg, achieved by infusion of phenylephrine or sodium nitroprusside. Neuropsychologic function was assessed with series of tests administered on the day prior to surgery, just before discharge from the hospital (mean 8.0, SD 5.8 days postoperatively, n = 82), and again 7 months later (mean 220.7, SD 54.4 days postoperatively, n = 75). The scores at 8 days showed wide variability and generalized impairment unrelated to the PaCO2 group or to hypotension during cardiopulmonary bypass. At 7 months no significant difference was observed in neuropsychologic performance between the PaCO2 groups. Regarding cardiac outcome, there were no significant differences between groups in the appearance of new Q-waves on the electrocardiogram, the postoperative creatine kinase-MB fraction, the need for inotropic or intraaortic balloon pump support, or the length of postoperative ventilation or intensive care unit stay. These findings support the hypothesis that CO2 management during cardiopulmonary bypass at moderate hypothermia has no clinically significant effect on either neurobehavioral or cardiac outcome.