Single-lung Ventilation Research Articles

Anesthetic Management for Left Ventricular Assist Device Implantation Without Using Cardiopulmonary Bypass: Case Series

PurposeVentricular assist devices are an alternative to medical treatment in patients with hemodynamic disturbances related to acute or chronic congestive heart failure. In this case series, we present our anesthesia management for implantation of left ventricular assist device (LVAD) with thoracotomy. MethodSixteen patients with end-stage heart failure undergoing LVAD implantation via thoracotomy between November 2012 and August 2014 were analyzed prospectively. Preoperative characteristics, intraoperative hemodynamic and respiratory parameters, use of anesthetic and blood products, and durations of mechanical ventilation, hospital, and intensive care stays were recorded. ResultsSixteen patients (mean age, 54.6 ± 13 years) were investigated. Single-lung ventilation was applied to 2 patients. Cardiopulmonary bypass (CPB) was required in 5 patients. Intraoperative ketamine, midazolam, fentanyl, and rocuronium requirements were 112 ± 63 mg, 5.5 ± 3.5 mg, 438 ± 187 μg, and 179 ± 49 mg, respectively. Requirements of fresh donor blood, fresh frozen plasma, and thrombocyte and erythrocyte suspension were 1.19 ± 1, 1 ± 0.8, 0.44 ± 0.5, and 0.25 ± 0.7 U, respectively. Durations of mechanical ventilation, intensive care unit, and hospital stay were 46 ± 53 hours, 8.2 ± 6.6 days, and 20.5 ± 11.6 days, respectively. Twelve patients were discharged from hospital with full recovery and 2 patients died; 2 patients are still receiving treatment in the hospital. ConclusionA left thoracotomy approach can be used without CPB, because it reduces the incidences of pump complications and blood transfusion. In addition, this case series showed that the implantation of LVAD by thoracotomy can be implemented securely with single-lumen endotracheal tube without single-lung ventilation.

The complex care of severe emphysema: role of awake lung volume reduction surgery.

The resectional lung volume reduction surgery (LVRS) procedure entailing nonanatomic resection of destroyed lung regions through general anesthesia with single-lung ventilation has shown to offer significant and long-lasting improvements in respiratory function, exercise capacity, quality of life and survival, particularly in patients with upper-lobe predominant emphysema and low exercise capacity. However mortality and morbidity rates as high as 5% and 59%, respectively, have led to a progressive underuse and have stimulated investigation towards less invasive surgical and bronchoscopic nonresectional methods that could assure equivalent clinical results with less morbidity. We have developed an original nonresectional LVRS method, which entails plication of the most severely emphysematous target areas performed in awake patients through thoracic epidural anesthesia (TEA). Clinical results of this ultra-minimally invasive procedure have been highly encouraging and in a uni-center randomized study, intermediate-term outcomes paralleled those of resectional LVRS with shorter hospital stay and fewer side-effects. In this review article we analyze indications, technical details and results of awake LVRS taking into consideration the available data from the literature.

Nonintubated Thoracoscopic Lobectomy for Lung Cancer Using Epidural Anesthesia and Intercostal Blockade

Intubated general anesthesia with single-lung ventilation has been considered mandatory for thoracoscopic lobectomy for nonsmall cell lung cancer. Few reports of thoracoscopic lobectomy without tracheal intubation are published, using either thoracic epidural anesthesia (TEA) or intercostal blockade. The comparisons of perioperative outcomes of nonintubated thoracoscopic lobectomy using epidural anesthesia and intercostal blockade are not reported previously.From September 2009 to August 2014, a total of 238 patients with lung cancer who underwent nonintubated thoracoscopic lobectomy were recruited from our prospectively maintained database of all patients undergoing nonintubated thoracoscopic surgery using TEA or intercostal blockade. A multiple regression analysis, adjusting for preoperative variables, was performed to compare the perioperative outcomes of the 2 anesthesia methods.Overall, 130 patients underwent nonintubated thoracoscopic lobectomy using epidural anesthesia whereas 108 had intercostal blockade. The 2 groups were similar in demographic data, except for sex, preoperative lung function, physical status classification, and history of smoking. After adjustment for the preoperative variables, nonintubated thoracoscopic lobectomy using intercostal blockade was associated with shorter durations of anesthetic induction and surgery (P < 0.001). Furthermore, hemodynamics were more stable with less use of vasoactive drugs (odds ratio: 0.53; 95% confidence interval [CI], 0.27 to 1.04; P = 0.064) and less blood loss (mean difference: −55.2 mL; 95% CI, −93 to −17.3; P = 0.004). Postoperatively, the 2 groups had comparable incidences of complications. Patients in the intercostal blockade group had a shorter average duration of chest tube drainage (P = 0.064) but a similar average length of hospital stay (P = 0.569). Conversion to tracheal intubation was required in 13 patients (5.5%), and no in-hospital mortality occurred in either group.Nonintubated thoracoscopic lobectomy using either epidural anesthesia or intercostal blockade is feasible and safe. Intercostal blockade is a simpler alternative to epidural anesthesia for nonintubated thoracoscopic lobectomy in selected patients with lung cancer.

Surgical management of bronchopulmonary malformations

BackgroundBronchopulmonary malformations (BPM) are rare conditions, which typically arise below the carina and can result in significant morbidity (infection and/or hemorrhage) and mortality (respiratory failure). Materials and methodsAll children with BPM surgically treated from 2001–2014 at a tertiary care children's hospital were identified. Patient demographics, surgical indications, procedure type, estimated blood loss, pathology, perioperative complications, length of stay, and outcomes were analyzed. ResultsA total of 41 BPM patients underwent surgery with 98% overall survival (one abdominal BPM expired) but 100% for thoracic lesions. Resections were performed thoracoscopically (37%), thoracoscopy converted to open (22%), and via thoracotomy (37%). Poor visualization (67%) or inability to tolerate single lung ventilation (33%) led to conversions. No conversions resulted from hemorrhage or received blood transfusions. Patients with prenatally diagnosed BPM were more likely to undergo thoracoscopic surgery (odds ratio [OR], 18.2) versus nonprenatally diagnosed, P = 0.002. Open/converted patients had longer chest tube days (6.2) versus thoracoscopic (2.9), P = 0.048. Additionally, respiratory distress was a more common indication in patients aged <4 mo (OR, 28.0) versus ≥4 mo and <6 kg (OR, 40.5) versus ≥6 kg, P < 0.001. Open resections were more common in patients aged <4 mo (OR, 26.3) versus ≥4 mo, P = 0.002. Operative time was shorter and estimated blood loss (mL/kg) was greater for <6 versus ≥6 kg, P < 0.05. ConclusionsBPM resections have high overall survival. Chest tube days are shorter among thoracoscopic patients, but conversion to thoracotomy can avoid hemorrhage and need for transfusion. Size and respiratory distress limit use of thoracoscopy in young infants with BPM.

Technical points of the operative procedure for robotic-assisted lung resection and lymph node dissection.

The operation is performed under general anesthesia with double-lumen endotracheal intubation. The patient is placed in the lateral position on the unaffected side. Singlelung ventilation is performed on the unaffected side. The patient holds a pillow with both upper limbs flexed and is placed in the jackknife position.

Application of sevoflurane intravenous inhalational anesthesia and remifentanil intravenous anesthesia for single lung ventilation in the department of thoracic surgery operation

Objective To investigate the effect of sevoflurane intravenous inhalational anesthesia and remifentanil intravenous anesthesia for single lung ventilation in the department of thoracic surgery operation. Methods 80 patients using thoracic surgery were randomly divided into the two groups with 40 cases in each group according to the number table methods, the study group were treated with sevoflurane inhalation anesthesia while the control group were treated with remifentanil intravenous anesthesia. HR,MAP and SBP of the two groups before induction of anesthesia(T0),1min before intubation(T1),10min after ventilation(T2),30min after ventilation(T3)and 1min before extubation(T4) were compared, and recovery time, extubation time, directional force the recovery time were recorded of the two group. Results The HR in the two groups at T 1,T2,T 3,T 4 time did not change significantly than T0 time,while MAP decreased significantly than T0 time,with significant difference(t= 8.12,7.82,8.14,8.05,all P 0.05);The SBP in the study group did not change obviously at each time while the SBP in the control group at T1 decreased significantly than T0 time,while it increased significantly at T2 time than T1 time,with a significant difference(t= 10.51,5.34,5.05,5.06,all P< 0.05);The patients in study group were elevated blood pressure during anesthesia or decreased more than 30% occurred in 8 cases while the control group occurred in 24 cases,there was significant differences between the two groups(χ2= 13.33,P<0.05);The postoperative recovery time,extubation time and orientation recovery time of the study group patients were(11.4±5.1)min,(13.4±6.8)min,(18.9± 5.8)min,which were significantly lower than(19.5±5.2)min,(26.5±7.6)min,(21.9±7.8)min of the control group(t= 5.34,6.12,6.15,all P< 0.05). Conclusion Sevoflurane intravenous inhalational anesthesia has a better anesthetic effect for single lung ventilation in the department of thoracic surgery operation than remifentanil intravenous anesthesia, and it can effectively maintain hemodynamics stability. Key words: Anesthesia; Thoracic surgical procedures

Re-expansion pulmonary oedema after minimally invasive cardiac surgery with right mini-thoracotomy

Re-expansion pulmonary oedema (RPO) sometimes occurs after minimally invasive cardiac surgery (MICS) with single-lung ventilation. However, it has not been widely recognized as a serious complication. The aim of this study is to evaluate the occurrence rate and risk factors of RPO. A total of 381 consecutive patients who underwent MICS with right mini-thoracotomy from March 2005 to October 2013 were retrospectively reviewed. RPO was observed in 8 (2.1%) patients. In the preoperative data, greater percentages of preoperative use of steroid or immunosuppressant were found in patients with RPO (25% [2/8] vs 1% [4/373]; P = 0.0056). In the operative data, significantly longer operation, cardiopulmonary bypass (CPB) and aortic cross-clamping (ACC) times as well as greater percentages of second CPB run were found in patients with RPO (388 ± 80 vs 272 ± 61 min; P < 0.0002, 253 ± 79 vs 158 ± 50 min; P = 0.0009, 162 ± 65 vs 108 ± 38 min; P = 0.020 and 38% [3/8] vs 1.3% [5/373]; P < 0.0003). The overall 30-day mortality rate was 0.8% (3/381) and the 30-day mortality rate of patients with RPO was 12.5% (1/8). Significantly prolonged initial ventilation time, intensive care unit and postoperative hospital stay were observed in patients with RPO (P = 0.0022, <0.0001 and 0.0003, respectively). Multivariate logistic analysis detected preoperative use of steroid or immunosuppressant and prolonged ACC time (≥156 min) as independent risk factors for RPO after MICS (odds ratio [OR]: 87.6 [95% confidence interval, CI: 4.1-2463.8]; P = 0.006 and OR: 36.0 [95% CI: 4.8-731.4]; P < 0.001). RPO should be recognized as one of the most serious complications after MICS with right mini-thoracotomy. More accurate risk factors of prolonged lung malperfusion and steroid use on RPO after MICS should be investigated.

Bilateral sympathicotomy for hyperhidrosis without using single-lung ventilation.

The goal of this retrospective study was to evaluate the outcomes and complications of bilateral videothoracoscopic sympathicotomy without using single-lung ventilation in the treatment of primary hyperhidrosis and facial blushing. We retrospectively reviewed 154 consecutive patients (70 females and 84 males) who underwent bilateral sympathicotomy for palmar, axillary, and facial/scalp hyperhidrosis or facial blushing from February 2005 to June 2013. The patients were intubated with single-lumen endotracheal tube, and then sympathicotomies were performed via videothoracoscopy during controlled apnea periods. Sympathicotomies were performed at costal levels 2, 3, and 4. No perioperative mortality or conversion to open surgery was recorded. Mean operation time was 31.2 ± 2.4 min and mean hospital stay was 1.1 ± 0.6 days. One patient experienced a unilateral pneumothorax that required treatment. There were no abnormal hemodynamic parameters measured during the perioperative apnea periods. The long term follow-up period was 21.4 ± 5 months. Twenty-nine cases (18.8%) were complicated by compensatory sweating. No recurrence was observed during the follow-up period. Video-assisted thoracoscopic sympathicotomy without lung isolation provides effective cure of primary hyperhidrosis and facial blushing. This procedure can shorten the operative time without any aberrant hemodynamic shifts.

Minimally invasive hybrid surgery combined with endoscopic and thoracoscopic approaches for submucosal tumor originating from thoracic esophagus.

BackgroundDespite the efficacy of molecular targeted therapy, surgical resection remains the only curative primary treatment for gastrointestinal stromal tumors (GISTs). However, in cases when the tumor originates from the thoracic esophagus, conventional transthoracic approach is highly invasive.MethodsAll procedures were performed with patients in a prone position through a double-lumen endotracheal tube for single-lung ventilation. First, to clarify the resection layer between the tumor and mucosal layer of the esophagus, a sodium hyaluronate solution colored with indigo carmine was injected into the submucosa via the esophagoscopic approach. Second, we thoracoscopically divided the longitudinal muscle of the esophagus and enucleated the tumor through three ports by dissecting along the artificially colored submucosa, thereby minimizing accidentally opening of the esophageal mucosa. Third, we sutured the divided longitudinal muscle layer and removed the tumor from the thoracic cavity.ResultsFour tumors, including one GIST, were successfully resected via this hybrid approach. The mean surgical time was 137.7 min (range, 60–231 min), and the mean blood loss was 21.2 ml (range, 3–65 ml). No perioperative complications occurred, including with accidental opening of the esophageal mucosa.ConclusionsOur minimally invasive hybrid surgery combined with esophagoscopic and thoracoscopic approaches demonstrated successful resection. This surgery could have advantages both for curing esophageal submucosal tumor and for minimizing surgical invasiveness.

Exhaled volatile organic compounds as lung cancer biomarkers during one-lung ventilation.

In this study, single-lung ventilation was used to detect differences in the volatile organic compound (VOCs) profiles between lung tissues in healthy and affected lungs. In addition, changes that occurred after lung cancer resection in both the VOCs profiles of exhaled breath from ipsilateral and contralateral lungs and the VOCs profiles of exhaled breath and blood sample headspaces were also determined. Eighteen patients with non-small cell carcinoma were enrolled. Alveolar breath samples were taken separately from healthy and diseased lungs before and after the tumor resection. Solid phase microextraction–gas chromatography/mass spectrometry was used to assess the exhaled VOCs of the study participants. The VOCs exhibited significant differences between the contralateral and ipsilateral lungs before surgery, the contralateral and ipsilateral lungs after surgery, the ipsilateral lungs before and after surgery, and the blood samples from before and after surgery; 12, 19, 12 and 5 characteristic metabolites played decisive roles in sample classification, respectively. 2,2-Dimethyldecane, tetradecane, 2,2,4,6,6-pentamethylheptane, 2,3,4-trimethyldecane, nonane, 3,4,5,6-tetramethyloctane, and hexadecane may be generated from lipid peroxidation during surgery. Caprolactam and propanoic acid may be more promising exhaled breath biomarkers for lung cancer.

Invited Commentary

Invited Commentary

Images in Anesthesiology: Severe Unilateral Atelectasis during Induction of Anesthesia

AN 11-yr-old scoliotic female presented for posterior spine fusion. After IV induction with an Fio2 of 1.0, mask ventilation briefly failed and her oxygen saturation dropped to 60%. Intubation took multiple attempts. Severe right-sided atelectasis was noted on chest x-ray (fig.), predominantly in the middle and lower lobes. The case was cancelled and she recovered uneventfully in a pediatric intensive care unit. Elective bronchoscopy performed 2 months later revealed moderate bronchomalacia of the bronchus intermedius.Atelectasis during general anesthesia occurs in approximately 90% of individuals, usually as microatelectasis particularly in alveoli in dependent regions, affecting intra- and postoperative pulmonary function.1 Severe atelectasis after anesthesia induction, as was seen in our patient, is uncommon. Mechanisms of atelectasis include compression (morbid obesity), absorption (bronchial obstruction), and surfactant deficiency. Absorption atelectasis may result from either complete or partial airway obstruction. In a partially obstructed airway, if the ventilation/perfusion ratio decreases below a critical value with less ventilation in than alveolar gas removal by capillary blood flow, then atelectasis can occur. We hypothesize that our patient developed absorption atelectasis as a result of partial bronchial obstruction from bronchomalacia, exacerbated by brief hypoventilation during masking. Alveolar gas composition may also contribute to atelectasis formation. Induction with 30% oxygen promotes less atelectasis when compared with 100% oxygen because of nitrogen’s slower blood diffusion.2 This may, however, cause quick and severe desaturation should apnea occur. Application of positive end-expiratory pressure or continuous positive airway pressure during anesthesia induction can also prevent atelectasis formation.3 When severe atelectasis is diagnosed, bronchoscopy and selective single-lung manual ventilation with high inflating pressures should be considered.The authors declare no competing interests.

Awake thoracoscopic surgery under epidural anesthesia: is it really safe?

Thoracoscopic surgeries usually require single-lung ventilation under general anesthesia because of the need to obtain a sufficient working space. In patients with impaired pulmonary function, if the patient can undergo general anesthesia, a more selected collapse of the lung is considered to be beneficial for intraoperative oxygenation. The selective bronchial blockade of the lobe to be resected has been reported by several investigators (1-3).

Sympathectomy versus Sympathicotomy in Palmar Hyperhidrosis Comparing T3 Ablation

The objective of this study was to evaluate and compare thoracoscopic sympathectomy and sympathicotomy at the third ganglia (T3) level for the treatment of primary palmar hyperhidrosis in terms of initial surgery results, complications, and patient satisfaction. Two groups of patient underwent T3 thoracoscopic sympathectomy and thoracoscopic sympathicotomy under general anesthesia using single-lung ventilation via a double-lumen endotracheal tube by the same surgical team for the treatment of severe primary palmar hyperhidrosis or a combination of levels for multiarea between 2008 and 2013. The groups were homogeneous for relevant demographic, physiological, and clinical data. All patients were examined preoperatively and were followed up at 6 months postoperatively. In both groups, patient's satisfaction was evaluated 6 months after surgery by a detailed interview and scored into three grades (1 = very satisfied, 2 = satisfied, and 3 = dissatisfied). No operative mortality, major intraoperative complication, infections, and Horner syndrome were recorded. There was no treatment failure. The average time of operation was 50 minutes for Group A (sympathectomy) and 36 minutes for Group B (sympathicotomy). Compensatory sweating occurred in 40 patients (89% for Group A and 85.11% for Group B) with a different accumulation of the severity degree. The satisfaction rate was 91.11% for Group A and 93.61% for Group B. There was no significant difference between thoracoscopic sympathectomy and sympathicotomy at the third ganglia (T3) level for the treatment of primary palmar hyperhidrosis in terms of initial surgery results, complications, and patient satisfaction. Neither surgical technique is better than the other one for palmar hyperhidrosis treatment. Development of severe compensatory sweating and postoperative pain are major determinant factors of patient dissatisfaction. Sympathicotomy should be preferred for palmar hyperhidrosis treatment, as it is much technically shorter, simpler to implement, and also easier to learn.

Abdominothoracic esophageal resection according to Ivor Lewis with intrathoracic anastomosis : standardized totally minimally invasive technique

The clinical and scientific interest in minimally invasive techniques for esophagectomy (MIE) are increasing; however, the intrathoracic esophagogastric anastomosis remains a surgical challenge and lacks standardization. Surgeons either transpose the anastomosis to the cervical region or perform hybrid thoracotomy for stapler access. This article reports technical details and early experiences with a completely laparoscopic-thoracoscopic approach for Ivor Lewis esophagectomy without additional thoracotomy. The extent of radical dissection follows clinical guidelines. Laparoscopy is performed with the patient in a beach chair position and thoracoscopy in a left lateral decubitus position using single lung ventilation. The anvil of the circular stapler is placed transorally into the esophageal stump. The specimen and gastric conduit are exteriorized through a subcostal rectus muscle split incision. The stapler body is placed into the gastric conduit and both are advanced through the abdominal mini-incision transhiatally into the right thoracic cavity, where the anastomosis is constructed. Data were collected prospectively and analyzed retrospectively. A total of 23 non-selected consecutive patients (mean age 69 years, range 46-80 years) with adenocarcinoma (n = 19) or squamous cell carcinoma (n = 4) were surgically treated between June 2010 and July 2013. Neoadjuvant therapy was performed in 15 patients resulting in 10 partial and 4 complete remissions. There were no technical complications and no conversions. Mean operative time was 305min (range 220-441min). The median lymph node count was 16 (range 4-42). An R0 resection was achieved in 91 % of patients and 3 anastomotic leaks occurred which were successfully managed endoscopically. There were no postoperative deaths. The intrathoracic esophagogastric anastomosis during minimally invasive Ivor Lewis esophagectomy can be constructed in a standardized fashion without an additional thoracotomy. Reduction of surgical morbidity remains the highest priority.

Coagulation and fibrinolysis during lung surgery:an experimental study.

Postoperative thromboembolism is a serious complication, but the incidence following surgery for lung cancer appears to be much lower compared with other surgical specialties. The reason is unknown and one may speculate that the lungs are reservoirs of anticoagulants or fibrinolytic substances, which are released by manipulation of the lung parenchyma during surgery. Standardized lung manipulation, single-lung ventilation and pneumonectomy were performed in 10 anaesthetized pigs. Baseline and serial postmanipulation intravenous and intra-arterial blood samples were analysed for a wide range of fibrinolytic substances as well as pro- and anticoagulant factors. We found a transient but significant decrease in activated partial thromboplastin time (aPTT) and plasminogen activator inhibitor following manipulation of the lungs. Pneumonectomy resulted in minor but significant decrease in antithrombin and a significant increase in aPTT. All other measured substances were virtually constant. A wide range of fibrinolytic and anticoagulant substances remained unchanged during experimental lung manipulation. Minor changes were transient and not considered clinically relevant. Future studies should be initiated in humans because we have no deeper understanding why thromboembolic complications are relatively uncommon after general thoracic surgery compared with other surgical specialties.

Double-lumen tube vs video assisted (ETview) uniblocker for single lung ventilation in distal oesophageal surgery: efficacy and safety

Pota, V.; Sansone, P.; Pace, M. C.; Passavanti, M. B.; Ferrante, L.; Aurilio, C. Author Information

EResponse. Re: Intraoperative management of failed single lung ventilation using a Fogarty balloon catheter through the open bronchus during off-pump left lung transplantation.

The use of balloon catheters as an interventional procedure is well established in various fields of medicine. Failure of single lung ventilation (SLV) can add difficulty to open bronchus procedures, and could result in a life-threatening situation very quickly. Trying to achieve single lung ventilation by alternate methods is fraught with dangers, and use of urgent cardiopulmonary bypass is less desirable because of increased primary graft dysfunction and mortality. We describe a novel approach of using a Fogarty balloon catheter through the open bronchus to achieve SLV during off-pump left lung transplantation when conventional SLV failed.

EComment. Re: Intraoperative management of failed single lung ventilation using a Fogarty balloon catheter through the open bronchus during off-pump left lung transplantation.

eComment. Re: Intraoperative management of failed single lung ventilation using a Fogarty balloon catheter through the open bronchus during off-pump left lung transplantation.

(60) - Outcomes of Intraoperative ECMO Versus Cardiopulmonary Bypass for Lung Transplantation

Cardiopulmonary support may be required during lung transplantation (LTx) mainly due to hemodynamic instability or inability to provide adequate gas exchange while on single-lung ventilation. With the increasing application of extracorporeal membrane oxygenation (ECMO) in critically ill patients, this mode of support has been explored as an alternative to conventional cardiopulmonary bypass (CPB) in the intra-operative course of LTx.