Chest Tube Research Articles

Periareolar approach in video-assisted thoracoscopic surgery for right middle lobectomy: a novel technique

BackgroundUniportal thoracoscopic right middle lobectomy (RML) poses greater technical challenges than other lobectomies. Although two-port thoracoscopy offers convenience, it results in heightened surgical trauma and scarring. The periareolar incision is rarely used in lobectomy while known for its cosmetic advantages. This study presents the periareolar access (combining a periareolar port and a 1-cm port) for video-assisted thoracoscopic surgery (VATS) in RML, comparing it with the traditional uniportal technique in both male and female patients.MethodsEighty patients who underwent RML were randomly divided into two groups: the periareolar VATS (PV) approach (n = 40) and the uniportal VATS (UV) approach (n = 40) from August 2020 to February 2023. All patients were followed up for 1 year and clinical data were collected and analyzed.ResultsNo significant differences in complications, blood loss, duration of chest tube placement, and length of postoperative hospital stay were observed between two methods. However, the PV group exhibited significantly shorter operative time, reduced postoperative visible scarring and lower visual analogue scores (VAS) for postoperative pain (P < 0.05). Additionally, the PV group demonstrated significantly higher cosmetic and satisfaction scores at the 6-month postoperative assessment (P < 0.05). Notably, breast ultrasound follow-up revealed two cases injuries of the mammary glands in female patients, and sensory function of most nipple and areola remained intact except two cases in all PV group patients.ConclusionsPeriareolar VATS emerges as a promising alternative approach for RML, providing clear benefits in pain management and cosmetic outcomes, while maintaining safety and convenience.Graphical

Efficacy of robot-assisted thoracoscopic surgery in the treatment of pulmonary sequestration in children

ObjectiveThis study was performed to evaluate the efficacy of robot-assisted thoracoscopic surgery (RATS) in the treatment of pulmonary sequestration (PS) in children.MethodsAll video-assisted thoracoscopic surgery (VATS) and RAST performed on...

Tube Thoracostomy Should Remain the Preferred Intervention for Traumatic Hemothorax

Tube Thoracostomy Should Remain the Preferred Intervention for Traumatic Hemothorax

Irreversible Electroporation in Treating Colorectal Liver Metastases in Proximity to Critical Structures

PurposeTo evaluate the safety, efficacy, and oncological outcomes of irreversible electroporation (IRE) of unresectable colorectal liver metastases (CRLMs) close to critical structures. Materials and MethodsThis is a single-center, institutional review board (IRB)–approved, retrospective analysis of patients who underwent percutaneous computed tomography (CT)–guided IRE of CRLM. Between August 2018 and October 2023, 26 patients had 46 tumors treated with percutaneous IRE in 30 ablation sessions. Primary end points were tumor response and local progression-free survival analyzed using Kaplan-Meier survival curves. Secondary end points were overall survival (OS), distant progression-free survival (DPFS) analyzed using Kaplan-Meier survival curves, adverse events rated according to the Common Terminology Criteria for Adverse Events (CTCAE), and length of hospital stay. ResultsAll tumors were close to critical structures, including the portal and hepatic veins, inferior vena cava, bile ducts, and gallbladder. All patients received preprocedural systemic therapy (median 10 cycles). Median length of hospital stay was 1 night. Adverse events occurred in 7 (23%) of 30 procedures, with four Grade 1 and two Grade 2 adverse events, including pleural effusions (n = 2), ileus (n = 1), small hematoma (n = 1), and pneumothorax (n = 2) requiring chest tube placements. Following IRE, the 1- and 2-year local tumor progression-free survival rates were 55.0% and 51.3%. The median DPFS was 3.5 months, with 1- and 2-year DPFS rates of 23.3% and 9.7%. Six patients (23.1%) died during follow-up, with a median OS of 40.4 months. The 1- and 2-year OS rates were 90.9% and 83.9%. ConclusionsIRE is a safe and viable option in the treatment of unresectable CRLMs in locations close to critical structures, but carries a risk of local recurrence.

Clinical observation of three-dimensional reconstruction in thoracoscopic segmental pneumonectomy.

Accurately identifying the branches of pulmonary segmental vessels and bronchi, as well as adjacent structures, and determining the spatial location of lesions within pulmonary segments, are major challenges for thoracic surgeons. The application of three-dimensional reconstruction technology holds promise in addressing this issue. To evaluate the clinical value of three-dimensional reconstruction in thoracoscopic segmental surgery. Seventy-seven patients who underwent thoracoscopic segmental surgery combined with three-dimensional reconstruction at our hospital from January 1, 2020, to August 31, 2023, were retrospectively analyzed. Preoperative chest enhanced CT scans were conducted, and MIMICS software aided in reconstructing DICOM format original data for patients with pulmonary nodules to facilitate intraoperative nodule localization. Accurate segmental pneumonectomy was performed by comparing preoperative anatomical identification of target segmental arteries, veins, and bronchi, with surgical details and postoperative outcomes recorded, including intraoperative pulmonary resection distribution, operation time, blood loss, chest tube drainage, extubation time, hospital stay, and complications. Following preoperative three-dimensional reconstruction, successful segmental lung surgeries were performed, predominantly with single segmental resection (92.2%), and a minority with combined segmentectomy (7.8%). Median operation time was 130225 minutes, with intraoperative blood loss at 70100 mL and postoperative chest tube drainage at 347 mL (159690mL). Median extubation time and hospital stay were 4 days and 7 days, respectively. Complications within the 3-month follow-up affected 11.7% of cases, including persistent pulmonary leakage (7.1%), pulmonary infection (4.3%), atelectasis (4.3%), and pleural effusion (1.4%), with no fatalities. Preoperative 3D reconstruction can help the operator to perform safe, efficient and accurate thoracoscopic segmental pneumonectomy, which is worth popularizing in clinic.

Point-of-Care Ultrasound for Earlier Detection of Pediatric Pneumonia.

An 8-month-old infant presented to a general emergency department with chief complaints of rhinorrhea, decreased activity, and fever. A point-of-care lung ultrasound (LUS) was performed at bedside with potential early findings of pneumonia. Based on these findings on LUS, a chest radiograph (CXR) was ordered and performed with no acute findings. He was discharged without antibiotics based on these findings; unfortunately, he returned two days later with worsening symptoms requiring chest tube placement, mechanical ventilation, and prolonged hospitalization for complicated bacterial pneumonia. Pneumonia is a major cause of pediatric morbidity and mortality worldwide. Despite evidence supporting the utilization of LUS for the diagnosis of pediatric pneumonia, CXR remains the default imaging for clinical decision-making in most settings. In this case, earlier antibiotics and higher reliance on LUS for clinical decision-making may have prevented the morbidity associated with this hospitalization.

Severe Thoracic Trauma Indications and Contraindications for Non-operative and Operative Treatment Strategies

Severe thoracic trauma can occur as a penetrating or blunt mono-injury or as part of a polytrauma. Almost half of all severely injured patients documented in the TraumaRegister DGU were diagnosed with severe chest trauma, defined according to the Abbreviated Injury Scale (AIS) as ≥3. In our own collective, the proportion was even higher with 60%. Emergency surgical treatment with a thoracotomy within the Trauma Resuscitation Unit or within the first hour of admission is an extremely rare intervention in Germany, accounting for 0.9% of severe thoracic injuries. The management of complex polytraumas and extensive pathophysiological reactions to the trauma, as well as knowledge about the development of secondary damage have led to the conclusion that minimally invasive procedures such as video-assisted thoracoscopy (VATS) or inserting a chest drain can resolve most severe thoracic injuries. At <4%, penetrating injuries to the thorax are a rarity. Among blunt thoracic injuries, >6% show an unstable thoracic wall that requires surgical reconstruction. The demographic development in Germany leads to a shift in injury pattern. Low-energy trauma results have lower incidence than higher-grade chest wall injuries with penetrating rib fractures in the pleura, lungs, peri-/myocardium and diaphragm. Sometimes this results in instability of the chest wall with severe restriction of respiratory mechanics, which leads to fulminant pneumonia and even ARDS (Acute Respiratory Distress Syndrome). With this background, surgical chest wall reconstruction has become increasingly important over the past decade. Together with the underlying strong evidence, the assessment of the extend and severity of the trauma and the degree of respiratory impairment are the basis for a structured decision on a non-surgical or surgical-reconstructive strategy, as well as the timing, type and extent of surgery. Early surgery within 72 hours can reduce morbidity (pneumonia rate, duration of intensive care and ventilation) and mortality. In the following article, evidence-based algorithms for surgical and non-operative strategies are discussed in the context on the management of severe thoracic injuries. Thus, a selective literature search was carried out for the leading publications on indications, treatment strategy and therapy recommendations for severe thoracic injury, chest wall reconstruction.

DELAYED PRESENTATION OF A TRAUMATIC ESOPHAGEALPERFORATION&amp; THE PHYSICAL AS WELL AS MENTAL BURDENASSOCIATED WITH IT

Esophageal perforations are an uncommon entity with an incidence of 3.1 per 1,000,000 per year in the USA. (1).There are numerous causes of esophageal perforations, the commonest ones being iatrogenic (those that occur secondary to esophageal instrumentation - endoscopy or post surgical repairs)and spontaneous(Boerhaave Syndrome). Among all esophageal perforations, the reported incidence of traumatic esophageal rupture varies from 4% to 14%. (2), (3).Esophageal injury following blunt chest trauma is extremely rare (up to 0.1%). (4)Hence , we present a case of a middle aged male who presented to our emergency department withhistory of progressively worseningleft sided chest pain, shortness of breath and lethargy since last 5 days. Chest Xray revealed a large left sided suspected hemo/hydropneumothorax for which an Intercostal drain was placed but a large amount of frank purulent discharge was drainedinstead of the anticipated blood/fluid. On further probing , patientrevealed history of blunt trauma to chest12 days priordue to a road traffic accident. The finding of empyema warranted urgent further evaluation. Hence a contrast Computed Tomography scan of the chest was done which revealed an intrathoracic esophageal perforation communicating to the left pleural space. This is a rare and interesting case for a few reasons Anesophageal perforation secondary to blunt chest trauma is a rare entity, this patientpresented to us after almost 2 weeks of trauma and the presenting symptoms led us to makea differential diagnosis of a post traumatic hydro/hemothorax vs an infected hydropneumothorax / empyema (? Tubercular). Hence, thorough history takingenabled us to take a quick and calculated step to rule inesophageal perforation.

Tube Thoracostomy Associated Horner Syndrome: A Case Report

Horner Syndrome is a clinical syndrome caused by disruption of the sympathetic pathway, typically characterized by ipsilateral ptosis, miosis, and facial anhidrosis. Complications can arise during interventional procedures in the thoracic region due to proximity to the upper preganglionic nerve. A 21-year-old female patient who developed drooping of the right eyelid and Horner's syndrome following tube thoracostomy procedure is presented here. It is important to keep in mind that the tube has been removed and the condition may be reversible in terms of treatment.

Comparison between Pigtail Catheter and Intercostal Chest Tube in Drainage of Empyema

Comparison between Pigtail Catheter and Intercostal Chest Tube in Drainage of Empyema

Impact of pneumothorax on mortality, morbidity, and hospital resource utilization in COVID-19 patients: a propensity matched analysis of nationwide inpatient sample database

BackgroundSpontaneous pneumothorax (PTX) is more prevalent among COVID-19 patients than other critically ill patients, but studies on this are limited. This study compared clinical characteristics and in-hospital outcomes among COVID-19 patients with concomitant PTX to provide insight into how PTX affects health care utilization and complications, which informs clinical decisions and healthcare resource allocation.MethodsThe 2020 Nationwide Inpatient Sample was used analyze patient demographics and outcomes, including age, race, sex, insurance status, median income, length of hospital stay, mortality rate, hospitalization costs, comorbidities, mechanical ventilation, and vasopressor support. Propensity score matching was employed for additional analysis.ResultsAmong 1,572,815 COVID-19 patients, 1.41% had PTX. These patients incurred significantly higher hospitalization costs ($435,508 vs. $96,668, p < 0.001) and longer stays (23.6 days vs. 8.6 days, p < 0.001). In-hospital mortality was substantially elevated for PTX patients (65.8% vs. 14.4%, p < 0.001), with an adjusted odds ratio of 14.3 (95% CI 12.7–16.2). Additionally, these patients were more likely to require vasopressors (16.6% vs. 3.3%), mechanical circulatory support (3.5% vs. 0.3%), hemodialysis (16.6% vs. 5.6%), invasive mechanical ventilation (76.9% vs. 15.1%), non-invasive mechanical ventilation (19.1% vs. 5.8%), tracheostomy (13.3% vs. 1.1%), and chest tube placement (59.8% vs. 0.8%).ConclusionsOur findings highlight the severe impact of PTX on COVID-19 patients, characterized by higher mortality, more complications, and increased resource utilization. Also, being Hispanic, male, or obese increased the risk of developing concomitant PTX with COVID-19.

Application of drainage strategy with bi-pigtail catheters in patients undergoing lobectomy by uniportal video-assisted thoracic surgery.

There are no standard guidelines regarding the number and size of chest tubes that should be selected after thoracic surgery. This study aimed to evaluate the effects of adopting a drainage strategy with bi-pigtail catheters (BPCs) on patients undergoing lobectomy by uniportal video-assisted thoracic surgery (VATS). A retrospective study was performed of patients undergoing uniportal lobectomy at the Department of Thoracic Surgery of the Cancer Hospital of Dalian University of Technology between August 2021 and August 2022. The patients were divided into the following two groups according to the drainage strategy adopted: (I) a traditional chest tube (TCT) group; and (II) a BPC group. The outcomes measured included postoperative complications, as measured by the Clavien-Dindo method, and the visual analogue scale (VAS) pain scores of the patients after surgery. In total, 868 patients underwent lung resection during the study period, after exclusion, the data of 470 patients who underwent uniport lobectomy were reviewed (235 in the TCT group, and 235 in the BPC group). There were no statistically significant differences between the two groups in terms of baseline data (P>0.05). The incidence of postoperative complications (7.7% vs. 19.1%) and postoperative VAS pain scores at 7-24 hours (3.3±1.0 vs. 3.7±1.5) and 25-48 hours (3.1±0.8 vs. 3.6±1.5) were significantly lower in the BPC group than the TCT group (all P<0.001). Additionally, the postoperative length of stay (4.6±1.5 vs. 5.4±4.5 days) and the collapse rate of the residual lung (19.2%±9.1% vs. 20.9%±9.6%) of the BPC group were better than those of the TCT group (P<0.05). The results of univariable and multivariable analyses showed that a drainage strategy with a TCT was an independent risk factor for decreased postoperative complications, and reduced moderate or severe pain scores at 7-24 and 25-48 hours after surgery. Our drainage strategy with BPCs decreased the incidence of postoperative complications and alleviated the postoperative pain of patients undergoing lobectomy by uniportal VATS and is safe and feasible.

Safety and efficacy of surgically performed continuous superficial serratus anterior plane block in uniportal video-assisted thoracic surgery.

The 'surgically performed' continuous superficial serratus anterior plane block (continuous s-SAPB) was never described before in uniportal video-assisted thoracic surgery (uniportal VATS) surgery. The aim of the study was to evaluate the safety and efficacy of the technique. Between March 2022 and April 2023, 50 patients, undergone uniportal VATS surgery at our thoracic surgery department, were scheduled for a surgically performed continuous s-SAPB as post-operative analgesia protocol. The mean execution time for the block was 3.92 ± 2.56 min. Ten patients (20%) required morphine for a visual analogue scale (VAS) score >4 immediately after surgery. The recorded VAS score at chest tube removal was 1.87 ± 1.41, whereas 2 h after the manoeuvre was 0.42 ± 0.72. No complication related to block insertion was recorded. The onset of chronic pain was observed in a total of 2 patients (4%). The surgically performed continuous s-SAPB in uniportal VATS seems to be safe and easy to perform, and it provides a satisfactory analgesic effect.

Priorities and strategy for the implementation of enhanced recovery after surgery (ERAS) in thoracic surgery.

Enhanced recovery after surgery (ERAS) is a perioperative care protocol, which was introduced several years ago and has gained increasing importance in thoracic surgery. The aim of this study was to provide guidance through clinical implementation and to identify factors for better compliance. This prospective cohort study collected data between July 2021 and June 2022 at the Department of Thoracic Surgery (University Hospital Regensburg, Germany). A modified enhanced recovery after thoracic surgery (ERATS) protocol with recommendations covering the pre-, intra- and postoperative phases was established and followed. The primary objective was to evaluate the implementation of the ERATS protocol. Secondary, specific and clinically relevant recommendations were analyzed regarding their compliance. The study included 139 patients undergoing elective lung resections. Many ERATS recommendations were already part of standard perioperative care, including perioperative antibiotics, venous thromboembolism prophylaxis and intraoperative warming. Other measures such as anemia management, carbohydrate loading or chest drain management were updated or newly established and standardized according to our ERATS protocol. The recommendations emphasizing early postoperative mobilization were found to be crucial. We identified three groups with significantly different compliance rates: (I) patient-dependent measures which require active participation (49.3%); (II) treatment measures requiring interdisciplinary consensus (85.8%); and (III) surgical measures (88%). The implementation and continuous evaluation of our perioperative ERATS protocol led to a new categorization of targeted measures into three groups with actors of different competencies. The new grouping enables gradual implementation and a step-by-step targeted approach in order to achieve a higher compliance of ERATS in the future as well as long-term sustainability.

Post-intubation tracheal injury during esophagectomy

Post-intubation tracheal injuries are rare complications with serious consequences. Several factors increase the risk of tracheal injuries which may be attributed to patient, or procedure related. Majority of the tracheal injuries are managed surgically, however, role of less invasive and conservative treatment are also emerging. Case: we report a case of an elderly lady who underwent minimally invasive esophagectomy for esophageal carcinoma. She developed significant surgical emphysema within hours after surgery and massive air leak through underwater seal chest drainage tube. She was taken for emergency re-exploration. On table bronchoscopy confirmed 5 cm longitudinal tear of membranous part of cervical and upper thoracic trachea. Thoracoscopic repair along with transcervical-transtracheal repair of membranous wall of trachea and a tracheostomy was performed. She made significant recovery with few complications which were managed successfully.

Evaluation of the effect of the quality and quantity of fluid drained due to pleural effusion on complications that may develop in intensive care unit

Aims: Pleural drainage volume is very important for oxygenation and perfusion in patients with massive pleural effusion. However, there is still no clear data between the complications that may develop after pleural drainage and the optimal volume of fluid to be removed. The primary aim of this study was to evaluate the effect of the quality and quantity of pleural fluid drained due to pleural effusion in the intensive care unit (ICU) on the complications that may develop after drainage and to determine the optimal drainage volume to prevent complications. The secondary aim was to determine the risk factors affecting the development of complications after pleural effusion drainage. Methods: A total of 176 patients who underwent pleural drainage for pleural effusion between April 1,2022 and December 31,2023 in an adult tertiary ICU were retrospectively analyzed. Demographic information, clinical follow-up information, quantity and quality of pleural effusion, laboratory values and complications were recorded and the relationship between these parameters and the amount of pleural fluid drained within 24 hours and complications were evaluated. Results: ICU duration, ICU mortality, activated partial thromboplastin time (aPTT) and vasopressor requirement were found to be statistically significantly higher in patients with complications after pleural drainage procedure. In multivariate logistic regression analysis, female gender (odds ratio=0.455, p=0.049) and need for vasopressors (odds ratio=2.373, p=0.034) increased the risk of complications. There was no statistically significant difference between the amount of pleural fluid drained and complications. In addition, when the optimal amount of drained fluid required to prevent complications was analyzed, a cut off value could not be given. Conclusion: In order to reduce the risk of complications that may develop after pleural drainage, we believe that paying more attention to the position during pleural drainage in patients receiving vasopressor support and performing pleural drainage with the help of ultrasound in patients whose position cannot be changed due to hemodynamic disorder will reduce the complication rate. We think that a decrease in the complication rate will be effective in terms of both cost and efficient use of ICU beds by reducing the length of ICU stay and ICU mortality. In our study, the quality and quantity of pleural fluid drained had no effect on the complications that may develop after drainage, and further studies with a larger patient population are needed to investigate this situation.

Multidisciplinary damage control strategy for Boerhaave’s syndrome: A case report

IntroductionBoerhaave's syndrome is a rare clinical condition, characterized by the rupture of the oesophagus following a sudden increase in intraoesophageal pressure. It can occur in various regions of the oesophagus. Its rarity, coupled with the diversity of its possible presentations, makes the diagnosis more challenging and results in non-standardized treatment. Case presentationWe report the case of a 71-year-old man who resorted to the emergency department with severe epigastric pain after vomiting. The patient's CT scan revealed an oesophageal rupture. A thoracoscopy was performed with pleural debridement and positioning of three pleural drainage. Endoscopic stenting was performed and a nutritional jejunostomy was prepared before admitting the patient to the Intensive Care Unit. The postoperative course was complicated by a para-oesophageal abscess and dislocation of the endoscopic stent. The patient was discharged home on the 46th day, and the endoscopic stents were successfully removed three months later. DiscussionIn the more extensive metanalysis we found, the majority of perforations were in the distal oesophagus, the initial therapeutic management consisted of surgery, followed by endoscopy, surgery and endoscopy together, and conservative treatment in 15 %. Most patients were admitted to ICU and the mortality reached 17 %. The time of diagnosis was crucially associated with clinical outcomes. ConclusionThe choice of the most suitable approach should be tailored to the patient and should be guided by the time of diagnosis, perforation severity and patient medical condition at presentation, but the management of Boerhaave’s syndrome remains a challenge.

Predictors of surgical intervention in first episode primary spontaneous pneumothorax requiring chest drain insertion.

Primary spontaneous pneumothorax occurs in patients with no underlying lung disease and guidelines recommend chest tube drainage for the first episode, with surgical intervention reserved for recurrent episodes, persistent air leak or failure of lung re-expansion. Modern surgical management is associated with reduced length of hospital stay and superior freedom from recurrence compared with chest tube drainage alone. The objective of this study was to identify risk factors for failed chest tube drainage in patients who present with first episode primary spontaneous pneumothorax. A retrospective analysis of patients who presented to Royal Prince Alfred Hospital, Australia with first episode PSP and underwent chest tube insertion was performed. Patient demographics and size of pneumothorax were examined in relation to the primary outcome, a composite of failed chest tube drainage and recurrent ipsilateral pneumothorax. Fifty-five patients underwent chest tube drainage for first episode primary spontaneous pneumothorax between 1st January 2017 and 31st December 2020. Complete lung collapse on admission chest x-ray was associated with an increased risk of the primary outcome (63% versus 19%, OR 7.3 [96% CI 2.0-27.4), P = 0.004). This small retrospective study found that patients that undergo chest drain insertion for first episode primary spontaneous pneumothorax who present with complete lung collapse on admission are at high risk of requiring pleurodesis and therefore may benefit from early surgical referral.

Advancements in Interventional Pulmonology: Harnessing Ultrasound Techniques for Precision Diagnosis and Treatment.

Medical ultrasound has emerged as an indispensable tool within interventional pulmonology, revolutionizing diagnostic and procedural practices through its non-invasive nature and real-time visualization capabilities. By harnessing the principles of sound waves and employing a variety of transducer types, ultrasound facilitates enhanced accuracy and safety in procedures such as transthoracic needle aspiration and pleural effusion drainage, consequently leading to improved patient outcomes. Understanding the fundamentals of ultrasound physics is paramount for clinicians, as it forms the basis for interpreting imaging results and optimizing interventions. Thoracic ultrasound plays a pivotal role in diagnosing conditions like pleural effusions and pneumothorax, while also optimizing procedures such as thoracentesis and biopsy by providing precise guidance. Advanced ultrasound techniques, including endobronchial ultrasound, has transformed the evaluation and biopsy of lymph nodes, bolstered by innovative features like elastography, which contribute to increased procedural efficacy and patient safety. Peripheral ultrasound techniques, notably radial endobronchial ultrasound (rEBUS), have become essential for assessing pulmonary nodules and evaluating airway structures, offering clinicians valuable insights into disease localization and severity. Neck ultrasound serves as a crucial tool in guiding supraclavicular lymph node biopsy and percutaneous dilatational tracheostomy procedures, ensuring safe placement and minimizing associated complications. Ultrasound technology is suited for further advancement through the integration of artificial intelligence, miniaturization, and the development of portable devices. These advancements hold the promise of not only improving diagnostic accuracy but also enhancing the accessibility of ultrasound imaging in diverse healthcare settings, ultimately expanding its utility and impact on patient care. Additionally, the integration of enhanced techniques such as contrast-enhanced ultrasound and 3D imaging is anticipated to revolutionize personalized medicine by providing clinicians with a more comprehensive understanding of anatomical structures and pathological processes. The transformative potential of medical ultrasound in interventional pulmonology extends beyond mere technological advancements; it represents a paradigm shift in healthcare delivery, empowering clinicians with unprecedented capabilities to diagnose and treat pulmonary conditions with precision and efficacy. By leveraging the latest innovations in ultrasound technology, clinicians can navigate complex anatomical structures with confidence, leading to more informed decision-making and ultimately improving patient outcomes. Moreover, the portability and versatility of modern ultrasound devices enable their deployment in various clinical settings, from traditional hospital environments to remote or resource-limited areas, thereby bridging gaps in healthcare access and equity.

Perioperative risks associated with administration of andexanet alfa during emergency cardiac surgery with circulatory arrest.

This case report describes the perioperative course of a patient undergoing emergency repair of acute type A thoracic aortic dissection. Andexanet alfa was administered intraoperatively to obtain a dry operative field for right axillary artery exposure and cannulation. Andexanet alfa-induced heparin resistance resulted in cardiopulmonary bypass circuit and pericardial thrombosis requiring more than 400,000 units of unfractionated heparin and antithrombin III to overcome. Postoperatively, excessive chest tube output was observed secondary to protracted heparin rebound requiring continuous dosing of protamine. This case demonstrates the significant challenging perioperative, not just intraoperative, hazards associated with intraoperative andexanet alfa use during emergency cardiac surgery with cardiopulmonary bypass.