Alistair Macfie

Guidelines on the radical management of patients with lung cancer.

A joint initiative by the British Thoracic Society and the Society for Cardiothoracic Surgery in Great Britain and Ireland was undertaken to update the 2001 guidelines for the selection and assessment of patients with lung cancer who can potentially be managed by radical treatment.

Anesthesia for thoracic surgery: a survey of middle eastern practice.

Purpose: The main objective of this survey is to describe the current practice of thoracic anesthesia in the Middle Eastern (ME) region. Methods: A prospective online survey. An invitation to participate was e-mailed to all members of the ME thoracic-anaesthesia group. A total of 58 members participated in the survey from 19 institutions in the Middle East. Questions concerned ventilation strategies during one-lung ventilation (OLV), anesthesia regimen, mode of postoperative analgesia, use of lung isolation techniques, and use of i.v. fluids. Results: Volume-controlled ventilation was favored over pressure-controlled ventilation (62% vs 38% of respondents, P<0.05); 43% report the routine use of positive end-expiratory pressure. One hundred percent of respondents report using double-lumen tube (DLT) as a first choice airway to establish OLV. Nearly a third of respondents, 31.1%, report never using bronchial blocker (BB) in their thoracic anesthesia practice. Failure to pass a DLT and difficult airway are the most commonly cited indications for BB use. Regarding postoperative analgesia, the majority 61.8% favor thoracic epidural analgesia over other techniques (P<0.05). Conclusions: Our survey provides a contemporary snapshot of the ME thoracic anesthetic practice.

Inadvertent Total Spinal Anesthesia After Intercostal Nerve Block Placement During Lung Resection

Intercostal nerve block is a recognized way of providing analgesia at thoracotomy. There is a rare association between intercostal nerve block and the complication of total spinal anesthesia. This may arise inadvertently by injection into a dural cuff extending outside the intervertebral foramen. We report our experience with a patient who sustained this life-threatening complication. The patient required postoperative ventilation until the neurologic deficits resolved. The operator must be aware that intercostal nerve block runs the rare but potentially fatal risk of total spinal block.

Where now for thoracic paravertebral blockade

In this issue of Anaesthesia, Luyet et al. report an elegant study examining the reliability of the classical landmark approach to paravertebral blockade (PVB) [1]. While this report will no doubt be of interest to thoracic anaesthetists, we urge all general anaesthetists not to be too hasty in turning the page, as this work has broader application. In 2006, Exadaktylos et al. published a retrospective study analysing the medical records of 129 consecutive patients undergoing surgery for breast cancer. The findings suggested that paravertebral anaesthesia and analgesia for breast cancer surgery may reduce the risk of tumour recurrence or metastasis [2]. While confirmation from prospective randomised controlled trials is awaited, the volume of in vitro data to support such a hypothesis is growing [3]. Should such an approach be convincingly demonstrated to confer survival benefits, the delivery of effective regional anaesthesia and analgesia will become an established standard of care in cancer surgery. This increases the drive to develop a safe, effective and reliable technique for unilateral regional blockade. In thoracic surgery, debate surrounding the ideal analgesic technique for thoracotomy has intensified in recent years with the suggestion that PVB has a better side-effect profile and has been associated with a reduction in complications compared with thoracic epidural analgesia (TEA) [4, 5]. The current practice of thoracic anaesthesia in the UK is represented by an approximately 2:1 split in favour of TEA over PVB [6], a split that has remained consistent over several years, perhaps suggesting that to many, either the reliability or the benefits of PVB over TEA are yet to be sufficiently proven to change practice. Luyet et al. report an observational study aiming to explore the association between the location of paravertebral catheters placed using the classical landmark technique, the distribution of contrast dye delivered through the catheter, and the extent of subsequent somatic block [1]. In doing so, the authors encounter one of the many methodological difficulties that challenges studies of this sort: what constitutes failure of regional anaesthetic blockade? In one recent, high-profile, meta-analysis comparing the analgesic efficacy and side effects of PVB versus TEA for thoracotomy, the included studies defined failed technique as anything from failure to catheterise the epidural space and inadequate analgesia (technique failure) to unavailability of an infusion pump (system failure) [4]. When appraising the regional anaesthetic literature, clinicians must pay careful attention to definitions of failure and decide what constitutes a clinically meaningful failure in their practice. It has been said that regional anaesthesia always works provided you put the right dose, of the right drug, in the right place [7]. The pertinent question is: how do you deliver local anaesthetic to the right place within the paravertebral space? It has been demonstrated that the analgesic effect of single-shot PVB lasts approximately six hours, and that as such, in order to provide prolonged postoperative analgesia via PVB, a catheter technique is required [8]. In Luyet et al.s study, the authors attempted to place PVB catheters by a percutaneous landmark technique in 31 patients. In one patient, difficulties were encountered during paravertebral catheter placement, leading the investigators to switch to an ultrasound-guided approach (undoubtedly a case of technique failure). The authors define the spread of contrast dye within the paravertebral space either close to the intervertebral neural foramen, extrapleural laterally at the level of the ribs, extrapleurally at the level of the vertebral bodies or anterior to the vertebral bodies, as a successful radiological endpoint; the right place. In nine out of 30 catheters, dye was not seen in these locations. Including the failed catheterisation,

Ventricular Assist Devices as Rescue Therapy in Cardiogenic Shock After Subarachnoid Hemorrhage

We review the journey to myocardial and neurologic recovery of a 42-year-old mother with severe acute cardiogenic shock and multiorgan failure after extensive subarachnoid hemorrhage, who was salvaged successfully using a CentriMag short-term biventricular assist device.

Critical care after lung resection: CALoR 1, a single-centre pilot study.

Lung resection is associated with significant perioperative morbidity, and a proportion of patients will require intensive care following surgery. We set out to characterise this population, assess their burden of disease and investigate the influence of anaesthetic and surgical techniques on their admission rate. Over a two‐year period, 1169 patients underwent surgery, with 30 patients (2.6%) requiring unplanned intensive care. Patients requiring support had a higher mortality (0.2% vs 26.7%, p < 0.001). Logistic regression (following adjustment for Thoracoscore) revealed that an open surgical approach was associated with higher likelihood of admission (p = 0.025, odds ratio = 5.25). There was also a trend towards increased likelihood of admission in patients who received volatile anaesthesia (p = 0.061, odds ratio = 2.08). This topic has been selected for further investigation as part of the 2015 Association of Cardiothoracic Anaesthetists (ACTA) second national collaborative audit, with this study providing pilot data before a multi‐centre study.

Type III procollagen as a biomarker of susceptibility to ARDS

Dear Editor, We read with interest Forel and colleagues’ prospective study of serum and alveolar N-terminal-peptide type III procollagen (NT-PCP III) levels in the setting of ARDS. The authors provide convincing histological evidence supporting NT-PCP III as a biomarker of fibroproliferation in established ARDS [1]. This adds to previous work describing type III procollagen (PCP III) and its related peptide byproducts (NT-PCP III and C-terminal-propeptide type III procollagen) as ‘early biomarkers’ of ARDS and a previously reported association between PCP III level and increased mortality [2, 3]. Forel et al. and previous investigators have focused on the potential role of PCP III to guide diagnosis and therapy in ARDS. We write to describe our pilot study investigating the role of PCP III in a human one-lung ventilation (OLV) model of ARDS [4] and to offer the hypothesis that PCP III may also serve as a biomarker of susceptibility to lung injury. With research ethics committee approval and informed consent we collected perioperative blood samples from 22 patients undergoing lateral thoracotomy for resection of primary lung cancer. Serum PCP III was directly measured by enzyme immunoassay (USCN Life Science Inc, China) pre-, immediately postand 24 h postoperatively. A PaO2/FiO2 ratio of 300 mmHg or less at 6 h postoperatively was defined as a surrogate end point reflecting poor postoperative oxygenation as described previously in an OLV population [5]. As hypothesised, PCP III levels were negatively associated with poor postoperative oxygenation (PaO2/ FiO2 ratio) immediately (r = -0.52, p = 0.02) and 24 h postoperatively (r = -0.50, p = 0.04; Pearson correlation). Somewhat unexpectedly however, a negative association also existed between preoperative PCP III levels and oxygenation at 6 h postoperatively (r = -0.55, p = 0.01; Fig. 1). A preoperative PCP III level of greater than 73.2 ng/ml had a sensitivity of 0.56 and specificity of 0.89 for a PaO2/FiO2 ratio of 300 mmHg or less at 6 h postoperatively with a positive predictive value of 83.3 % and a negative predictive value of 66.7 %. This was signified by an area under the receiver operating characteristic curve (AUROC) of 0.80, 95 % CI 0.58–1.00 (p = 0.03). The role of PCP III as a biomarker of susceptibility to ARDS is biologically plausible. PCP III has previously been described as a biomarker of both hepatic and pulmonary fibrosis and may be elevated in major trauma i.e. groups known to be at an increased risk of developing ARDS. A possible explanation for our hypothesis is that PCP III is a preoperative marker of subclinical concurrent disease which is increasing susceptibility to ARDS. If validated, a reliable biomarker to predict susceptibility to lung injury could prove valuable in patients undergoing all types of high-risk surgery and throughout the wider hospital population. We are currently conducting a larger study investigating the predictive role of PCP III in a

Cardiothoracic critical care

Cardiothoracic critical care / , Cardiothoracic critical care / , کتابخانه دیجیتال جندی شاپور اهواز

721: INCIDENCE AND MORTALITY OF POST-LUNG RESECTION LUNG INJURY OVER TIME; A META-REGRESSION ANALYSIS

Lung injury is the major cause of early mortality in patients undergoing lung resection. A restrictive approach to fluid management and lung protective ventilatory techniques have been widely incorporated into thoracic anaesthetic practice in the belief they will prevent lung injury. We hypothesised that the incidence and mortality of ALI/ARDS following lung resection have fallen over time.