Chun-Yu Wu

Feasibility and Safety of Nonintubated Thoracoscopic Lobectomy for Geriatric Lung Cancer Patients

BACKGROUNDnThe feasibility and safety of thoracoscopic lobectomy using anesthesia without tracheal intubation for treatment of geriatric non-small cell lung cancer patients is unclear, although it has been used with success in younger populations.nnnMETHODSnFrom 2009 through 2011, 84 consecutive patients aged 65 years or older with stage I or II non-small cell lung cancer underwent thoracoscopic lobectomy. Among them, 36 patients were treated without tracheal intubation using epidural anesthesia, intrathoracic vagal blockade, and sedation (nonintubated group). The other 48 patients were treated with single-lung ventilation under general anesthesia intubated with a double-lumen tube (intubated group). The perioperative profiles and short-term outcomes of the two groups were compared.nnnRESULTSnThe 84 patients were a mean age of 73.0 years (range, 65-87 years). Both groups had comparable preoperative demographic and cancer staging profiles. The anesthetic duration of the nonintubated group was shorter. Both groups had comparable operation duration and blood loss. One patient in the nonintubated group was converted to tracheal intubation due to persistent hypoxemia. Postoperatively, the two groups had comparable hospital stays, complication rates, and dissected lymph nodes. Stridor was noted in 3 patients and delirium in 4 in the intubated group, but none occurred in the nonintubated group.nnnCONCLUSIONSnNonintubated thoracoscopic lobectomy is technically feasible and was as safe as thoracoscopic lobectomy performed with tracheal intubation in the geriatric lung cancer patients. Thoracoscopic lobectomy without tracheal intubation during anesthesia is a valid alternative for managing selected geriatric patients with non-small cell lung cancer.

Patient-controlled analgesia (PCA) following video-assisted thoracoscopic lobectomy: Comparison of epidural PCA and intravenous PCA

OBJECTIVESnTo compare the efficacy and side effects of epidural patient-controlled analgesia (EPCA) with those of intravenous patient-controlled analgesia (IVPCA) in fast-track video-assisted thoracoscopic (VATS) lobectomy.nnnPATIENTS AND METHODSnEPCA or IVPCA was chosen by patients and was started immediately following tracheal extubation in the wake of completion of VATS lobectomy. EPCA analgesia was carried out with the PCA device programmed to deliver a bolus dose of 3 mL of 0.1% bupivacaine combined with 1.2 μg/mL fentanyl, and continuous epidural infusion at a rate of 4 mL/hour through an epidural catheter placed at the T(6-7) or T(7-8) level. IVPCA was made possible by a patient controlled infusion pump programmed to deliver 0.1% morphine with a loading dose of 3 mg, and the controlled bolus of 1 mg, at a lockout interval of 5 minutes. A rescue dose of 5 mg intravenous morphine was available for all patients in postoperative care unit. Pain management was assessed with visual analog scale at rest (VAS-R) and during motion (VAS-M); side effects including nausea, vomiting, pruritus, dizziness and sleepiness were recorded and analyzed from postoperative Day 1 (POD1) to Day 3 (POD3).nnnRESULTSnThis study included 105 patients. Satisfactory pain control was achieved, although 9/70 patients in the EPCA group and 5/35 patients in the IVPCA group needed rescue morphine in the recovery room. The VAS-R was significantly higher on POD1 than on POD2 or POD3 in both groups (p < 0.001). The VAS-R and VAS-M were comparable in both groups on POD1 and POD3 but significant lower VAS-M was seen in the EPCA group on POD2 (p = 0.008). Higher incidence of dizziness was found in the IVPCA group on POD1 (p = 0.044) but the EPCA group had a higher incidence of pruritus on POD2 (p = 0.024) and POD3 (p = 0.03).nnnCONCLUSIONnOur results indicated that the necessity of pain control was higher on POD1 for VATS lobectomy. Both EPCA and IVPCA can provide an adequate, continuous and effective means for postoperative pain management and a lower VAS-M was found in EPCA on POD2.

Changes in endotracheal tube cuff pressure during laparoscopic surgery in head-up or head-down position

BackgroundThe abdominal insufflation and surgical positioning in the laparoscopic surgery have been reported to result in an increase of airway pressure. However, associated effects on changes of endotracheal tube cuff pressure are not well established.Methods70 patients undergoing elective laparoscopic colorectal tumor resection (head-down position, nu2009=u200938) and laparoscopic cholecystecomy (head-up position, nu2009=u200932) were enrolled and were compared to 15 patients undergoing elective open abdominal surgery. Changes of cuff and airway pressures before and after abdominal insufflation in supine position and after head-down or head-up positioning were analysed and compared.ResultsThere was no significant cuff and airway pressure changes during the first fifteen minutes in open abdominal surgery. After insufflation, the cuff pressure increased from 26u2009±u20093 to 32u2009±u20096 and 27u2009±u20093 to 33u2009±u20095 cmH2O in patients receiving laparoscopic cholecystecomy and laparoscopic colorectal tumor resection respectively (both pu2009<u20090.001). The head-down tilt further increased cuff pressure from 33u2009±u20095 to 35u2009±u20095 cmH2O (pu2009<u20090.001). There six patients undergoing colorectal tumor resection (18.8%) and eight patients undergoing cholecystecomy (21.1%) had a total increase of cuff pressure more than 10xa0cm H2O (18.8%). There was no significant correlation between increase of cuff pressure and either the patients body mass index or the common range of intra-abdominal pressure (10-15xa0mmHg) used in laparoscopic surgery.ConclusionsAn increase of endotracheal tube cuff pressure may occur during laparoscopic surgery especially in the head-down position.

Does targeted pre-load optimisation by stroke volume variation attenuate a reduction in cardiac output in the prone position

The prone position can reduce cardiac output by up to 25% due to reduced preload. We hypothesised that preload optimisation targeted to stroke volume variation before turning prone might alleviate this. A supine threshold stroke volume variation of 14% in a preliminary study identified patients whose cardiac outputs would decline when turned prone. In 45 patients, cardiac output declined only in the group whose supine stroke volume variation was high (mean (SD) 5.1 (2.0) to 3.9 (1.9) l.min−1; pu2003<u20030.001), but not in patients in whom it was low, or in those in whom stroke volume variation was high, but who received volume preload (pu2003=u20030.525 and 0.941, respectively). We conclude that targeted preload optimisation using a supine stroke volume variation value <u200314% is effective in preventing falls in cardiac output induced by the prone position.

Effects of Dexmedetomidine on Intestinal Microcirculation and Intestinal Epithelial Barrier in Endotoxemic Rats.

Background:Dexmedetomidine reduces cytokine production in septic patients and reduces inflammation and mortality in experimental models of endotoxemia and sepsis. This study investigated whether dexmedetomidine attenuates endothelial dysfunction, intestinal microcirculatory dysfunction, and intestinal epithelial barrier disruption in endotoxemic rats. Methods:Ninety-two male Wistar rats were randomly assigned to the following four groups: (1) Sham; (2) lipopolysaccharide, received IV lipopolysaccharide 15 and 10u2009mg/kg at 0 and 120u2009min; (3) dexmedetomidine, received IV dexmedetomidine for 240u2009min; and (4) lipopolysaccharide + dexmedetomidine, received both lipopolysaccharide and dexmedetomidine. Sidestream dark-field videomicroscope, tissue oxygen monitor, and full-field laser perfusion image were used to investigate the microcirculation of the terminal ileum. Serum endocan level was measured. The Ussing chamber permeability assay, lumen-to-blood gadodiamide passage by magnetic resonance imaging, and bacterial translocation were conducted to determine epithelial barrier function. Mucosal apoptotic levels and tight junctional integrity were also examined. Results:The density of perfused small vessels in mucosa, serosal muscular layer, and Peyer patch in the lipopolysaccharide + dexmedetomidine group was higher than that of the lipopolysaccharide group. Serum endocan level was lower in the lipopolysaccharide + dexmedetomidine group than in the lipopolysaccharide group. Mucosal ratio of cleaved to full-length occludin and spleen bacterial counts were significantly lower in the lipopolysaccharide + dexmedetomidine group than in the lipopolysaccharide group. Conclusion:The study finding suggests that dexmedetomidine protects against intestinal epithelial barrier disruption in endotoxemic rats by attenuating intestinal microcirculatory dysfunction and reducing mucosal cell death and tight junctional damage. (Anesthesiology 2016; 125:355-67)

Fast Track Ultrasound Protocol to Detect Acute Complications After Totally Implantable Venous Access Device Placement

BackgroundThe role of ultrasound examination in detection of postprocedure complications from totally implantable venous access devices (TIVAD) placement is still uncertain. In a cohort of 665 cancer outpatients, we assessed a quick ultrasound examination protocol in early detection of mechanical complications of catheterization.MethodsImmediately after TIVAD placement, an ultrasound examination and chest radiography were performed to detect hemothorax, pneumothorax, and catheter malposition. The two methods were compared.ResultsOf the 668 catheters inserted, 628 were placed into axillary veins and 40 into internal jugular veins. The ultrasound examination took 2.5xa0±xa01.1xa0min. No hemothorax was detected, and neither pneumothorax nor catheter malposition was evident among the 40 internal jugular vein cannulations. Ultrasound and chest radiography examinations of the 628 axillary vein cannulations detected five and four instances of pneumothorax, respectively. Ultrasound detected all six catheter malpositions into the internal jugular vein. However, ultrasound failed to detect two out of three malpositions in the contralateral brachiocephalic vein and one kinking inside the superior vena cava. Without revision surgery, the operating time was 34.1xa0±xa015.6xa0min. With revision surgery, the operating time was shorter when ultrasound detected catheter malposition than when chest radiography was used (96.8xa0±xa012.9 vs. 188.8xa0±xa010.3xa0min, pxa0<xa00.001).ConclusionsPostprocedure ultrasound examination is a quick and sensitive method to detect TIVAD-related pneumothorax. It also precisely detects catheter malposition to internal jugular vein thus reduces time needed for revision surgery while chest radiography remains necessary to confirm catheter final position.

Pretreatment serum lactate level as a prognostic biomarker in patients undergoing supratentorial primary brain tumor resection

INTRODUCTIONnMalignant primary brain tumors are one of the most aggressive cancers. Pretreatment serum nonneuronal biomarkers closely associated with postoperative outcomes are of high clinical relevance. The present study aimed to identify potential pretreatment serum biomarkers that may influence oncological outcomes in patients with primary brain tumors.nnnMETHODSnA total of 74 patients undergoing supratentorial primary brain tumor resection were enrolled. Before tumor resection, serum neuronal biomarkers, namely neuron-specific enolase (NSE), S100β, and glial fibrillary acidic protein (GFAP), and serum nonneuronal biomarkers, namely neutrophil gelatinase-associated lipocalin (NGAL), lactate dehydrogenase (LDH), and lactate, were measured and associated postoperative oncological outcomes, including brain tumor grading, progression-free survival (PFS), and overall survival (OS), were compared.nnnRESULTSnPatients with high-grade brain tumors had significantly higher pretreatment serum lactate levels (p = 0.011). By contrast, other biomarkers were comparable between patients with high-grade and low-grade brain tumors. Receiver operating characteristic curve analysis of serum lactate levels yielded an area under the curve of 0.71 for differentiating between high-grade and low-grade brain tumors. Kaplan-Meier survival analysis revealed patients with high serum lactate levels (âx89§2.0 mmol/L) had shorter PFS and OS (p = 0.021 and p = 0.093, respectively). In a multiple regression model, only elevated serum lactate levels were associated with poor PFS and OS (p = 0.021 and p = 0.048, respectively).nnnCONCLUSIONSnAn elevated pretreatment serum lactate level is a prognostic biomarker of high-grade primary brain tumors and is significantly associated with poor PFS in patients with supratentorial brain tumors undergoing tumor resection. By contrast, other serum biomarkers are not significantly associated with oncological outcomes.Introduction Malignant primary brain tumors are one of the most aggressive cancers. Pretreatment serum nonneuronal biomarkers closely associated with postoperative outcomes are of high clinical relevance. The present study aimed to identify potential pretreatment serum biomarkers that may influence oncological outcomes in patients with primary brain tumors. Methods A total of 74 patients undergoing supratentorial primary brain tumor resection were enrolled. Before tumor resection, serum neuronal biomarkers, namely neuron-specific enolase (NSE), S100β, and glial fibrillary acidic protein (GFAP), and serum nonneuronal biomarkers, namely neutrophil gelatinase-associated lipocalin (NGAL), lactate dehydrogenase (LDH), and lactate, were measured and associated postoperative oncological outcomes, including brain tumor grading, progression-free survival (PFS), and overall survival (OS), were compared. Results Patients with high-grade brain tumors had significantly higher pretreatment serum lactate levels (p = 0.011). By contrast, other biomarkers were comparable between patients with high-grade and low-grade brain tumors. Receiver operating characteristic curve analysis of serum lactate levels yielded an area under the curve of 0.71 for differentiating between high-grade and low-grade brain tumors. Kaplan–Meier survival analysis revealed patients with high serum lactate levels (≧2.0 mmol/L) had shorter PFS and OS (p = 0.021 and p = 0.093, respectively). In a multiple regression model, only elevated serum lactate levels were associated with poor PFS and OS (p = 0.021 and p = 0.048, respectively). Conclusions An elevated pretreatment serum lactate level is a prognostic biomarker of high-grade primary brain tumors and is significantly associated with poor PFS in patients with supratentorial brain tumors undergoing tumor resection. By contrast, other serum biomarkers are not significantly associated with oncological outcomes.

Effects of endotoxin absorber hemoperfusion on microcirculation in septic pigs

BACKGROUNDnEndotoxins contribute to systemic inflammatory response and microcirculatory dysfunctions under conditions of sepsis. Polymyxin B hemoperfusion (PMX-HP) is used to remove circulating endotoxins and improve clinical outcomes. This study aims to investigate the effect of PMX-HP on microcirculation in septic pigs.nnnMATERIALS AND METHODSnBy using a septic pig model, we tested the hypothesis that PMX-HP can correct intestinal microcirculation, tissue oxygenation saturation, and histopathologic alterations. A total of 18 male pigs were divided into three groups: (1) sham; (2) sepsis (fecal peritonitis); and (3) sepsisxa0+xa0PMX-HP groups. A sidestream dark field video microscope was used to record microcirculation throughout the terminal ileal mucosa, colon mucosa, kidney surface, and sublingual area. A superficial tissue oxygenation monitor employing the light reflectance spectroscopy technique was used to measure the tissue oxygen saturation. Hematoxylin and eosin staining was used for histologic examination.nnnRESULTSnThe perfused small vessel density and tissue oxygen saturation of the ileal mucosa at 6xa0h were higher in the sepsisxa0+xa0PMX-HP group than those in the sepsis group. The fluid amount and norepinephrine infusion rate between the sepsis group and sepsisxa0+xa0PMX-HP groups did not differ significantly. The histologic score for the ileal mucosa was lower in the sepsisxa0+xa0PMX-HP group than that in the sepsis group. Finally, the urine output was higher in the sepsisxa0+xa0PMX-HP group than it was in the sepsis group.nnnCONCLUSIONSnThis study demonstrates that PMX-HP attenuates microcirculatory dysfunction, tissue desaturation, and histopathologic alterations in the ileal mucosa in septic pigs.

Effects of Dexmedetomidine Infusion on Inflammatory Responses and Injury of Lung Tidal Volume Changes during One-Lung Ventilation in Thoracoscopic Surgery: A Randomized Controlled Trial

One-lung ventilation in thoracic surgery provokes profound systemic inflammatory responses and injury related to lung tidal volume changes. We hypothesized that the highly selective a2-adrenergic agonist dexmedetomidine attenuates these injurious responses. Sixty patients were randomly assigned to receive dexmedetomidine or saline during thoracoscopic surgery. There is a trend of less postoperative medical complication including that no patients in the dexmedetomidine group developed postoperative medical complications, whereas four patients in the saline group did (0% versus 13.3%, p = 0.1124). Plasma inflammatory and injurious biomarkers between the baseline and after resumption of two-lung ventilation were particularly notable. The plasma high-mobility group box 1 level decreased significantly from 51.7 (58.1) to 33.9 (45.0) ng.ml−1 (p < 0.05) in the dexmedetomidine group, which was not observed in the saline group. Plasma monocyte chemoattractant protein 1 [151.8 (115.1) to 235.2 (186.9) pg.ml−1, p < 0.05] and neutrophil elastase [350.8 (154.5) to 421.9 (106.1) ng.ml−1, p < 0.05] increased significantly only in the saline group. In addition, plasma interleukin-6 was higher in the saline group than in the dexmedetomidine group at postoperative day 1 [118.8 (68.8) versus 78.5 (58.8) pg.ml−1, p = 0.0271]. We conclude that dexmedetomidine attenuates one-lung ventilation-associated inflammatory and injurious responses by inhibiting alveolar neutrophil recruitment in thoracoscopic surgery.

Patterns of perioperative thoracic fluid indices changes in liver transplantation with or without postoperative acute lung injury.

BACKGROUND/PURPOSEnPostoperative acute lung injury (ALI) after liver transplantation is clinically relevant and common. The perioperative thoracic fluid indices changes as well as the association with ALI in liver transplantation have not been thoroughly investigated.nnnMETHODSnA total of 52 consecutive adult recipients for elective living donor liver transplantation were enrolled. Each recipient received the same perioperative care plan. Thoracic fluid indices, including the cardiac index, intrathoracic blood volume index (ITBVI), extravascular lung water index (EVLWI), and pulmonary vascular permeability index (PVPI), were obtained at seven time points (pretransplantation, anhepatic phase, 30xa0minutes after reperfusion, 2xa0hours after reperfusion, and postoperative days 1-3) using the pulse contour cardiac output system. The indices of those who developed ALI (PaO2/FiO2xa0<xa0300 mmHg with lung infiltrates on chest X-ray) were compared with the indices of those who did not.nnnRESULTSnRecipients who developed postoperative ALI had longer mechanical ventilation duration and had a higher model for end-stage liver disease score, required more platelet transfusion, and were higher in pretransplant EVLWI and PVPI level. During the anhepatic phase, ITBVI, central venous pressure, cardiac index, and EVLWI decreased and PVPI increased. After transplantation, ITBVI increased above pretransplant status, while EVLWI and PVPI were comparable in both groups.nnnCONCLUSIONnRecipients who did or did not develop ALI after liver transplantation had a longer mechanical ventilation duration and showed different patterns of perioperative thoracic fluid indices, especially in the pretransplant status of PVPI level. Knowledge of these perioperative changes may provide clinicians with helpful information to make postoperative care choices.