Edmond Cohen

An update on anesthesia for thoracoscopic surgery.

Purpose of review The surgical management of patients partly determines the anesthetic management. A shift has taken place in thoracic surgery, with a large portion of procedures now being performed through a video-assisted thoracoscopic surgery (VATS) approach. This review is intended to provide the anesthesiologist with an update on the management of thoracic surgical patients presenting for VATS. Recent findings Although there are cosmetic and economical advantages to the VATS approach, large randomized controlled trials are still lacking documenting the benefit of VATS versus conventional ‘thoracotomy’. The classic division in absolute and relative indications for one-lung ventilation (OLV) should be viewed as antiquated. All VATS procedures represent an indication for OLV. A better classification is to divide the purpose of OLV: separation versus isolation. Treatment for hypoxemia during OLV also needs to be modified. Patient expectations are also different as a minimal invasive approach is often falsely associated with minimal risk. This leads to an additional stress factor imposed upon the anesthesiologist. Summary Minimal invasive VATS is gaining widespread popularity among our surgical colleagues. The anesthesiologist must recognize the impact that this change in surgical philosophy will have upon the anesthetic management of these complex patients.

Methylene Blue for Vasopressor-Resistant Vasoplegia Syndrome During Liver Transplantation

HE NUMBER OF liver transplant procedures is increasing worldwide. The ischemia-reperfusion syndrome seen during liver transplant surgery can manifest as a state of vasoplegia that frequently requires vasopressor support to maintain stable hemodynamics. Occasionally, the conventional treatment for vasoplegic syndrome (VS) (eg, phenylephrine, norepinephrine, or vasopressin) does not suffice to restore adequate systemic vascular resistance (SVR) and support systemic pressures. The first utilization of methylene blue (MB) as a last resort pharmacologic agent to treat vasopressor-refractory vasoplegic syndrome during liver transplantation surgery is reported. CASE REPORT A 61-year-old black male in fulminant hepatorenal failure secondary to autoimmune hepatitis presented for orthotopic liver and kidney transplantation. His past medical history was significant for previous liver transplantation 6 years before current hospitalization and type 2 diabetes mellitus. The patient had been hospitalized for 2 weeks before this transplant for esophageal variceal hemorrhage and ascites. A preoperative cardiac workup placed the patient at low risk for myocardial ischemia. A transthoracic echocardiogram revealed aortic sclerosis and normal biventricular size and function (left ventricular ejection fraction, 0.75). Preoperative laboratory values included a white cell count of 3.3 103/mm3, hemoglobin of 11.0 g/dL, hematocrit of

Incidence of arrhythmias after thoracic surgery: Thoracotomy versus video-assisted thoracoscopy

PURPOSEnAtrial arrhythmias, especially supraventricular tachycardia (SVT) and atrial fibrillation, are common after thoracotomy and lung surgery. There are few existing data on the incidence of postoperative arrhythmias after video-assisted thoracoscopy (VAT). The purpose of the present investigation was to retrospectively determine the incidence of postoperative arrhythmias in patients who underwent VAT compared with those who underwent thoracotomy, and which factors are associated with an increased risk for arrhythmias in both groups.nnnDESIGNnA retrospective investigation.nnnSETTINGnA metropolitan university hospital.nnnPARTICIPANTSnThe medical records of 124 patients who underwent thoracotomy and 81 patients who underwent VAT over a 2-year period were reviewed.nnnMEASUREMENTS AND MAIN RESULTSnThere was a 17% incidence of atrial arrhythmias after thoracotomy and 10% after VAT, but the difference was not statistically significant. In both groups, atrial fibrillation was the most common atrial arrhythmia.nnnCONCLUSIONnPatients receiving digoxin were at higher risk for postoperative arrhythmias. Patients older than 65 years were at risk for arrhythmias after thoracotomy and patients older than 80 years were at risk for arrhythmias after VAT. Patients who had postoperative arrhythmias had prolonged hospital stays compared with patients who did not have arrhythmias.

Intraoperative mechanical ventilation strategies for one-lung ventilation

One-lung ventilation (OLV) has two major challenges: oxygenation and lung protection. The former is mainly because the ventilation of one lung is stopped while the perfusion continues; the latter is mainly because the whole ventilation is applied to only one lung. Recommendations for maintaining the oxygenation and methods of lung protection can contradict each other (such as high vs. low inspiratory oxygen fraction (FiO2), high vs. low tidal volume (TV), etc.). In light of the (very few) randomized clinical trials, this review focuses on a recent strategy for OLV, which includes a possible decrease in FiO2, lower TVs, positive end-expiratory pressure (PEEP) to the dependent lung, continuous positive airway pressure (CPAP) to the non-dependent lung and recruitment manoeuvres. Other applications such as anaesthetic choice and fluid management can affect the success of ventilatory strategy; new developments have changed the classical approach in this respect.

Strategies for lung isolation: to block or not to block?

In this issue of the Journal, Bussières et al. report their findings of a randomized-controlled trial evaluating the use of a bronchial blocker (BB) vs a left-sided double-lumen endotracheal tube (DL-ETT) during video-assisted thoracoscopic surgery (VATS). The focus of their study was on the quality of lung collapse and the time to achieve optimal lung deflation. The authors studied 40 patients requiring one-lung ventilation (OLV) and randomized to receive a BB or a left-sided DL-ETT. The time from opening the pleura until complete lung collapse as well as the quality of lung collapse (graded from 1-3) were evaluated in real time by the surgeons who were blinded to the method used to achieve lung separation. The time to lung collapse and the quality of the collapse were also graded offline by independent observers —i.e., two thoracic surgeons and an anesthesiologist who reviewed video recordings of the VATS procedures. Finally, the operating surgeons were asked to guess which device was used for lung isolation. The findings of the study showed that the time to complete lung collapse in patients having elective VATS was significantly faster with a BB than with a left-sided DL-ETT. The scores of the quality of lung deflation at 5, 10, and 20 min following opening of the pleura were also better in the BB group than in the DL-ETT group, in both real-time and offline assessments. Finally, when the surgeons were asked to guess which method was being used for lung isolation, they were correct only 37% of the time. This outcome would suggest that the two devices could be used interchangeably without the surgeon noticing any differences. As DL-ETTs are considered the ‘‘gold standard’’ for lung separation, they are the most widely used devices for performing this procedure. They have been used for more than 50 years, and as a result, most anesthesiologists and surgeons are familiar with them and are comfortable with their use. The decision whether to use a DL-ETT or BB depends on three factors: patient safety, the anesthesiologist’s comfort with the selected device, and the surgeon’s preference. Unfortunately, there are sometimes situations where these three factors cannot coincide. As with many devices, correct use of a BB involves a significant learning curve, and most anesthesiologists are unfamiliar with the device and inexperienced in its use. As a result, a thoracic surgeon who is not accustomed to having a BB used for OLV may be reluctant to accept this new technique. The study by Bussières et al. addresses some of the myths surrounding the use of a BB. Indeed, there may be a bias against its use and an impression amongst surgeons (and some anesthesiologists) that a BB fails to provide optimal lung separation. These myths regarding the BB include the view that the quality of lung collapse is inferior to that with the DLT; that it would take more time to achieve adequate lung deflation than with the DL-ETT; and that it takes less time to insert and position a DL-ETT than to perform the same procedure with a BB. Despite these myths, the present study reinforces the points of view supported by the literature — i.e., the performance of the BB is at least on a par with that of the DL-ETT. There are clearly certain clinical situations that mandate the use of a DL-ETT, particularly when the non-diseased lung must be protected from life-threatening contamination from the diseased lung. In addition, if a tumour is E. Cohen, MD (&) Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, Box 1010, One Gustave L. Levy Place, New York, NY, USA e-mail: edmond.cohen@mountsinai.org

Bronchoscopic treatment of end-stage chronic obstructive pulmonary disease.

Purpose of review Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating disease that in its final stages cripples the patient. The disappointing results of the National Emphysema Treatment Trial study led to a decrease in the acceptance of lung volume reduction surgery as a therapy. Thus, it became clear that debilitated COPD patients would need innovative alternative nonsurgical procedures to potentially alleviate their symptoms. This review will address the various techniques of bronchoscopic lung volume reduction (BLVR). Recent findings In recent years, a variety of noninvasive BLVR procedures were developed in the hope of improving the respiratory status of these patients. BLVR aims to decrease the extent of hyperinflation due to emphysema and result in a beneficial effect similar to that from surgical resection. The most widely used BLVR devices are: endobronchial valves, foam sealant, metallic coils, airway bypass stents and vapor thermal ablation. In the USA, BLVR remains in the experimental phase. The treatment modalities should be individually tailored for each patient. Endobronchial valves are designed to exclude the most affected emphysematous regions from ventilation in order to induce lobar absorption atelectasis. Airway bypass stents target homogenous emphysema, whereas valves and thermal vapor ablation target heterogeneous emphysema. Biological sealants and endoscopic coil implants have been used in both homogenous and heterogeneous emphysema. Summary BLVR appears to be safer than surgery and presents an attractive alternative for the treatment of COPD patients. Unfortunately, the outcome data to date are inconclusive; the procedures remain experimental and any benefits unproven. However, the data that are emerging continue to appear promising.

Prolonged Intraoperative Cardiac Resuscitation Complicated by Intracardiac Thrombus in a Patient Undergoing Orthotopic Liver Transplantation

We report the case of successful resuscitation after prolonged cardiac arrest during orthotopic liver transplantation. After reperfusion, the patient developed ventricular tachycardia, complicated by intracardiac clot formation and massive hemorrhage. Transesophageal echocardiography demonstrated stunned and nonfunctioning right and left ventricles, with developing intracardiac clots. Treatment with heparin, massive transfusion and prolonged cardiopulmonary resuscitation ensued for 51 minutes. Serial arterial blood gases demonstrated adequate oxygenation and ventilation during cardiopulmonary resuscitation. Cardiothoracic surgery was consulted for potential use of extracorporeal membrane oxygenation, however, the myocardial function improved and the surgery was completed without further intervention. On postoperative day 6, the patient was extubated without neurologic or cardiac impairment. The patient continues to do well 2 years posttransplant, able to perform independent daily activities of living and his previous job. This case underscores the potential for positive outcomes with profoundly prolonged, effective advanced cardiovascular life support in patients who experience postreperfusion syndrome.

What Are the Specific Challenges in the Postoperative Mechanical Ventilation After Thoracic Surgery

Incidence of the requirement of prolonged mechanical ventilation after thoracic surgery appears to be decreasing. However, the importance of some severe and specific challenges remains the same. As an example, combination of prolonged air leakage and respiratory insufficiency can be considered as a double-edged sword. Besides the classical approach of “protective” ventilation, which should also be examined again and again, methods like “high-frequency jet ventilation” and “independent lung ventilation” should be considered in selected cases. Not at least, a physician dealing with the postthoracotomy patient should be familiar with the management of chest tubes in different cases.

A Ballooning Crisis: Three Cases of Bronchial Blocker Malfunction and A Review

THE USE OF ENDOBRONCHIAL BLOCKERS (BB) to achieve one-lung ventilation (OLV) is increasing worldwide. In this report, 3 cases of BB malfunction are presented. In all 3 cases, the endobronchial balloon failed to deflate at the conclusion of the surgery. This placed the patients at risk since the operative lung could not be reinflated. Furthermore, the BB could not be removed from the endotracheal tube (ET) given the size mismatch between the lumen of the ET tube and the inflated BB balloon. Attempted forceful removal would have been risky given the possibility of the inflated balloon becoming wedged within the lumen of the ET tube. This would have led to the complete occlusion of the ET tube lumen with inability to ventilate, necessitating emergent tracheal extubation while on OLV in the lateral position. In this report, 3 challenging dilemmas and the ways in which they were resolved successfully are presented. The known complications of BB use also are reviewed.

Fluid Management in Thoracic Surgery

Fluid and electrolyte balance is of paramount importance for patients undergoing major non-cardiac intrathoracic surgery. The intravenous fluid resuscitation profoundly influences perioperative morbidity and mortality [1]. Despite significant differences in anesthetic techniques during these operations, the approach to the fluid therapy seems to follow the same direction.