Juan J. Fibla

External Validation of the Recalibrated Thoracic Revised Cardiac Risk Index for Predicting the Risk of Major Cardiac Complications After Lung Resection

BACKGROUND The recalibrated thoracic revised cardiac risk index (ThRCRI) has been recently proposed as a specific tool for cardiac risk stratification before lung resection. However, the ThRCRI has never been externally validated in a population other than the one from which it was derived. The objective of this study was to validate the ThRCRI in an external population of candidates having undergone major lung resections to assess its reliability for cardiac risk stratification across different samples. METHODS We analyzed 2,621 patients undergoing lobectomy (2,431) or pneumonectomy (190) in a single center from 2000 to 2009. Patients were grouped into four classes of risk (A, B, C, and D) according to the recalibrated ThRCRI. The outcome variable measured was the occurrence of major cardiac complications (cardiac arrest, complete heart block, acute myocardial infarction, pulmonary edema, cardiac death during admission). Incidence of major cardiac events was assessed in the four risk class groupings to assess the discriminative ability of the index score. RESULTS The incidence of major cardiac morbidity was 2.2% (59 cases). Patients were grouped into four risk classes according to their recalibrated ThRCRI. Incidence of major cardiac morbidity in risk classes A, B, C, and D were 0.9%, 4.2%, 8%, and 18%, respectively (p<0.0001). CONCLUSIONS The recalibrated ThRCRI is a reliable instrument that can be used during preoperative workup to differentiate patients needing further cardiologic testing from those who can proceed without any further cardiac testing.

Digital measurements of air leak flow and intrapleural pressures in the immediate postoperative period predict risk of prolonged air leak after pulmonary lobectomy

BACKGROUND The objective of this prospective observational study was to evaluate the association between the airflow and intrapleural pressures digitally recorded during the immediate postoperative period after lobectomy and their ability to predict the risk of subsequent prolonged air leak (PAL). METHODS A total of 145 consecutive patients underwent pulmonary lobectomy in two centers. All patients were managed with the chest tube placed on suction (-20 cm H(2)O) until the morning of the first postoperative day. Measurement of airflow and maximum and minimum intrapleural pressures were recorded during the 6th postoperative hour using a digital chest drainage device. Logistic regression analysis validated by bootstrap was used to test independent association of variables with PAL (air leak>72 h). RESULTS The mean air leak flow at the 6th postoperative hour was 86 ml min(-1) (0-1100 ml min(-1)). The mean maximum and minimum pleural pressures at the 6th postoperative hour were -11.4 cm H(2)O and -21.9 cm H(2)O, respectively. Logistic regression and bootstrap showed that the mean air leak flow (p=0.007) and the mean differential pleural pressure (ΔP: maximum-minimum intrapleural pressure) (p=0.02) at the 6th postoperative hour were reliably associated with PAL, independent of the effect of age, forced expiratory volume 1 (FEV1), chronic obstructive pulmonary disease (COPD) status, diffusing capacity of the lung for carbon monoxide (DLCO), side, and site of lobectomy. According to best cutoffs derived by receiver operating characteristic (ROC) analysis the following combinations showed incremental risk of PAL: ΔP<10+Flow<50: 4% (3/73); ΔP>10+Flow<50: 15% (5/33); ΔP<10+Flow>50: 36% (5/14); ΔP>10+Flow>50: 52% (13/25). CONCLUSIONS The levels of both air leak flow and pleural pressure measured at the 6th postoperative hour are associated to a different extent with the duration of air leak. Interpretation of the data measured at an early time point by digital chest drainage systems allows estimation of the risk of subsequent PAL. In this way, digital devices may help to plan postoperative management to allow both safe and more accurate implementation of fast-tracking strategies.

Comparative analysis of analgesic quality in the postoperative of thoracotomy: paravertebral block with bupivacaine 0.5% vs ropivacaine 0.2%.

OBJECTIVES Paravertebral block is an effective alternative to epidural analgesia in the management of post-thoracotomy pain, however, there are no established guidelines regarding what is the most suitable strategy when varying drugs and dosages between different groups. Our objective was to evaluate the effectiveness of paravertebral block comparing the most frequently employed drugs in this procedure (bupivacaine vs ropivacaine). METHODS Prospective randomized study of 70 patients submitted to thoracotomy. Patients were divided in two independent groups (anterior thoracotomy (AT) and posterolateral thoracotomy (PT)). At the end of surgery a catheter was inserted under direct vision in the thoracic paravertebral space at the level of incision. In each group (AT or PT) patients were randomized to receive a bolus of 15 ml of bupivacaine 0.5% or 20 ml of ropivacaine 0.2% before closing the thoracotomy. They postoperatively received 10 ml of bupivacaine or 15 ml of ropivacaine every 6h combined with methamizol (every 6h). Subcutaneous meperidine was employed as rescue drug. The level of pain was measured with the visual analogic scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. The need of meperidine as rescue drug and secondary effects was also recorded. RESULTS We did not register secondary effects in relation to the paravertebral catheter (paravertebral or cutaneous bleeding or hematoma, respiratory depression (respiratory rate <8 breaths per minute), cardiotoxicity, confusion, sedation, urinary retention, nausea, vomiting and pruritus). Eleven patients (16%) needed meperidine as rescue drug (six with ropivacaine and five with bupivacaine). Mean VAS values were the following: all the cases (n=70): 5.2+/-2.1, AT (n=38): 4.5+/-2.1, PT (n=32): 5.9+/-1.7, bupivacaine (n=35): 4.9+/-2.1, ropivacaine (n=35): 5.4+/-1.9, AT with bupivacaine (n=19): 4.2+/-2.2, AT with ropivacaine (n=19): 4.9+/-2.0, PT with bupivacaine (n=16): 5.7+/-1.6, PT with ropivacaine (n=16): 6.0+/-1.7. CONCLUSIONS Post-thoracotomy analgesia combining paravertebral catheter and a nonsteroidal anti-inflammatory drug is a safe and effective practice, VAS values are acceptable (only 16% of patients required meperidine as rescue). It prevents the risk of side effects related to epidural analgesia. Patients submitted to AT experienced less pain than those with PT (4.5 vs 5.9, p<0.01). Bupivacaine got slightly better VAS values than ropivacaine (4.9 vs 5.4 p<0.05). Higher doses and volumes of local anesthetic could be used to obtain better VAS values.

Effectiveness of sympathetic block by clipping in the treatment of hyperhidrosis and facial blushing.

Main cause of dissatisfaction after videothoracoscopic (VATS) sympathectomy in the treatment of hyperhidrosis (HH) and facial blushing (FB) is compensatory sweating (CS). Sympathetic nerve (SN) clipping permits to revert the block effect by removing the clips in case of an intolerable CS. We present our experience with this technique. Sixty-one patients diagnosed for HH and/or FB were operated on VATS SN clipping. Clipping levels varied in function for the sort of disease: FB: T2, palmar HH: T3, axillary HH: T4, palmar-axillary HH: T3-4. Results were evaluated 1 week, 3 months and 12 months after surgery. Fifty-eight of the 61 patients showed improvement of their symptoms (95%). There were minor complications in three patients (5.5%). CS was seen in 38/61 (62.2%), being labelled as mild in 33/61 (54%) and severe in 5/61 patients (8.2%), no patient qualified it as intolerable and it was not necessary to remove the clips for CS in any case. SN clipping by VATS is a safe and effective procedure for the management of FB and palmar/axillary HH. Levels of CS are similar or lesser than with the standard sympathicotomy and, if necessary, this technique allows to revert the sympathetic block removing the clips.

Beneficios del uso de dispositivos digitales para medir la fuga aérea después de una resección pulmonar: estudio prospectivo y comparativo

INTRODUCTION Persistent air leaks represent the most common pulmonary complication after elective lung resection. Since there are insufficient data in the literature regarding variability in the withdrawal of postoperative pleural drainages, we have designed a prospective, consecutive and comparative study to evaluate if the use of digital devices (Thopaz and DigiVent) to measure postoperative air leak compared to a Pleur-Evac varies on deciding when to withdraw chest tubes after lung resection. METHODS A prospective, consecutive and comparative trial was conducted in 75 patients who underwent elective pulmonary resection for non small cell lung cancer. This study compared two digitals devices with the current analogue version in 75 patients. The digital and analogue groups had 26, 24, and 25 patients, respectively. RESULTS Clinical population data were not statistically different between the groups. The withdrawal of the chest tube was Thopaz, 2.4 days; Digivent, 3.3 days and PleurEvac, 4.5 days. Patients and nurses were subjectively more comfortable with digital devices. Surgeons obtained more objective information with digital devices. The safety mechanism of the Thopaz was also subjectively better, and one patient was discharged home without complications after one week. CONCLUSIONS The digital and continuous measurement of air leak instead of the currently used static analogue systems reduced the chest tube withdrawal and hospital stay by more accurately and reproducibly measuring air leak. Intrapleural pressure curves from the Digivent may also help predict the optimal chest tube setting for each patient. The Thopaz alarm mechanism is very useful to prevent deficiencies in the mechanism and do not required wall suction.

Aggregate risk score for predicting mortality after surgical biopsy for interstitial lung disease

In order to develop a practical risk score for 90-day mortality following surgical lung biopsy (SLB) for interstitial lung disease (ILD) we reviewed 311 consecutive patients undergoing SLB for ILD between 2002 and 2009. Postoperative complication, 30-day and 90-day mortality rates were 11.5%, 9% and 10.6% respectively. Univariable and multivariable analyses, validated by bootstrap statistics, were used to identify factors associated with 90-day mortality. A scoring system was developed by proportionally weighting the regression coefficients of the significant predictors of 90-day mortality: age >67 (P < 0.0001, weighted score 1.5), preoperative intensive care unit (ICU) admission (P = 0.006, weighted score 2), immunosuppressive treatment (P = 0.004, weighted score 1.5) and open surgery (P = 0.03, weighted score 1). Patients were grouped in four classes showing incremental risk of death at 90 days: class A, score 0 (2%); class B, score 1-2 (12%); class C, score 2.5-3 (40%); class D, score >3 (86%); P <0.0001). SLB entails a considerable surgical risk with an overall 90-day mortality around 10%. We were able to develop a practical risk score which, if validated by other independent studies, can be easily used to stratify the risk of SLB candidates and assess the cost-effectiveness of this procedure.

Outcome of lung transplantation in elderly recipients.

OBJECTIVE Lung transplantation is a standard treatment option for patients with end-stage lung disease. Lung transplantation in the elderly is controversial due to concerns over anticipated increased surgical risks, inferior long-term outcomes and proper stewardship in allocating limited donor organs. With demographic trends showing an increasing proportion of patients over 60 years old, we evaluated our outcomes with lung transplantation in this older cohort. METHODS Between January 1990 and July 2009, 142 patients underwent lung transplantation at our institution. A total of 15 patients receiving heart/lung transplantation and one patient declining research participation were excluded. As many as 126 patients were analyzed in two groups: <60 and ≥ 60 years old. RESULTS There were 65 females (52%) and 61 males (48%). A total of 53 patients (42%) underwent bilateral sequential lung transplantation and 73 patients single-lung transplantation (58%). Median age at transplantation was 55.3 years (range, 21.6-73.1 years) with 94 patients <60 years (75%) and 32 patients ≥ 60 years (25%). Median follow-up was 4.3 years (range, 0-17.8 years). Overall survival at 30 days was 93.7% with no difference between age groups (p=0.95). There was no difference between the groups for in-hospital, postoperative complications (p=0.86), or unplanned readmission rates within 90 days of the hospitalization (p=0.26). Postoperative pulmonary function (forced expiratory volume in 1s (FEV1) % predicted) at transplant, 4 weeks, 3 months, and 6 months after transplantation was not different between groups (p=0.93). No difference in long-term survival was observed (p=0.59), with 5-year survival of 52.2% for patients <60 years and 47.3% for patients ≥ 60 years. Overall, 20 patients developed bronchiolitis obliterans syndrome and 13 posttransplant lymphoproliferative disease, which was not statistically different between age groups (p=0.87, p=0.37, respectively). CONCLUSION Increased age of 60 years and greater, in highly selected patients, does not appear to have a significant impact on the short- or long-term outcome in patients undergoing lung transplantation. Judicious selection of older patients, who are otherwise excellent candidates for lung transplantation, remains a reasonable option.

The benefits of digital air leak assessment after pulmonary resection: Prospective and comparative study

Abstract Introduction Persistent air leaks represent the most common pulmonary complication after elective lung resection. Since there are insufficient data in the literature regarding variability in the withdrawal of postoperative pleural drainages, we have designed a prospective, consecutive and comparative study to evaluate if the use of digital devices (Thopaz and DigiVent) to measure postoperative air leak compared to a Pleur-Evac varies on deciding when to withdraw chest tubes after lung resection. Methods A prospective, consecutive and comparative trial was conducted in 75 patients who underwent elective pulmonary resection for non small cell lung cancer. This study compared two digitals devices with the current analogue version in 75 patients. The digital and analogue groups had 26, 24, and 25 patients, respectively. Results Clinical population data were not statistically different between the groups. The withdrawal of the chest tube was Thopaz, 2.4 days; Digivent, 3.3 days and PleurEvac, 4.5 days. Patients and nurses were subjectively more comfortable with digital devices. Surgeons obtained more objective information with digital devices. The safety mechanism of the Thopaz was also subjectively better, and one patient was discharged home without complications after one week. Conclusions The digital and continuous measurement of air leak instead of the currently used static analogue systems reduced the chest tube withdrawal and hospital stay by more accurately and reproducibly measuring air leak. Intrapleural pressure curves from the Digivent may also help predict the optimal chest tube setting for each patient. The Thopaz alarm mechanism is very useful to prevent deficiencies in the mechanism and do not required wall suction.

Outpatient Thoracic Surgery

In summary, from the different alternatives to conventional hospitalization developed in the last decades, outpatient surgery has been the one with the greatest growth. However, only few studies have been reported on thoracic surgery and there is still great potential for an increase in outpatient thoracic surgery. The aim of this article has been to evaluate the clinical aspects, results, and economical impact of an outpatient thoracic surgery program (OTSP). Video-assisted mediastinoscopy, lung biopsy, and bilateral thoracic sympathectomy can be accomplished safely in a significant percentage of cases as ambulatory patients. The impact of the economical benefit of outpatient thoracic surgical program over the conventional hospitalization depends on the previous departments policy on hospital stay. Further experience is needed to increase the substitution index and expand the OTSP to other procedures.

A prospective study of analgesic quality after a thoracotomy: paravertebral block with ropivacaine before and after rib spreading §

OBJECTIVE Paravertebral block (PVB) is an effective alternative to epidural analgesia in the management of post-thoracotomy pain. Rib spreading (RS) is an important noxious stimulus considered a major cause of post-thoracotomy pain. Our hypothesis was that a bolus of ropivacaine 0.2% through a paravertebral catheter (PVC) inserted before RS could decrease pain during the first 72 postoperative hours. METHODS The methodology employed was to perform a prospective randomised study of 60 consecutive patients submitted to thoracotomy. Patients were divided in two independent groups (anterior thoracotomy (AT) and posterolateral thoracotomy (PT)). A catheter was inserted under direct vision in the thoracic paravertebral space at the level of incision. In each group, patients were randomised to receive a bolus of 20 ml of ropivacaine 0.2% before rib spreading (pre-RS) or after (post-RS), just before closing the thoracotomy. They postoperatively received 15 ml of ropivacaine 0.2% every 6 h combined with methamizol (every 6h). Subcutaneous meperidine was employed as a rescue drug. The level of pain was measured with the visual analogue scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. The need of meperidine as a rescue drug and secondary effects were also recorded. RESULTS We did not register secondary effects in relation to the PVC (paravertebral or cutaneous bleeding or haematoma, respiratory depression, cardiotoxicity, confusion, sedation, urinary retention, nausea, vomiting or pruritus). Seven patients (11.6%) needed meperidine as rescue drug (four pre-RS and three post-RS). The mean VAS values were the following: all cases (n=60): 4.7+/-2.0; AT (n=32): 4.0+/-2.1; PT (n=28): 5.6+/-1.8; pre-RS (n=30): 4.8+/-1.9; post-RS (n=30): 4.6+/-2.0; AT-pre-RS (n=16): 4.1+/-2.0; AT-post-RS (n=16): 3.9+/-2.1; PT-pre-RS (n=14): 5.6+/-1.6; PT-post-RS (n=14): 5.4+/-1.7. CONCLUSIONS Post-thoracotomy analgesia combining PVC and a non-steroidal anti-inflammatory drug is a safe and effective practice. VAS values are acceptable (only 11.6% of patients required meperidine). It prevents the risk of side effects related to epidural analgesia. Patients submitted to AT experienced less pain than those with PT (4.0 vs 5.6; p<0.01). PVB with ropivacaine before RS got similar VAS values than the block after RS (4.8 vs 4.6; p>0.05). The moment of the insertion of the PVC does not seem to affect postoperative pain levels.