Man-Ling Wang

Nasal high-flow oxygen therapy improves arterial oxygenation during one-lung ventilation in non-intubated thoracoscopic surgery

OBJECTIVES Intraoperative hypoxaemia during one-lung ventilation (OLV) remains a major concern in thoracic surgery. Non-intubated video-assisted thoracic surgery (VATS) involves a greater risk of consequent emergent conversion to endotracheal intubation. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) has recently been reported to be beneficial for higher oxygen reserves during difficult intubations and for enhancing postoperative recovery after thoracic surgery. However, the effects of THRIVE on oxygenation and carbon dioxide elimination before and during OLV in non-intubated VATS have not been investigated. METHODS Between September 2016 and October 2016, 30 patients underwent non-intubated VATS for lung tumour and were maintained with THRIVE at a flow of 20 l/min. These patients were compared with a historical control group comprising 30 patients who were maintained with oxygen masks at an oxygen flow of 10 l/min using a propensity score matching algorithm between September 2015 and July 2016. RESULTS The preoperative arterial oxygen tension was significantly higher in patients maintained with THRIVE than it was in patients maintained with oxygen masks (mean 416.0 vs 265.9 mmHg, P < 0.01). During OLV, arterial oxygen tension remained significantly higher in the THRIVE group than in the oxygen mask group (mean 207.0 vs 127.8 mmHg, P = 0.01). The arterial carbon dioxide tension was comparable before and during OLV. CONCLUSIONS The results indicated that THRIVE effectively increases the oxygen reserve both during OLV and after anaesthesia. Furthermore, non-intubated VATS is safer if THRIVE with flow adjustment is incorporated into a minimally invasive surgical approach, although carbon dioxide elimination is not facilitated.

Non-intubated single-incision video-assisted thoracic surgery: a two-center cohort of 188 patients

BACKGROUND Non-intubated single-incision procedures are slowly expanding because of high experience and skill required, and stricter selection criteria. The aim of this study is to present the first retrospective two-center series in Taiwan and Spain. METHODS We performed a retrospective analysis of 188 patients undergoing non-intubated single-incision video-assisted thoracic surgery (NI-SI-VATS) procedures between July 2013 to November 2015 in two centers in Taiwan (170 patients) and Spain (18 patients) with two different anesthetic methods. Demographic data, clinicopathological features, preoperative tests, and final outcomes were analyzed to compare the outcomes with the two different techniques. RESULTS Of the 188 patients, 147 (78%) were women, with a mean body mass index (BMI) of 22.7. Of the 196 specimens, 145 (74%) were malignancies with a mean size of 9.7 mm. Wedge resection was performed in 172 patients (91.4%), anatomical segmentectomy with lymphadenectomy in 8 (4.7%), and lobectomy with lymphadenectomy in 5 (2.6%). Three patients (1.6%) required conversion to orotracheal intubation, while 5 patients (2.7%) required additional ports. Complications appeared in 16 patients (8.5%) with air leak as the most frequent in 7 cases (3.7%). Median chest drainage was 1 day, and median postoperative stay was 3 days. There was neither perioperative death nor postoperative readmission. CONCLUSIONS Non-intubated single-incision procedures can be feasible and safe in expert hands and experienced teams, even for anatomical resections. Strict selection criteria, skill and experience are mandatory. Comparative cohorts and randomized trials are needed.

Chlorhexidine-related refractory anaphylactic shock: a case successfully resuscitated with extracorporeal membrane oxygenation

IMPORTANCE We report a patient with a life-threatening anaphylactic reaction to a chlorhexidine-coated central venous catheter, confirmed with a high serum level of chlorhexidine-specific IgE. To our knowledge, this is the first case successfully resuscitated using extracorporeal membrane oxygenation (ECMO). Great caution is required when using chlorhexidine and chlorhexidine-impregnated catheters, given that its widespread use has the potential to sensitize certain patients and may result in life-threatening anaphylaxis on subsequent exposure. OBSERVATIONS A case report of a single patient with life-threatening anaphylactic shock to chlorhexidine, who was successfully resuscitated using ECMO. CONCLUSIONS We have designed a flowchart for the diagnosis and management of severe anaphylaxis. This case report highlights the potential for chlorhexidine to be a source for the development of refractory anaphylactic shock. We suggest that ECMO may save the lives of patients with severe bronchospasm and refractory anaphylactic shock secondary to chlorhexidine.

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.

Is fibre-optic bronchoscopy necessary to confirm the position of rigid-angled endobronchial blockers before thoracic surgery? A randomized controlled trial

OBJECTIVES To determine the success rate of blind insertion and the usefulness of fibre-optic bronchoscopy for directing rigid-angled endobronchial blockers (EBs) to the correct side and achieving satisfactory surgical fields. METHODS A randomized trial was designed to determine the extent to which the Coopdech Endobronchial Blocker Tube (Daiken Medical Co., Ltd) could successfully be placed through either auscultation (n = 57) or fibre-optic bronchoscopy (n = 55) in patients scheduled for thoracic surgery. The placement time was recorded and quality of the thoracoscopic operation field was determined by the thoracic surgeon. Anaesthesiologists with varying thoracic experience levels were enrolled. RESULTS The success rates of insertion through auscultation were 100% (32 of 32) for the right side and 88% (22 of 25) for the left side. Placement through auscultation was faster than that through bronchoscopy (mean 89.6 vs 141.1 s, P = 0.008) in the right-sided procedure but non-significant in the left-sided procedure (mean 138.5 vs 130 s, P = 0.795). Surgical grading of the operation field was not significantly different between both techniques (P = 0.502). Experienced anaesthesiologists took less time to position EBs (mean 91.0 vs 138.0 s, P = 0.015). Surgical grading was comparable between specialists and residents (P = 0.058). CONCLUSIONS Once an EB was correctly inserted and confirmed through auscultation, the corresponding surgical satisfaction was comparable to that through bronchoscopy. In the majority of cases, bronchoscopy is unnecessary for correct and efficient EB positioning. However, bronchoscopy is still mandatory in left-sided EB insertion and in patients with deviated tracheobronchial anatomy. Clinical registration number NCT02133235, registered at ClinicalTrials.gov [https://clinicaltrials.gov/ct2/show/NCT02133235 (8 July 2017, date last accessed)].

Nonintubated thoracoscopic anatomical segmentectomy for lung cancer: a single-center experience with consecutive 89 cases

Background: Recent development in minimally invasive thoracic surgery for lung cancer includes a combination of nonintubated anesthetic management and sublobar resection in patients with compromised cardiopulmonary function or with early-stage lung cancer. Methods: From August 2009 to December 2016, 89 patients with lung cancer underwent thoracoscopic anatomical segmentectomy without endotracheal intubation, using a combination of thoracic regional anesthesia and targeted sedation during surgery. Results: There were 28 patients (31%) undergoing compromised nonintubated thoracoscopic anatomical segmentectomy due to advanced age or poor lung function reserve. Left upper apical trisegmentectomy was most commonly performed (n=21), followed by left upper lingulectomy (n=16) and right upper superior segmentectomy (n=15). Conversion to intubated general anesthesia was required in two patients because of vigorous mediastinal movement. No patient required conversion to a thoracotomy or lobectomy. Prolonged chest tube drainage was noted in three patients who had air leak (n=2) or chylothorax (n=1). The median chest drainage and hospital stay were 2 and 4 days, respectively. The median time of anesthetic induction and operation were 15 and 135 minutes, respectively. Conclusions: Nonintubated thoracoscopic anatomical segmentectomy is safe and technically feasible using regional thoracic anesthesia and conscious sedation. In selective lung cancer patients, a less invasive nonintubated thoracoscopic segmentectomy can be an alternative to intubated one-lung ventilation or to a complete lobectomy.