Ronaldo V. Purugganan

A possible association between aprotinin and improved survival after radical surgery for mesothelioma

Aprotinin has been used to decrease blood loss with complicated cardiac surgery but has not been investigated in extrapleural pneumonectomy, an operation that does not use cardiopulmonary bypass. In this prospective, randomized, placebo‐controlled, double‐blind trial, the authors investigated whether aprotinin decreased blood loss in patients who underwent this operation.

A Prospective, Randomized, Controlled Trial of Paravertebral Block versus General Anesthesia Alone for Prosthetic Breast Reconstruction.

Background: Paravertebral blocks have gained popularity because of ease of implementation and a shift toward ambulatory breast surgery procedures. Previous retrospective studies have reported potential benefits of paravertebral blocks, including decreased narcotic and antiemetic use. Methods: The authors conducted a prospective controlled trial of patients undergoing breast reconstruction over a 3-year period. The patients were randomized to either a study group of paravertebral blocks with general anesthesia or a control group of general anesthesia alone. Demographic and procedural data, in addition to data regarding pain and nausea patient-reported numeric scores and consumption of opioid and antiemetic medications, were recorded. Results: A total of 74 patients were enrolled to either the paravertebral block (n = 35) or the control group (n = 39). There were no significant differences in age, body mass index, procedure type, or cancer diagnosis between the two groups. Patients who received a paravertebral block required less opioid intraoperatively and postoperatively combined compared with patients who did not receive paravertebral blocks (109 versus 246 fentanyl equivalent units; p < 0.001), and reported significantly lower pain scores at 0 to 1 (3.0 versus 4.6; p = 0.02), 1 to 3 (2.0 versus 3.2; p = 0.01), and 3 to 6 (1.9 versus 2.7; p = 0.04) hours postoperatively. The study group also consumed less antiemetic medication (0.7 versus 2.1; p = 0.05). Conclusions: Incorporating paravertebral blocks carries considerable potential for improving pathways for breast cancer patients undergoing breast reconstruction—with minimal procedure-related morbidity. This is the first prospective study designed to assess paravertebral blocks in the setting of prosthetic breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A Randomized Controlled Study of the Use of Video Double-Lumen Endobronchial Tubes Versus Double-Lumen Endobronchial Tubes in Thoracic Surgery

OBJECTIVE To compare the incidence of fiberoptic bronchoscope (FOB) use (1) during verification of initial placement and (2) for reconfirmation of correct placement following repositioning, when either a double-lumen tube (DLT) or video double-lumen tube (VDLT) was used for lung isolation during thoracic surgery. DESIGN A randomized controlled study. SETTING Single-center university teaching hospital. PARTICIPANTS The study comprised 80 patients who were 18 years or older requiring lung isolation for surgery. INTERVENTIONS After institutional review board approval, patients were randomized prior to surgery to either DLT or VDLT usage. Attending anesthesiologists placed the Mallinckrodt DLT or Vivasight (ET View Ltd, Misgav, Israel) VDLT with conventional laryngoscopy or video laryngoscopy then verified correct tube position through the view provided with either VDLT external monitor or FOB. MEASUREMENTS AND MAIN RESULTS Data collected included: sex, body mass index, successful intubation and endobronchial placement, intubation time, confirmation time of tube position, FOB use, quality of view, dislodgement of tube, and ability to forewarn dislodgement of endobronchial cuff and complications. FOB use for verification of final position of the tube (VDLT 13.2% [5/38] v DLT 100% [42/42], p < 0.0001), need for FOB to correct the dislodgement (VDLT 7.7% [1/13] v DLT 100% [14/14], p < 0.0001), dislodgement during positioning (VDLT 61.5% [8/13] v DLT 64.3% [9/14], p = ns), dislodgement during surgery (VDLT 38.5% [5/13] v DLT 21.4% [3/14], p = ns), and ability to forewarn dislodgement of endobronchial cuff (VDLT 18.4% [7/38] v DLT 4.8% [2/42], p = 0.078). CONCLUSION This study demonstrated a reduction of 86.8% in FOB use, which was a similar reduction found in other published studies.

Anesthesia for Thoracic Surgical Procedures

As thoracic surgery evolved, anesthesia evolved in parallel, allowing even the most compli‐ cated surgical procedures to be performed relatively safely. This co-evolution mirrors the close association of the thoracic surgeon and anesthesiologist when caring for their patients. This unique association is predicated on the nature of thoracic procedures, where the surgeon and anesthesiologist share a “thoracic workspace” the surgeon operating on vital thoracic structures and the anesthesiologist managing ventilation, oxygenation, and hemodynamics. Because of this close partnering, it is valuable for thoracic surgeons to be familiar with anesthetic considerations exclusive to their patients.

Aprotinin significantly decreases transfusion rates in extrapleural pneumonectomy

INTRODUCTION: Aprotinin (TrasylolTM Bayer Corporation, West Haven, CT) is a serine protease inhibitor, which inhibits all serine proteases including plasmin. It has been used to significantly decrease blood loss during repeat cardiac surgery utilizing cardiopulmonary bypass and is currently the only pharmacologic agent approved by the FDA for this purpose. The operation of extrapleural pneumonectomy (EPP), done almost exclusively for mesothelioma, is associated with the potential for significant blood loss due to the large raw surface of the hemithorax left behind after resection of the parietal pleura. We investigated whether aprotinin would decrease blood loss and transfusion requirement in this major operation.