In the past three decades, there has been a significant clinical shift in the performance of resuscitative thoracotomy (RT), from a nearly obligatory procedure before declaring any trauma patient ...deceased to a more selective application of RT. We have sought to formulate an evidence-based guideline for the current indications for RT after injury in the patient.
The Western Trauma Association Critical Decisions Committee queried the literature for studies defining the appropriate role of RT in the trauma patient. When good data were not available, the Committee relied on expert opinion.
There are no published PRCT and it is not likely that there will be; recommendations are based on published prospective observational and retrospective studies, as well as expert opinion of Western Trauma Association members. Patients undergoing cardiopulmonary resuscitation (CPR) on arrival to the hospital should be stratified based on injury and transport time. Indications for RT include the following: blunt trauma patients with less than 10 minutes of prehospital CPR, penetrating torso trauma patients with less than 15 minutes of CPR, patients with penetrating trauma to the neck or extremity with less than 5 minutes of prehospital CPR, and patients in profound refractory shock. After RT, the patient's intrinsic cardiac activity is evaluated; patients in asystole without cardiac tamponade are declared dead. Patients with a cardiac wound, tamponade, and associated asystole are aggressively treated. Patients with an intrinsic rhythm following RT should be treated according to underlying primary pathology. Following several minutes of such treatment as well as generalized resuscitation, salvageability is reassessed; we define this as the patient's ability to generate a systolic blood pressure of greater than 70 mm Hg with an aortic cross-clamp if necessary.
The success of RT approximates 35% for the patient arriving in shock with a penetrating cardiac wound and 15% for all patients with penetrating wounds. Conversely, patient outcome is relatively poor when RT is performed for blunt trauma, 2% survival for patients in shock and less than 1% survival for patients with no vital signs. Patients undergoing CPR on arrival to the hospital should be stratified based on injury and transport time to determine the utility of RT. This algorithm represents a rational approach that could be followed at trauma centers with the appropriate resources; it may not be applicable at all hospitals caring for the injured. There will be patient, personnel, institutional, and situational factors that may warrant deviation from the recommended guideline. The annotated algorithm is intended to serve as a quick bedside reference for clinicians.
Operations on structures in the chest (usually the lungs) involve cutting between the ribs (thoracotomy). Severe post-thoracotomy pain can result from pleural (lung lining) and muscular damage, ...costovertebral joint (ribcage) disruption and intercostal nerve (nerves that run along the ribs) damage during surgery. Poor pain relief after surgery can impede recovery and increase the risks of developing complications such as lung collapse, chest infections and blood clots due to ineffective breathing and clearing of secretions. Effective management of acute pain following thoracotomy may prevent these complications and reduce the likelihood of developing chronic pain. A multi-modal approach to analgesia is widely employed by thoracic anaesthetists using a combination of regional anaesthetic blockade and systemic analgesia, with both non-opioid and opioid medications and local anaesthesia blockade.There is some evidence that blocking the nerves as they emerge from the spinal column (paravertebral block, PVB) may be associated with a lower risk of major complications in thoracic surgery but the majority of thoracic anaesthetists still prefer to use a thoracic epidural blockade (TEB) as analgesia for their patients undergoing thoracotomy. In order to bring about a change in practice, anaesthetists need a review that evaluates the risk of all major complications associated with thoracic epidural and paravertebral block in thoracotomy.
To compare the two regional techniques of TEB and PVB in adults undergoing elective thoracotomy with respect to:1. analgesic efficacy;2. the incidence of major complications (including mortality);3. the incidence of minor complications;4. length of hospital stay;5. cost effectiveness.
We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 9); MEDLINE via Ovid (1966 to 16 October 2013); EMBASE via Ovid (1980 to 16 October 2013); CINAHL via EBSCO host (1982 to 16 October 2013); and reference lists of retrieved studies. We handsearched the Journal of Cardiothoracic Surgery and Journal of Cardiothoracic and Vascular Anesthesia (16 October 2013). We reran the search on 31st January 2015. We found one additional study which is awaiting classification and will be addressed when we update the review.
We included all randomized controlled trials (RCTs) comparing PVB with TEB in thoracotomy, including upper gastrointestinal surgery.
We used standard methodological procedures expected by Cochrane. Two review authors (JY and SG) independently assessed the studies for inclusion and then extracted data as eligible for inclusion in qualitative and quantitative synthesis (meta-analysis).
We included 14 studies with a total of 698 participants undergoing thoracotomy. There are two studies awaiting classification. The studies demonstrated high heterogeneity in insertion and use of both regional techniques, reflecting real-world differences in the anaesthesia techniques. Overall, the included studies have a moderate to high potential for bias, lacking details of randomization, group allocation concealment or arrangements to blind participants or outcome assessors. There was low to very low-quality evidence that showed no significant difference in 30-day mortality (2 studies, 125 participants. risk ratio (RR) 1.28, 95% confidence interval (CI) 0.39 to 4.23, P value = 0.68) and major complications (cardiovascular: 2 studies, 114 participants. Hypotension RR 0.30, 95% CI 0.01 to 6.62, P value = 0.45; arrhythmias RR 0.36, 95% CI 0.04 to 3.29, P value = 0.36, myocardial infarction RR 3.19, 95% CI 0.13, 76.42, P value = 0.47); respiratory: 5 studies, 280 participants. RR 0.62, 95% CI 0.26 to 1.52, P value = 0.30). There was moderate-quality evidence that showed comparable analgesic efficacy across all time points both at rest and after coughing or physiotherapy (14 studies, 698 participants). There was moderate-quality evidence that showed PVB had a better minor complication profile than TEB including hypotension (8 studies, 445 participants. RR 0.16, 95% CI 0.07 to 0.38, P value < 0.0001), nausea and vomiting (6 studies, 345 participants. RR 0.48, 95% CI 0.30 to 0.75, P value = 0.001), pruritis (5 studies, 249 participants. RR 0.29, 95% CI 0.14 to 0.59, P value = 0.0005) and urinary retention (5 studies, 258 participants. RR 0.22, 95% CI 0.11 to 0.46, P value < 0.0001). There was insufficient data in chronic pain (six or 12 months). There was no difference found in and length of hospital stay (3 studies, 124 participants). We found no studies that reported costs.
Paravertebral blockade reduced the risks of developing minor complications compared to thoracic epidural blockade. Paravertebral blockade was as effective as thoracic epidural blockade in controlling acute pain. There was a lack of evidence in other outcomes. There was no difference in 30-day mortality, major complications, or length of hospital stay. There was insufficient data on chronic pain and costs. Results from this review should be interpreted with caution due to the heterogeneity of the included studies and the lack of reliable evidence. Future studies in this area need well-conducted, adequately-powered RCTs that focus not only on acute pain but also on major complications, chronic pain, length of stay and costs.
Within the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following ...PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present pulseless after critical injuries (with and without signs of life after penetrating thoracic, extrathoracic, or blunt injuries) undergo emergency department thoracotomy (EDT) (vs. resuscitation without EDT) to improve survival and neurologically intact survival?
All patients who underwent EDT were included while those involving either prehospital resuscitative thoracotomy or operating room thoracotomy were excluded. Quantitative synthesis via meta-analysis was not possible because no comparison or control group (i.e., survival or neurologically intact survival data for similar patients who did not undergo EDT) was available for the PICO questions of interest.
The 72 included studies provided 10,238 patients who underwent EDT. Patients presenting pulseless after penetrating thoracic injury had the most favorable EDT outcomes both with (survival, 182 21.3% of 853; neurologically intact survival, 53 11.7% of 454) and without (survival, 76 8.3% of 920; neurologically intact survival, 25 3.9% of 641) signs of life. In patients presenting pulseless after penetrating extrathoracic injury, EDT outcomes were more favorable with signs of life (survival, 25 15.6% of 160; neurologically intact survival, 14 16.5% of 85) than without (survival, 4 2.9% of 139; neurologically intact survival, 3 5.0% of 60). Outcomes after EDT in pulseless blunt injury patients were limited with signs of life (survival, 21 4.6% of 454; neurologically intact survival, 7 2.4% of 298) and dismal without signs of life (survival, 7 0.7% of 995; neurologically intact survival, 1 0.1% of 825).
We strongly recommend that patients who present pulseless with signs of life after penetrating thoracic injury undergo EDT. We conditionally recommend EDT for patients who present pulseless and have absent signs of life after penetrating thoracic injury, present or absent signs of life after penetrating extrathoracic injury, or present signs of life after blunt injury. Lastly, we conditionally recommend against EDT for pulseless patients without signs of life after blunt injury.
Systematic review/guideline, level III.
Continuous-flow left ventricular assist devices (CF-LVADs) have revolutionized the management of patients with advanced heart failure. Alternative implant strategies are increasingly used for device ...placement. We reviewed our experience from the Mechanical Circulatory Support Research Network registry with the HeartWare centrifugal CF-LVAD (HVAD). From May 2004 to August 2015, 1,150 patients underwent primary CF-LVAD implantation at our institutions. Within this group, a total of 283 patients (25%) were implanted with the HVAD. A minimally invasive left lateral thoracotomy (MILT) implant strategy was used in 53 patients (20%), of which 22 (42%) were implanted off-pump. Median age at implant was 59 years and 183 patients (65%) were implanted as bridge-to-transplantation. Follow-up was 100% complete for a total of 302 patient-years of support. In-hospital mortality was 4.9% (14 patients), and was comparable between the conventional sternotomy (CS) and MILT cohorts (p = 0.15). Patients in the MILT cohort had a shorter median length of stay (p < 0.01) and had a lower incidence of postimplant pump thrombus (p = 0.02). Cumulative survival at the end of follow-up reached 84%, and was comparable between the two groups (p = 0.298). Multivariate analysis identified preoperative bilirubin level as the only independent predictor of survival. Surgical technique had no impact on survival. In this large, multicenter experience, data demonstrate excellent survival and adverse event profiles for patients supported with the HVAD technology, regardless of surgical implant technique. With constant advancements in device technology along with our increasing clinical experience with the newer techniques, minimally invasive LVAD implantation continues to evolve as a valuable alternative to CS in selected patients.
To date, reports on outcomes after robotic-assisted pulmonary resection have been confined to small, single-institution case series. Furthermore, no comparison has been made between robotic, open, ...and video-assisted thoracic surgery (VATS) procedures. We sought to compare the outcomes between these approaches using the State Inpatient Databases (SID).
Using the 2008 to 2010 SID, we identified patients who underwent an open, VATS, or robotic lobectomy from 8 states. Patients who underwent segmentectomy were also included. A comparison of outcomes was performed using a propensity-matched analysis.
We identified a total of 33,095 patients (open: 20,238; VATS: 12,427; robotic: 430). Case volumes for robotic resections increased over the study period from 0.2% in 2008 to 3.4% in 2010. Robotic resections were performed in all 8 states, and 38% were conducted in a community hospital. In propensity-matched analysis, robotic resections were associated with significant reductions in mortality (0.2% vs 2.0%, p = 0.016), length of stay (5.9 vs 8.2 days, p < 0.0001), and overall complication rates (43.8% vs 54.1%, p = 0.003) when compared with open thoracotomy. Robotic resection was also associated with reductions in mortality (0.2% vs 1.1%, p = 0.12), length of stay (5.9 days vs 6.3 days, p = 0.45), and overall complication rates (43.8% vs 45.3%, p = 0.68) when compared with VATS; however, none of these differences were statistically significant.
Case volume for robotic pulmonary resections has increased significantly during the study period, and thoracic surgeons have been able to adopt the robotic approach safely. Robotic resection appears to be an appropriate alternative to VATS and is associated with improved outcomes compared with open thoracotomy.
Aims and objectives
To investigate the developing course of postoperative pain in a Chinese sample of patients following thoracic surgery.
Background
Chronic postoperative pain following thoracic ...surgery including both thoracotomy and video‐assisted thoracic surgery is often reported. However, research on pain trends concerning this topic is scarce with a notable lack of culturally focused studies by nurses.
Design
A prospective observational study.
Methods
The sample included patients undergoing thoracotomy (n = 137) and video‐assisted thoracic surgery (n = 143). Pain intensity and interference of pain with function were assessed during hospitalisation (day 1 to day 7 postoperatively) and followed up by telephone at 2 weeks and then at 1, 2, 3 and 6 months after surgery.
Results
Moderate‐to‐severe pain when coughing and moving was reported in over 85% during hospitalisation, and a significant difference in pain was found between those undergoing a thoracotomy (61%) and those having video‐assisted surgery (34%). Many patients whose immediate postoperative pain was poorly managed tended to report high pain levels after discharge and continued to have clinically important chronic pain 6 months after surgery. The pain intensity mean score during movement in the first five postoperative days was an important predictor of clinically important chronic pain, and those experiencing severe acute pain during hospitalisation had a higher probability of developing chronic pain.
Conclusions
Postoperative pain after thoracic surgery warrants greater attention because those experiencing severe acute pain during hospitalisation have a higher probability of developing chronic pain. Aggressive pain management and multimodal analgesia are recommended to prevent long‐term suffering in patients.
Relevance to clinical practice
Chronic pain after thoracic surgery remains a challenge in clinical nursing. To improve pain management quality and to prevent the transition of acute postoperative pain to chronic pain, standardised practice protocols and comprehensive physician and nurse education are highly recommended.
The video-assisted thoracoscopic surgery (VATS) approach has become a standard for the treatment of early-stage non-small-cell lung cancer (NSCLC). Recently published meta-analyses proved the benefit ...of VATS versus thoracotomy for overall survival (OS) and reduction of postoperative complications. The aim of this study was to compare early outcomes, long-term survival and rate of postoperative complications of the VATS approach versus thoracotomy.
In this retrospective cohort study, we analysed 982 individuals who underwent surgical resection for Stage I-IIA NSCLC between 2007 and 2015. Thirty- and 90-day mortality rates, length of hospital stay, rate of complications and OS were assessed. Propensity score matching was performed to compare 2 groups of patients. Two hundred and twenty-five individuals from the thoracotomy group and 225 patients from the VATS group were matched regarding pTNM, sex, the Charlson comorbidity index, type of resection and histological diagnosis.
In the propensity score-matched patient group, the VATS approach was associated with a significant benefit regarding OS (P = 0.042). Although no significant difference was observed (P = 0.14) in the 3-year survival rate of patients who had a thoracotomy versus VATS, the 5-year survival rate among patients with VATS increased significantly (61% vs 78%, P = 0.0081). The adjusted VATS-related hazard ratio for pTNM, sex and age was 0.63 (95% confidence interval 0.40-0.98). The VATS surgical approach also reduced both the rate of postoperative atelectasis (4% for VATS vs 10% for open thoracotomy; P = 0.0052) and the need for blood transfusions (4% vs 12% respectively, P = 0.0054) and significantly shortened the postoperative length of stay (mean 7.25 vs 9.34 days, P < 0.0001). No significant differences in the 30-day mortality (1% vs 1%, P = 0.66) and 90-day mortality (1% vs 1%, P = 0.48) rates were observed.
Patients with early-stage NSCLC operated on with VATS had fewer complications, shorter postoperative length of stay and better OS compared to those who were operated on by thoracotomy.
OBJECTIVES
Lung cancer is the most common cause of cancer-related deaths worldwide. Survival is highly dependent on surgery. Video-assisted thoracoscopic surgery (VATS) is increasingly chosen over ...open thoracotomy (OT) because of the possible benefits of the minimally invasive approach. Consequently, our aim was to compare the 30-day morbidity and mortality for lung cancer patients operated by VATS lobectomy or lobectomy by OT.
METHOD
Data were obtained from prospective national and regional databases, including patients who underwent lobectomy for lung cancer in the eastern part of Denmark from 1 January 2005 to 31 December 2011. All patients operated before 2009 were re-staged according to the latest International Association for the Study of Lung Cancer lung cancer classification. Patient characteristics, comorbidities, pathology and operative data were assessed using an independent samples t-test, Pearson's χ
2, Fisher’s exact test and Mann–Whitney test. Morbidity was assessed using multinomial logistic regression adjusted for gender, age, cancer stage, forced expiratory volume in 1 s (FEV1), year of surgery and Charlson comorbidity score.
RESULTS
In total, 1379 patients underwent lobectomy, 785 patients via VATS and 594 patients via thoracotomy. The two groups were similar in gender and FEV1. The patients operated by VATS were older (P < 0.001), and had a lower Charlson comorbidity score (P = 0.034), higher frequency of adenocarcinomas (P < 0.001) and lower cancer stage (P < 0.001). Among the VATS patients, 285 (36.3%) and among the thoracotomy patients, 288 (48.5%) had minor complications (P < 0.001); and 157 (20.0%) VATS patients and 212 (35.7%) thoracotomy patients had major complications (P < 0.001). The 30-day mortality rate was 1% in the VATS group and 1.5% in the thoracotomy group (P = 0.47). Multinomial logistic regression analysis showed that the prevalence of both minor odds ratio (OR) = 1.51; 95% confidence interval (Cl) = 1.18–1.96 and major complications (OR = 1.91, 95% Cl = 1.44–2.53) was significantly higher for patients who underwent lobectomy via thoracotomy compared with VATS.
CONCLUSION
Patients undergoing lobectomy via VATS were less likely to have at least one minor complication within the first 30 postoperative days and less likely to have at least one major complication, compared with patients operated by thoracotomy. These findings remained after adjusting for gender, age, FEV1, cancer stage, year of surgery and Charlson comorbidity score.
The HeartMate 3 (Abbott) left ventricular assist device provides substantial improvement in long-term morbidity and mortality in patients with advanced heart failure. The Implantation of the ...HeartMate 3 in Subjects With Heart Failure Using Surgical Techniques Other Than Full Median Sternotomy study compares thoracotomy-based implantation clinical outcomes with standard median sternotomy.
We conducted a prospective, multicenter, single-arm study in patients eligible for HeartMate 3 implantation with thoracotomy-based surgical technique (bilateral thoracotomy or partial upper sternotomy with left thoracotomy). The composite primary end point was survival free of disabling stroke (modified Rankin score >3), or reoperation to remove or replace a malfunctioning device, or conversion to median sternotomy at 6-months postimplant (elective transplants were treated as a success). The primary end point (noninferiority, −15% margin) was assessed with >90% power compared with a propensity score-matched cohort (ratio 1:2) derived from the Multi-Center Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 continued access protocol.
The study enrolled 102 patients between December 2020 and July 2022 in the thoracotomy-based arm at 23 North American centers. Follow-up concluded in December 2022. In the Implantation of the HeartMate 3 in Subjects With Heart Failure Using Surgical Techniques Other Than Full Median Sternotomy study group, noninferiority criteria was met (absolute between-group difference, −1.2%; Farrington Manning lower 1-sided 95% CI, −9.3%; P < .0025) and event-free survival was not different (85.0% vs 86.2%; hazard ratio, 1.01; 95% CI, 0.58-2.10). Length of stay with thoracotomy-based implant was longer (median, 20 vs 17 days; P = .03). No differences were observed for blood product utilization, adverse events (including right heart failure), functional status, and quality of life between cohorts.
Thoracotomy-based implantation of the HeartMate 3 left ventricular assist device is noninferior to implantation via standard full sternotomy. This study supports thoracotomy-based implantation as an additional standard for surgical implantation of the HeartMate 3 left ventricular assist device.
Abstract Aims Selected patients in traumatic cardiac arrest may benefit from pre-hospital thoracotomy. Pre-hospital care physicians rarely have surgical training and the procedure is rarely performed ...in most European systems. Limited data exists to inform teaching and training for this procedure. We set out to run a pilot study to determine the time required to perform a thoracotomy and the a priori defined complication rate. Methods We adapted an existing system operating procedure requiring four instruments (Plaster-of-Paris shears, dressing scissors, non-toothed forceps, scalpel) for this study. We identified a convenience sample of surgically trained and non-surgically trained participants. All received a training package including a lecture, practical demonstration and cadaver experience. Time to perform the procedure, anatomical accuracy and a priori complication rates were assessed. Results The mean total time for the clamshell thoracotomy from thoracic incision to delivery of the heart was 167 s (02:47 min:sec). There was no statistical difference in the time to complete the procedure or complication rate among surgeons, non-surgeons and students. The complication rate dropped from 36% in the first attempt to 7% in the second attempt but this was not statistically significant. This is a pilot study and small numbers of participants arguably saw it underpowered to define differences between study groups. Conclusion Clamshell thoracotomy can be taught using cadaver models. In this simulated environment, the procedure may be performed rapidly with minimum equipment.
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