Postoperative atrial fibrillation is a common complication after lung resection. It
is burdened by increased mortality and morbidity, prolonged hospitalization, and higher resource
utilization in ...thoracic surgery patients. Therefore, some kind of pharmacological prophylaxis is recommended.
In our patients, diltiazem, a calcium antagonist, is administered. We collected data on all 608
patients having undergone lung resection (no less than lobectomy) between November 2012 and May
2015. This period included patients having received diltiazem during their postoperative stay in our
Intensive Care Unit and surgical ward, and those that did not receive it. Patients having had atrial
fibrillation before the surgery and patients with cardiac pacemaker were excluded from the trial. Other
patients were divided into three groups: patients with some kind of antiarrhythmic therapy before and
continued after the surgery; patients with diltiazem prophylaxis; and patients without any antiarrhythmic
prophylaxis. The data collected were statistically analyzed. We found no statistically
significant difference in the incidence of postoperative atrial fibrillation among the groups (p<0.05).
Inhibitori kotransportera natrija i glukoze 2 (engl. Sodium-glucose cotransporter-2 inhibitors – SGLT2i) noviji su oralni antidijabetici koji mogu uzrokovati euglikemijsku dijabetičku ketoacidozu ...(eDKA), i to češće kod bolesnika sa šećernom bolesti tipa 1, a rijetko u onih s tipom 2 šećerne bolesti. Glavna karakteristika eDKA-a jest gotovo normalna razina glukoze u krvi (GUK) uz metaboličku ketoacidozu. U našem prikazu riječ je o 42-godišnjoj bolesnici u koje su se u ranome postoperativnom periodu, uz gotovo normalne vrijednosti GUK-a, razvili metabolička acidoza, povraćanje i pospanost. Sumnju da se radi o dijabetičkoj ketoacidozi potvrdio je, uz ostalo, pozitivan nalaz ketona u urinu. Na temelju kliničke slike, nalaza plinskih analiza arterijske krvi i laboratorijskih nalaza krvi i urina postavila se dijagnoza eDKA-a, nastalog kao posljedica SGLT2i-ja. Bolesnica je liječena inzulinom, kristaloidnim otopinama i elektrolitima. Trećega postoperativnog dana liječenja otpuštena je s Odjela anestezije i intenzivnog liječenja na Kirurški odjel, uz prethodni pregled endokrinologa. Rutinska perioperativna provjera plinskih analiza arterijske krvi pomogla nam je pri detekciji bolesti i liječenju bolesnice. Ovaj prikaz upućuje na važnost
ranoga preoperativnog probira pacijenata na SGLT2i, mogući nastanak eDKA-a, važnost preoperativne pripreme i potrebe za liječenjem.
To perform an external validation of the original Simplified Acute Physiology Score II (SAPS II) system and to assess its performance in a selected group of patients in major Croatian hospitals.
A ...prospective, multicenter study was conducted in five university hospitals and one general hospital during a six-month period between November 1, 2007 and May 1, 2008. Standardized hospital mortality ratio (SMR) was calculated from the mean predicted mortality of all the 2756 patients and the actual mortality for the same group of patients. The validation of SAPS II was made using the area under receiver operating characteristic curve (AUC), 2×2 classification tables, and Hosmer-Lemeshow tests.
The predicted mortality was as low as 14.6% due to a small proportion of medical patients and the SMR being 0.89 (95% confidence interval CI, 0.78-0.98). The SAPS II system demonstrated a good discriminatory power as measured by the AUC (0.85; standard error SE=0.012; 95% CI=0.840-0.866; P<0.001). This system significantly overestimated the actual mortality (Hosmer-Lemeshow goodness-of-fit H statistic: χ(2) =584.4; P<0.001 and C statistics: χ(2)(8) =313.0; P<0.001) in the group of patients included in the study.
The SAPS II had a good discrimination, but it significantly overestimated the observed mortality in comparison with the predicted mortality in this group of patients in Croatia. Therefore, caution is required when an evaluation is performed at the individual level.
Postoperative pulmonary complications (PPC) may result in longer duration of in-hospital stay and even mortality. Both thoracic surgery and intraoperative mechanical ventilation settings add ...considerably to the risk of PPC. It is unclear if one-lung ventilation (OLV) for thoracic surgery with a strategy of intraoperative high positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM) reduces PPC, compared to low PEEP without RM.
PROTHOR is an international, multicenter, randomized, controlled, assessor-blinded, two-arm trial initiated by investigators of the PROtective VEntilation NETwork. In total, 2378 patients will be randomly assigned to one of two different intraoperative mechanical ventilation strategies. Investigators screen patients aged 18 years or older, scheduled for open thoracic or video-assisted thoracoscopic surgery under general anesthesia requiring OLV, with a maximal body mass index of 35 kg/m
, and a planned duration of surgery of more than 60 min. Further, the expected duration of OLV shall be longer than two-lung ventilation, and lung separation is planned with a double lumen tube. Patients will be randomly assigned to PEEP of 10 cmH
O with lung RM, or PEEP of 5 cmH
O without RM. During two-lung ventilation tidal volume is set at 7 mL/kg predicted body weight and, during OLV, it will be decreased to 5 mL/kg. The occurrence of PPC will be recorded as a collapsed composite of single adverse pulmonary events and represents the primary endpoint.
PROTHOR is the first randomized controlled trial in patients undergoing thoracic surgery with OLV that is adequately powered to compare the effects of intraoperative high PEEP with RM versus low PEEP without RM on PPC. The results of the PROTHOR trial will support anesthesiologists in their decision to set intraoperative PEEP during protective ventilation for OLV in thoracic surgery.
The trial was registered in clinicaltrials.gov ( NCT02963025 ) on 15 November 2016.
Atrial fibrillation prophylaxis and esophageal resection u2013 our experienceAuthors: Karadza V., Hodoba N., Spicek Macan J., Stancic-Rokotov D., Kolaric N., Sakan S.Institute: University Hospital ...Centre Zagreb, Thoracic surgery, Zagreb, CroatiaText: Background and Goal of Study: Atrial fibrillation (FA) is a common complication in major thoracic surgery including esophageal resection. Recent guidelines suggest pharmacological prophylaxis of FA in thoracic surgery. The goal of this study is to find out is there a difference in FA incidence before and after introducing diltiazem FA prophylaxis.Materials and methods: For this study we collected data (age, sex, comorbidity, FA prophylaxis, incidence of FA, the highest observed ventricular answer in FA, ASA status) for patients before the introducing the diltiazem prophylaxis and after it. Only patients with radical esophageal resection are included in the study. We got three groups of patients: one with no prophylaxis, one with diltiazem prophylaxis and one with perioperative continued preoperative antiarrhythmic therapy (beta blocker, amiodarone). The collected data were analyzed.Results and discussion: There were 82 esophageal resections conducted in our Clinics for thoracic surgery u201cJordanovacu201d, University Hospital Centre Zagreb, between November 2012 and May 2015. Postoperative FA is counted in 11 cases (13.41%). 23 patient received diltiazem FA prophylaxis, 16 patients continued their preoperative beta-antagonist therapy, one patients continued preoperative amiodarone therapy and 42 patients did not receive any FA prophylaxis. Among the patients with postoperative FA, 4 patients were from the group received no FA prophylaxis, 4 patients were from the group received beta blockers, and 3 patients received diltiazem as FA prophylaxis. If we correlate patients with prophylaxis with diltiazem and patients with no FA prophylaxis, we get no significant difference (The Chi-square statistic is 0.1916. The P value is 0.661598. This result is not significant at p <0.05). The highest noticed ventricular answer to FA was 140/min (110-140, median 130) in patients with diltiazem prophylaxis and 180/min (130-180, median 159) with no prophylaxis.Conclusion(s): It seems that the diltiazem prophylaxis does not protect from FA, but we can speculate that it could make FA less deleterious by slowing the ventricular rhythm. To determine the significance of these findings further studies and bigger sample are needed.References: Frendel G et al. 2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgery procedures. The J Thorac Cardiovasc Surg. 2014;148.3:153-193
Poslijeoperacijska atrijska fibrilacija je česta komplikacija resekcije pluća. Ona dovodi do povišenog pobola i smrtnosti, produljenog bolničkog liječenja i povećane potrošnje sredstava u ...torakokirurških bolesnika. U skladu s tim, savjetuje se neki oblik farmakološke profilakse. U naših bolesnika odabrani lijek je kalcijev antagonist diltiazem. Skupili smo podatke o svih 608 bolesnika podvrgnutih resekciji pluća (ne manjoj od lobektomije) u razdoblju između studenog 2012. i svibnja 2015. Ovo razdoblje uključuje bolesnike koji su primali diltiazem tijekom njihova poslijeoperacijskog boravka u Jedinici intenzivnog liječenja i na kirurškom odjelu te bolesnike koji ga nisu primali. Bolesnici s atrijskom fibrilacijom prije operacije i bolesnici s elektrostimulatorom srca isključeni su iz obrade. Ostali bolesnici podijeljeni su u tri skupine: skupinu liječenu nekim antiaritmikom prije operacije koji su nastavili svoju terapiju i nakon operativnog zahvata, skupinu na profilaksi diltiazemom i skupinu bez profilakse. Skupljeni podaci su statistički analizirani. Nismo našli statistički značajnu razliku između skupina u incidenciji poslijeoperacijske atrijske fibrilacije (p<0,05).
We present three patients in whom life-threatening haemorrhage following lung resection was successfully managed using activated recombinant factor VII (NovoSeven). In one case, activated recombinant ...factor VII was the only therapy administered to manage bleeding, and in the two remaining cases, activated recombinant factor VII was administered after patients failed to respond to conventional therapy. All patients demonstrated effective haemostasis and improved coagulation parameters as a result of treatment with activated recombinant factor VII. Our experience with the clinical use of rFVIIa suggests that this agent may provide effective hemostasis following lifethreatening postoperative bleeding after major thoracic surgery. Despite these favorable results, randomized, placebo - controlled trials are needed to identify optimal treatment strategy, patient selection, and safety of treatment in patients with massive bleeding following major thoracic surgery.
A 70-year old female patient was admitted to the hospital because of scheduled thoracotomy and biopsy of posterior mediastinal retrocardiac tumor of unrecognized etiology. The patient had no ...complaints regarding the tumor. Routine anesthesiological preoperative examination revealed status ASA III. Induction in anesthesia was usually stable. At the moment when the surgeon intraoperatively touched the tumor, hemodinamic instability started and arterial blood pressure and heart rate dramatically increased. Our first reaction was to deepen the anesthesia. Very soon it was obvious that blood pressure increased by the surgeon's manipulation of the tumor and we started to doubt on catecholamine-secreting tumor. During the course of the operation there were several hypertensive episodes and we managed them by alternately using atenolol, glyceroltrinitrate and anesthetic drug. The patient was extubated 5 hours after transfer to the intensive care unit. Postoperative period was hemodynamically stable. The level of catecholamines in 24-hour urine collection was significantly increased. Pathohistologic diagnosis was mediastinal paraganglioma.
It is not precisely defined which group of non-cardiac surgery patients should undergo transthoracic echocardiography in preoperative preparation. This study was prospectively performed to find out ...whether the routine use of echocardiography is justified in patients scheduled for lung resection, and to assess its role in cardiac risk evaluation.
Patients classified as ASA III who were identified as having minor or intermediate predictors of cardiac risk were included in the study. Based on this triage, 130 patients underwent transthoracic echocardiography.
Intermediate index of increased perioperative cardiovascular risk was recorded in 36.2% and low index in 63.8% of patients. Preoperative anesthesiologic examination revealed some form of cardiac arrhythmia in 28.5%, symptoms of coronary disease in 25.4%; hypertension in 52.3%, and chronic obstructive pulmonary disease in 16.9% of patients. Transthoracic echocardiography showed the ejection fraction of 60% in 86.9% and of 40%-49% in only one patient. Left ventricular contractility was preserved in 96.2% of patients. Diastolic relaxation was weakened in 42.3% of patients. Mild mitral insufficiency was found in 29.2%; aortic stenosis in 1.5%, mild aortic insufficiency in 2.3%, mild pulmonary hypertension in 70.8%, and severe pulmonary hypertension in only 1.5% of patients. Pulmonectomy was performed in 26.9%, lobectomy in 62.3% and segmental tumor resection in 10.8% of patients. Only 26.2% of patients had peri- and postoperative complications: tachyarrhythmia and atrial fibrillation with rapid ventricular answer in 16.2%, hypotension 1.5%; hypertension in 2.3% and hypertension and arrhythmia in 1.5% of patients. Three (2.3%) patients died. None of our patients had Goldman's score higher than 25; according to Detsky index our patients belonged to 0-15 point group, class I, with the foreseen risk %.
Transthoracic echocardiography is not justified in the routine preoperative preparation of thoracosurgical patients classified as ASA III with clinically minor and intermediate indexes of increased cardiovascular risk. It should be done in selected patients, primarily those that have history data and clinical picture consistent with major indices of an increased cardiovascular risk.
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