Summary
Double‐lumen intubation is more difficult than single‐lumen tracheal intubation. Videolaryngoscopes have many advantages in airway management. However, the advantages of videolaryngoscopy for ...intubation with a double‐lumen tube remain controversial compared with traditional Macintosh laryngoscopy. In this study, we searched MEDLINE, Embase, Cochrane Library and the Web of Science for randomised controlled trials comparing videolaryngoscopy with Macintosh laryngoscopy for double‐lumen tube intubation. We found that videolaryngoscopy provided a higher success rate at first attempt for double‐lumen tube intubation, with an odds ratio (95%CI) of 2.77 (1.92–4.00) (12 studies, 1215 patients, moderate‐quality evidence, p < 0.00001), as well as a lower incidence of oral, mucosal or dental injuries during double‐lumen tube intubation, odds ratio (95%CI) 0.36 (0.15–0.85) (11 studies, 1145 patients, low‐quality evidence, p = 0.02), and for postoperative sore throat, odds ratio (95%CI) 0.54 (0.36–0.81) (7 studies, 561 patients, moderate‐quality evidence, p = 0.003), compared with Macintosh laryngoscopy. There were no significant differences in intubation time, with a standardised mean difference (95%CI) of −0.10 (−0.62 to 0.42) (14 studies, 1310 patients, very low‐quality evidence, p = 0.71); and the incidence of postoperative voice change, odds ratio (95%CI) 0.53 (0.21–1.31) (7 studies, 535 patients, low‐quality evidence, p = 0.17). Videolaryngoscopy led to a higher incidence of malpositioned double‐lumen tube, with an odds ratio (95%CI) of 2.23 (1.10–4.52) (six studies, 487 patients, moderate‐quality evidence, p = 0.03).
Although bupivacaine remains a standard local anesthetic for postoperative epidural infusions in pediatric patients, it is increasingly being replaced with ropivacaine by many anesthesiologists. ...Ropivacaine is associated with less risk for cardiac and central nervous system toxicity.
The purpose of this study was to compare analgesic efficacy and adverse events of postoperative epidural analgesia with ropivacaine/fentanyl versus bupivacaine/fentanyl in children after the Ravitch procedure and thoracotomy.
This was a prospective randomized controlled study.
This study was conducted at the Department of Thoracic Surgery of the Institute of Tuberculosis and Lung Diseases in Rabka Zdroj, Poland.
94 patients undergoing elective thoracic surgery.
Patients aged 7-17 years were randomly allocated into a ropivacaine 0.2% (RF, n = 45) or bupivacaine 0.125% (BF, n = 45) group; 1 mL of each analgesic solution contained 5 μg fentanyl. All patients received acetaminophen and nonsteroidal anti-inflammatory drugs. Nurses assessed pain intensity and incidence of adverse events over 72 hours after surgery and modified analgesia if patient pain intensity was greater than 2 out of 10.
There was no statistically significant difference in median pain scores and incidence of adverse events between the RF group and the BF group. The analgesia was excellent (median pain intensity scores at rest, during deep breathing, and when coughing was less than 1 out of 10 in all patients). Adverse events included incidents of desaturation (64/90), nausea (18/90), vomiting (31/90), pruritus (12/90), urinary retention (2/90), paresthesia (11/90), anisocoria (2/90), and Horner syndrome (2/90).
Thoracic epidural analgesia using an RF and BF solution resulted in similar pain relief and adverse event profiles.
•Thoracic epidural analgesia using a ropivacaine 0.2% combined with 5.0 μg/ml fentanyl and 0.125% bupivacaine with 5.0 μg/ml fentanyl resulted in similar pain relief and adverse event profiles.•Any adverse events are minor and easily reversible.•The modification of postoperative epidural analgesia by a nurse based on pain assessment and early identification and proper management of adverse events are a key to effective and safe epidural analgesia.
Using the national Society of Thoracic Surgeons Adult Cardiac Surgery Database data for thoracic aortic surgical procedures for aortic aneurysm, this study aimed to (1) characterize patients' risk ...profiles and outcomes, (2) evaluate center volume-outcome relationships across US centers, and (3) identify risk factors for operative mortality.
Between 2011 and 2016, 53,559 operations for ascending aortic aneurysm performed across 1,045 centers in the United States were identified. Logistic regression related baseline characteristics and comorbidities to operative mortality. Ten-fold cross-validation was performed to estimate sensitivity and specificity across a range of the discrimination threshold. Centers were stratified into five strata by average annual case volume. Predicted probability of operative mortality was calculated from the model and was used to evaluate patients' risk profiles across the volume strata.
Operative mortality occurred in 3.2% of all cases and in 2.2% of elective cases. Only 24 (2.3%) centers performed ≥50 cases annually, whereas 609 (58.3%) centers performed fewer than five cases annually. Multiple logistic regression, of which the c-index was 0.80, revealed that compared with centers with ≥50 cases, centers with fewer than five cases had an increased risk of mortality (odds ratio, 2.50; 95% confidence interval, 2.08 to 3.01; p < 0.0001). The predicted probability of operative mortality was similar across the volume strata, but the observed mortality rate varied significantly, with lower volume yielding higher operative mortality.
Proximal thoracic aortic surgical procedures for aortic aneurysms in the United States are associated with a low operative mortality rate of 2.2% for elective cases. Risk of operative death decreases significantly at an annual center volume of more than 20 to 25 cases per year.
The use of bronchial blockers has been increased for one-lung ventilation; however, the placement of bronchial blockers is time consuming. The objective of this study was to compare the novel ...extraluminal technique of Uniblocker placement supported by trachea length measurement on computerized tomography images with conventional intraluminal Uniblocker placement method.
Seventy adult patients undergoing left side thoracic surgery were included in the study. All the patients were randomly assigned to one of two groups: conventional intraluminal intubation group (CV-IN group, n = 35) or extraluminal CT guided group (CT-EX group, n = 35). The primary endpoints were the optimal positions of Uniblocker and the injuries of bronchi and carina. The secondary outcomes included the time of Uniblocker placement, the adequacy of lung collapse, the incidences of Uniblocker displacement, sore throat, and hoarseness postoperative.
In the CV-IN group, 19 of 35 Uniblockers went to the left main-stem bronchus on the initial blind insertion and 15 of 35 Uniblockers were considered as in optimal depth, whereas in the CT-EX group, 32 of 35 Uniblockers went to the left main-stem bronchus on the initial blind insertion and 31 of 35 Uniblockers were considered as in optimal depth (P < .01). The incidence of bronchi and carina injuries was obviously lower in the CT-EX group (occurred in 1 of 35 cases) than that in the CV-IN group (occurred in 8 of 35 cases) (P < .05). The time of Uniblocker placement took 145.4 s in the CV-IN group and 85.4 s in the CT-EX group (P < .01). The malpositions of Uniblocker, the degree of pulmonary collapse and the adverse events postoperative such as sore throat and hoarseness were not significantly different between the two groups (P > .05).
The novel extraluminal technique of Uniblocker placement supported by trachea length measurement on computerized tomography images was proved to be more rapid, more accurate and less complications than conventional intraluminal Uniblocker placement method.
The use of lung-protective ventilation (LPV) strategies may minimize iatrogenic lung injury in surgical patients. However, the identification of an ideal LPV strategy, particularly during one-lung ...ventilation (OLV), remains elusive. This study examines the role of ventilator management during OLV and its impact on clinical outcomes.
Data were retrospectively collected from the hospital electronic medical record and the Society of Thoracic Surgery database for subjects undergoing thoracic surgery with OLV between 2012 and 2014. Mean tidal volume (VT) during two-lung ventilation and OLV and ventilator driving pressure (ΔP) (plateau pressure - positive end-expiratory pressure PEEP) were analyzed for the 1,019 cases that met the inclusion criteria. Associations between ventilator parameters and clinical outcomes were examined by multivariate linear regression.
After the initiation of OLV, 73.3, 43.3, 18.8, and 7.2% of patients received VT greater than 5, 6, 7, and 8 ml/kg predicted body weight, respectively. One hundred and eighty-four primary and 288 secondary outcome events were recorded. In multivariate logistic regression modeling, VT was inversely related to the incidence of respiratory complications (odds ratio, 0.837; 95% CI, 0.729 to 0.958), while ΔP predicted the development of major morbidity when modeled with VT (odds ratio, 1.034; 95% CI, 1.001 to 1.068).
Low VT per se (i.e., in the absence of sufficient PEEP) has not been unambiguously demonstrated to be beneficial. The authors found that a large proportion of patients continue to receive high VT during OLV and that VT was inversely related to the incidence of respiratory complications and major postoperative morbidity. While low (physiologically appropriate) VT is an important component of an LPV strategy for surgical patients during OLV, current evidence suggests that, without adequate PEEP, low VT does not prevent postoperative respiratory complications. Thus, use of physiologic VT may represent a necessary, but not independently sufficient, component of LPV.
Positive end-expiratory pressure (PEEP) is an important part of the lung protection strategies for one-lung ventilation (OLV). However, a fixed PEEP value is not suitable for all patients. Our ...objective was to determine the prevention of individualized PEEP on postoperative complications in patients undergoing one-lung ventilation.
We searched the PubMed, Embase, and Cochrane and performed a meta-analysis to compare the effect of individual PEEP vs fixed PEEP during single lung ventilation on postoperative pulmonary complications. Our primary outcome was the occurrence of postoperative pulmonary complications during follow-up. Secondary outcomes included the partial pressure of arterial oxygen and oxygenation index during one-lung ventilation.
Eight studies examining 849 patients were included in this review. The rate of postoperative pulmonary complications was reduced in the individualized PEEP group with a risk ratio of 0.52 (95% CI:0.37-0.73; P = .0001). The partial pressure of arterial oxygen during the OLV in the individualized PEEP group was higher with a mean difference 34.20 mm Hg (95% CI: 8.92-59.48; P = .0004). Similarly, the individualized PEEP group had a higher oxygenation index, MD: 49.07mmHg, (95% CI: 27.21-70.92; P < .0001).
Individualized PEEP setting during one-lung ventilation in patients undergoing thoracic surgery was associated with fewer postoperative pulmonary complications and better perioperative oxygenation.
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