Comparison of several methods for pain management after video-assisted thoracic surgery for pneumothorax: an observational study.

BACKGROUND: There is no defined gold standard for pain management after video-assisted thoracic surgery (VATS) for pneumothorax. In addition to systemic analgesia, various loco-regional analgesic techniques have been proposed but remain poorly evaluated in this context. We aimed to assess the analgesic efficacy of several of these techniques for the management of postoperative pain. METHODS: We conducted a monocentric prospective observational cohort study from February 2017 to April 2018 in patients suffering from spontaneous pneumothorax and scheduled for VATS (n = 59). Patients received systemic analgesia (i) alone (n = 15); (ii) combined with a continuous paravertebral block (n = 9); (iii) combined with a continuous serratus plane block (n = 19); or (iv) single-shot serratus plane block (n = 16) as decided by the attending physician. Pain scores and analgesic-related side effects were prospectively collected by an independent observer during the first postoperative 72 h. The primary endpoint criterion was the cumulative oral morphine consumption at the end of the third postoperative day. Statistical analysis used univariate and multivariate step-by-step forward logistic regression models to determine risk factors associated with the main criteria. RESULTS: Mean pain scores and morphine consumption were not significantly different between the 4 groups. In the multivariate analysis, the use of a continuous serratus plane block through a catheter was the only technique associated with a reduced incidence of high-dose oral morphine consumption (OR 0.09-95%CI [0.01-0.79], p = 0.03). CONCLUSION: This study suggests that serratus plane block combined with continuous infusion through a catheter may have some benefits, although further studies are needed to confirm these results and determine the true place of the serratus plane block in pain management after VATS for pneumothorax.

Face-To-Face Double-Lumen Tube Intubation With the Airtraq Video Laryngoscope for Emergency Thoracic Surgery: A Case Report.

Double-lumen intubation is commonly used for thoracic surgery as it allows rapid and effective one-lung ventilation. However, it is more difficult than single-lumen tube intubation, notably in the context of emergency surgery and/or in hypoxemic patients. We report the case of a 57-year-old patient requiring emergency revision surgery after an upper right lobectomy due to postoperative pneumothorax and pleuropneumonia. As rapid lung isolation was required due to a bronchopleural fistula, rapid sequence induction and double-lumen tube intubation were performed. In addition, as the patient was hypoxemic with incomplete pre-oxygenation and too uncomfortable to tolerate the recumbent position despite high-flow oxygen, intubation was performed in face-to-face position. The patient was successfully intubated in 22 seconds and the right lung immediately isolated, allowing the surgeon to clean the pleural cavity. This is the first report of a double-lumen tube intubation in face-to-face position. The expected difficulties related to this type of intubation were successfully prevented using an Airtraq laryngoscope. Although such a strategy cannot be recommended from this one case, this report is encouraging for future studies evaluating the potential advantages of Airtraq use for double-lumen face-to-face intubation for emergency thoracic surgery.

The risk of atrial fibrillation after pneumonectomy is not impaired by preoperative administration of dexamethasone. A cohort study.

INTRODUCTION: Atrial fibrillation (AF) is one of the most frequent complications occurring after thoracic surgery especially after lung resection. It is associated with an increase in postoperative morbidity and mortality. Recent data having documented the preventive role of corticosteroids on the occurrence of AF in cardiac surgery, we sought to evaluate the effect of preoperative administration of dexamethasone on the incidence of AF after pneumonectomy. METHODS: We reviewed the files of all consecutive patients who underwent a pneumonectomy in one single centre between July 2004 and July 2012. For each patient, demographics, medical status, the surgical procedure and treatments administered including dexamethasone, were recorded. The data were analysed using a univariate analysis and a multivariate logistic regression. RESULTS: Among them, 153 patients were included and analysed; 35 (23%) presented with at least one episode of AF occurring within 48hours after surgery. Mortality was higher in these patients (26.5% versus 12.1%, P=0.06). The univariate analysis indicated that patients who had a postoperative course complicated by the occurrence of AF were older (P=0.003), had a higher SAPS2 score (P=0.002) and a higher CHADS score (P=0.05). Older age (OR=1.08; P=0.048) and preoperative treatment by anti-arrhythmics (OR=3.9; P=0.029) were documented as independent risk factors in the multivariate analysis. Preoperative administration of dexamethasone 8-12mg did not impair the incidence of AF. DISCUSSION: AF is a frequent complication after pneumonectomy associated with increased mortality. Whereas corticosteroids have been documented as preventing AF following cardiac surgery, no such effect was found after pneumonectomy.