One-Lung Ventilation and Postoperative Pulmonary Complications After Major Lung Resection Surgery. A Multicenter Randomized Controlled Trial.

OBJECTIVES: The effect of one-lung ventilation (OLV) strategy based on low tidal volume (TV), application of positive end-expiratory pressure (PEEP), and alveolar recruitment maneuvers (ARM) to reduce postoperative acute respiratory distress syndrome (ARDS) and pulmonary complications (PPCs) compared with higher TV without PEEP and ARM strategy in adult patients undergoing lobectomy or pneumonectomy has not been well established. DESIGN: Multicenter, randomized, single-blind, controlled trial. SETTING: Sixteen Italian hospitals. PARTICIPANTS: A total of 880 patients undergoing elective major lung resection. INTERVENTIONS: Patients were randomized to receive lower tidal volume (LTV group: 4 mL/kg predicted body weight, PEEP of 5 cmH2O, and ARMs) or higher tidal volume (HTL group: 6 mL/kg predicted body weight, no PEEP, and no ARMs). After OLV, until extubation, both groups were ventilated using a tidal volume of 8 mL/kg and a PEEP value of 5 cmH2O. The primary outcome was the incidence of in-hospital ARDS. Secondary outcomes were the in-hospital rate of PPCs, major cardiovascular events, unplanned intensive care unit (ICU) admission, in-hospital mortality, ICU length of stay, and in-hospital length of stay. MEASUREMENTS AND MAIN RESULTS: ARDS occurred in 3 of 438 patients (0.7%, 95% CI 0.1-2.0) and in 1 of 442 patients (0.2%, 95% CI 0-1.4) in the LTV and HTV group, respectively (Risk ratio: 3.03 95% CI 0.32-29, p = 0.372). Pulmonary complications occurred in 125 of 438 patients (28.5%, 95% CI 24.5-32.9) and in 136 of 442 patients (30.8%, 95% CI 26.6-35.2) in the LTV and HTV group, respectively (risk ratio: 0.93, 95% CI 0.76-1.14, p = 0.507). The incidence of major complications, in-hospital mortality, and unplanned ICU admission, ICU and in-hospital length of stay were comparable in both groups. CONCLUSIONS: In conclusion, among adult patients undergoing elective lung resection, an OLV with lower tidal volume, PEEP 5 cmH2O, and ARMs and a higher tidal volume strategy resulted in low ARDS incidence and comparable postoperative complications, in-hospital length of stay, and mortality.

Prolonged air leak after video-assisted thoracic anatomical pulmonary resections: a clinical predicting model based on data from the Italian VATS group registry, a machine learning approach.

Background: Prolonged air leak (PAL) is a frequent complication after lung resection surgery and has a high clinical and economic impact. A useful risk predictor model can help recognize those patients who might benefit from additional preventive procedures. Currently, no risk model has sufficient discriminatory capacity to be used in common clinical practice. The aim of this study is to identify predictive risk factors for PAL after video-assisted thoracoscopic surgery (VATS) anatomical resections in the Italian VATS group database and to evaluate their clinical and statistical performance. Methods: We processed data collected in the second edition of the Italian VATS group registry. It includes patients that underwent a thoracoscopic anatomical resection for benign or malignant diseases, between November 2015 and December 2020. We used recursive feature elimination (RFE), using a backward selection process, to find the optimal combination of predictors. The study population was randomly split based on the outcome into a derivation (80%) and an internal validation cohort (20%). Discrimination of the model was measured using the area under the curve, or C-statistic. Calibration was displayed using a calibration plot and was measured using Emax and Eavg, the maximum and the average difference in predicted versus loess calibrated probabilities. Results: A cohort of 6,236 patients was eligible for the study after application of the exclusion criteria. Five-day PAL rate in this patient cohort was 11.3%. For the construction of our predictive model, we used both preoperative and intraoperative variables, with a total of 320 variables. The presence of variables with missing values greater than 5% led to 120 remaining predictors. RFE algorithm recommended 8 features for the model that are relevant in predicting the target variable. Conclusions: We confirmed significant prognostic risk factors for the prediction of PAL: decreased DLCO/VA ratio, longer duration of surgery, male sex, the need for adhesiolysis, COPD, and right side. We identified middle lobe resections and ground glass opacity as protective factors. After internal validation, a C statistic of 0.63 was revealed, which is too low to generate a reliable score in clinical practice.

Are Thoracic Wall Blocks Efficient After Video-Assisted Thoracoscopy Surgery-Lobectomy Pain? A Comparison Between Serratus Anterior Plane Block and Intercostal Nerve Block.

OBJECTIVES: Video-assisted thoracoscopy surgery-lobectomy is less invasive than conventional thoracotomy and is associated with fewer complications. However, the pain related is classified as moderate and requires adequate treatment. Ultrasound-guided serratus anterior plane block (SAPB) provides analgesia by blocking the lateral branches of the intercostal nerves, avoiding the complications of epidural analgesia and paravertebral block. The aim of the present study was to evaluate the efficacy and safety of the SAPB compared with the intercostal nerve block (ICNB). DESIGN: This was a non-randomized prospective study, in which surgery-lobectomy pain after video-assisted thoracoscopy was treated with the following multimodal approach: SAPB or ICNB, morphine-patient controlled analgesia, and paracetamol. SETTING: The study was undertaken in a single community hospital. PARTICIPANTS: The study comprised 40 patients. INTERVENTIONS: Execution of ultrasound-guided SAPB. MEASUREMENTS AND MAIN RESULTS: Nineteen (47.5%) men and 21 (52.5%) women were enrolled, and the mean age was 67.22 ± 11 years. Both groups showed any visual analog scale values >4, which was significantly lower in the SAPB group at the 6th hour and at the 12th and 24th hours only during coughing (p < 0.05). The sedation score was significantly lower in the ICNB group at 0 and at the 2nd and 4th hours; it was lower in the SAPB group at the 6th hour. All patients had a sedation score <1, and they all were awake and oriented. After 24 hours, the total morphine requirement was 19.3 ± 14.4 mg and 11.3 ± 8.5 mg (p = 0.038); after 48 hours, it was 12.2 ± 7.9 mg and 8.2 ± 5.8 mg in the ICNB and SAPB groups, respectively. CONCLUSIONS: The multimodal approach of SAPB, morphine-patient controlled analgesia, and paracetamol is effective, safe, and time efficient.

Airway management in anesthesia for thoracic surgery: a "real life" observational study.

BACKGROUND: One-lung ventilation (OLV) in thoracic anesthesia is required to provide good surgical exposure. OLV is commonly achieved through a double lumen tube (DLT) or a bronchial blocker (BB). Malposition is a relevant issue related to these devices use. No prospective studies with adequately large sample size have been performed to evaluate the malposition rate of DLTs and BBs. METHODS: A total of 2,127 patients requiring OLV during thoracic surgery were enrolled. The aim of this multicenter prospective observational study performed across 26 academic and community hospitals is to evaluate intraoperative malposition rate of DLTs and BBs. We also aim to assess: which device is the most used to achieve OLV, the frequency of bronchoscope (BRO) use, the incidence rate of desaturation during OLV and the role of other factors that can correlate to this event, and incidence of difficult airway. RESULTS: Malposition rate for DLTs was 14%, for BBs 33%. DLTs were used in 95% of patients and BBs in 5%. Mean positioning time was shorter for DLT than BB (156±230 vs. 321±290 s). BRO was used in 54% of patients to check the correct positioning of the DLT. Desaturation occurred in 20% of all cases during OLV achieved through a DLT. Predicting factors of desaturation were dislocation (OR 2.03) and big size of DLT (OR 1.15). BRO use (OR 0.69) and left surgical side (OR 0.41) proved to be protective factors. Difficult airway prevalence was 16%; 10.8% predicted and 5.2% unpredicted. CONCLUSIONS: DLT has a low malpositioning rate and is the preferred device to achieve OLV. BRO use recorded was unexpectedly low. The possibility of encountering a difficult airway is frequent, with an overall prevalence of 16%. Risk factors of desaturation are malposition and increased size of DLT. Left procedures and BRO use could lead to fewer episodes of desaturation.

Evaluation of the correct position of peripherally inserted central catheters: anatomical landmark vs. electrocardiographic technique.

PURPOSE: The purpose of this study is to verify as early as possible the correct positioning of the peripherally inserted central catheter (PICC) tip in order to reduce complications due to possible malpositioning. The ECG-guided technique proved to be reliable, easy to carry out, straightforward, low-cost and allows us to recognize an incorrect or a suboptimal positioning throughout the procedure. The purpose of this study is to compare two methods used during the PICC insertion so as to prevent catheter malpositioning; the first study estimates the catheter length by the landmark method (based on cutaneous anatomical landmarks, CALs) with the addition of the postprocedural verification of tip location by chest X-Ray (CxR), whereas the second method of intraprocedural tip location is based on the observation of the morphological variations of the P wave (ECG-guided technique) with the addition of the postprocedural verification by CxR. METHODS: From 2010 to 2012, 90 PICCs were positioned, 48 using the anatomical landmarks and 42 using the ECG technique. RESULTS: Twenty-five percent of the catheters positioned with the anatomical landmark technique did not reach the correct position of the tip in SVC; of these, 6.25% were placed in an aberrant position and others in a sub-optimal position.Of the 42 PICCs positioned with the ECG technique, only in three cases (equal to 7.14%), a suboptimal position of the tip was observed, whereas there was no case of aberrant positioning. CONCLUSIONS: The ECG technique represents an accurate, low-cost and safe technique to verify the correct positioning of the tip. The use of the ECG allowed a more correct positioning in terms of catheter tip-carina distance and catheter tip-tracheobronchial angle, and in no patient was it necessary to place a catheter again.

Asleep-awake-asleep technique during carotid endarterectomy: a case series.

OBJECTIVE: Carotid endarterectomy (CEA) has become one of the most common vascular procedures in the world. It can be performed both under general anesthesia (GA) and regional anesthesia (RA). The aim of this study was to present results of a technique for CEA in which the patients anesthetized with target-controlled infusions of propofol and remifentanil were awake during the endarterectomy phase. Neurologic function was evaluated as if under RA. Patient satisfaction and the incidence of major complications also were investigated. DESIGN: A prospective nonrandomized case series. SETTING: A single-institution, regional hospital. PARTICIPANTS: One hundred eight patients with carotid artery stenosis undergoing CEA. INTERVENTIONS: Anesthesia was induced using TCI remifentanil at an initial effect-site concentration of 3 ng/mL and propofol TCI at an effect-site concentration of 2.5 to 3 microg/mL. Both drugs gradually were reduced shortly before the clamping phase until the patients were awake. The patients were asked to squeeze a child's toy placed in the contralateral hand from the side of the operation. If a deficiency of motor function occurred, the level of anesthesia was increased and a shunt was inserted. When the carotid artery was unclamped and there was no evidence that any other neurologic deficiency had occurred, both propofol and remifentanil infusions were increased until the patient fell asleep. MEASUREMENTS AND RESULTS: Seventeen patients (15.7%) developed a neurologic deficiency within 13 minutes of the carotid artery clamping, which required a shunt. All patients were interviewed the next day; 2 patients (1.8%) felt a sense of anxiety when the technique was explained to them. No patients suffered from anxiety or agitation during the intraoperative awakening. One patient (0.9%) complained about discomfort because of the orotracheal tube, and 2 patients suffered from slight pain. One patient (0.9%) suffered from angina pectoris the following day, but no other major complication occurred. Six months later, a telephone interview was held with the patients included in the study; 5 had died and 2 had had a stroke within this period. All the interviewed patients judged this technique good, and they would recommend it to other patients. CONCLUSIONS: Although this is a case series, the authors believe that this technique combines the advantages of RA (good evaluation of the patients' neurologic status) and GA (patients relaxed and comfortable). Moreover, the analysis of the results of the questionnaire suggests that the patients can tolerate the operation awake under propofol and remifentanil, and major complications also were low. It can be concluded that this technique appears to be safe and well accepted by patients and could be a good alternative in patients in whom RA cannot be performed.