RESUMEN
BACKGROUND: Thoracic Epidural has long been the most recommended treatment for postoperative pain management in general thoracic surgery. This study compares liposomal bupivacaine (LB) as an alternative method for pain control and compares it to the standard. METHODS: LB was compared to thoracic epidural bupivacaine hydrochloride (TE BH) in 387 patients who underwent video-assisted thoracoscopic pulmonary resection (VATS-R) at our institution. Patients received either continuous TE BH or intraoperative LB at a predetermined dose. A total of 237 patients received TE BH from April 2010 to March 2014 and 143 patients received LB from April 2014 to March 2016. After propensity matching, 95 patients in each group had similar demographics and clinical characteristics including gender, age, race, American Society of Anesthesia (ASA) classification, Zubrod scores, and FEV1 and DLCO percent predicted measurements. Outcome measures included hospital costs, length of stay (LOS), adverse events, postoperative opioid medication use, and pain scores. RESULTS: Compared to the TE BH group, the LB group had significantly lower pain scores (average visual analogue scale the day of surgery: 3.9 versus 4.5, pâ¯<â¯0.05), decreased postoperative opioid medication (morphine equivalent dose during the first 3 days: 344.5 versus 269.5, pâ¯<â¯0.05), and lower total and direct hospital costs ($2906 and $1865 respectively, pâ¯<â¯0.05). Although a shorter LOS in the LB group was not statistically significant (4.3 versus 5.1 days, pâ¯=â¯0.156), more patients in the LB group were discharged directly home than the control group (44.2% versus 28.4%, pâ¯<â¯0.05). There was no difference noted in overall adverse events including 30-day readmissions between the two groups. CONCLUSION: LB is a viable alternative for pain management in patients undergoing VATS-R. With recent scrutiny on healthcare costs and the opioid epidemic, these results are encouraging and should be further investigated.
Asunto(s)
Analgesia Epidural/economía , Anestésicos Locales/economía , Bupivacaína/uso terapéutico , Preparaciones de Acción Retardada/economía , Enfermedades Pulmonares/cirugía , Manejo del Dolor/economía , Dolor Postoperatorio/prevención & control , Cirugía Torácica Asistida por Video , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Liposomas , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Estudios RetrospectivosAsunto(s)
Bronquios/fisiopatología , Neoplasias Pulmonares/cirugía , Neumonectomía/efectos adversos , Bronquios/cirugía , Broncoscopía/métodos , Estudios de Seguimiento , Humanos , Imagenología Tridimensional , Neoplasias Pulmonares/patología , Masculino , Persona de Mediana Edad , Neumonectomía/métodos , Complicaciones Posoperatorias/cirugía , Medición de Riesgo , Toracotomía/métodos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVE: The Thoratec Implantable Ventricular Assist Device (Thoratec Corporation, Pleasanton, Calif) can be used for univentricular or biventricular support in patients with a body surface area as low as 1.3 m(2). Results of the multicenter clinical trial are reviewed. METHODS: Between October 2001 and June 2004, a total of 39 patients at 12 institutions were supported with the Thoratec Implantable Ventricular Assist Device. Twenty-four patients (62%) received left ventricular assist devices and 15 (38%) received biventricular assist devices. Indications included bridge to transplantation (n = 30) and postcardiotomy failure (n = 9). The control group included 100 patients from the Food and Drug Administration approval submissions for the paracorporeal version of the ventricular assist device. RESULTS: Twenty-eight male and 11 female patients, with mean age of 48 years (16-71 years) and body surface area of 1.9 m(2) (1.3-2.4 m2) were supported for 3938 patient-days (10.8 patient-years). Mean left ventricular assist device flow index on the first postoperative day was 2.5 +/- 0.5 L/(min x m2). Mean duration of support was 101 days (9-597 days). Eighteen patients were discharged after a mean duration of 96 days. There were no ventricular assist device failures. Complications included 13 cases of bleeding requiring reexploration (33.3%), 1 embolic and 2 hemorrhagic strokes (7.7%), 5 driveline infections (12.8%), and 2 pocket infections (5%). Support to successful outcomes was 70% for bridge to transplantation and 67% for postcardiotomy recovery, versus historical results for the paracorporeal ventricular assist device of 69% for bridge to transplantation and 48% for postcardiotomy recovery. CONCLUSION: The Thoratec Implantable Ventricular Assist Device is a new implantable pulsatile ventricular assist device that allows hospital discharge for patients as a bridge to transplantation or for postcardiotomy failure. It is the first Food and Drug Administration-approved implantable ventricular assist device with biventricular capability.
Asunto(s)
Corazón Auxiliar , Adolescente , Adulto , Anciano , Femenino , Trasplante de Corazón/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Prospectivos , Diseño de Prótesis , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
Tracheal resections for benign and malignant disease are well described. The addition of release procedures, including suprathyroid and suprahyoid laryngeal release, has increased the capability of extended tracheal resection and primary reconstruction. Constant neck flexion by a suture between the skin of the point of the chin and midline of the chest over the manubrium is also widely considered paramount to successful tracheal resections. We designed a straightforward alternative to this method for patient comfort and compliance.
Asunto(s)
Cuello , Férulas (Fijadores) , Tráquea/cirugía , Obstrucción de las Vías Aéreas/etiología , Asma/etiología , Diseño de Equipo , Femenino , Humanos , Persona de Mediana Edad , Aceptación de la Atención de Salud , Postura , Dehiscencia de la Herida Operatoria/prevención & control , Neoplasias de la Tráquea/complicaciones , Neoplasias de la Tráquea/cirugíaRESUMEN
A 73-year-old man with a history of postpneumonectomy empyema and a long-term chest tube since 1979 presented with fever, chills, leukocytosis, and purulent fluid from the left tube thoracostomy. CT scan and bronchoscopy demonstrated a right lower lobe pneumonia and a left mainstem dehiscence with direct communication to the left tube thoracostomy. He underwent primary closure of the bronchopleural fistula with latissimus dorsi muscle flap coverage after antibiotic therapy for right lower lobe pneumonia.