Increased Extravascular Lung Water and Plasma Biomarkers of Acute Lung Injury Precede Oxygenation Impairment in Primary Graft Dysfunction After Lung Transplantation.

BACKGROUND: After lung transplantation (LT), early prediction of grade 3 pulmonary graft dysfunction (PGD) remains a research gap for clinicians. We hypothesized that it could be improved using extravascular lung water (EVLWi) and plasma biomarkers of acute lung injury. METHODS: After institutional review board approval and informed consent, consecutive LT recipients were included. Transpulmonary thermodilution-based EVLWi, plasma concentrations of epithelial (soluble receptor for advanced glycation endproducts [sRAGE]) and endothelial biomarkers (soluble intercellular adhesion molecule-1 and endocan [full-length and cleaved p14 fragment]) were obtained before and after LT (0 [H0], 6, 12, 24, 48 and 72 hours after pulmonary artery unclamping). Grade 3 PGD was defined according to the International Society for Lung and Heart Transplantation definition, combining arterial oxygen partial pressure (PaO2)/inspired fraction of oxygen (FiO2) ratio and chest X-rays. Association of clinical risk factors, EVLWi and biomarkers with grade 3 PGD was analyzed under the Bayesian paradigm, using logistic model and areas under the receiver operating characteristic curves (AUCs). RESULTS: In 47 LT recipients, 10 developed grade 3 PGD, which was obvious at H6 in 8 cases. Clinical risk factors, soluble intercellular adhesion molecule-1 and endocan (both forms) were not associated with grade 3 PGD. Significant predictors of grade 3 PGD included (1) EVLWi (optimal cutoff, 13.7 mL/kg; AUC, 0.74; 95% confidence interval [CI], 0.48-0.99), (2) PaO2/FiO2 ratio (optimal cutoff, 236; AUC, 0.68; 95% CI, 0.52-0.84), and (3) sRAGE (optimal cutoff, 11 760 pg/mL; AUC, 0.66; 95% CI, 0.41-0.91) measured at H0. CONCLUSIONS: Immediate postreperfusion increases in EVLWi and sRAGE along with impaired PaO2/FiO2 ratios were early predictors of grade 3 PGD at or beyond 6 hours and may trigger early therapeutic interventions.

Surgery for aspergilloma: time trend towards improved results?

Surgery of aspergilloma has been renowned to be technically challenging and has a high complication rate. We have already demonstrated an improved outcome as a result of a reduction in complex cases related to history of tuberculosis. In this paper we will evaluate whether this time trend has continued during recent years. Initial presentation and postoperative outcome of 33 patients who underwent surgical treatment between 1998 and 2009 were reviewed and compared with two previous reports (group 1: 55 patients from 1974 to 1991; group 2: 12 patients from 1992 to 1997). Underlying disease was tuberculosis in 15% of patients (57% in group 1, 17% in group 2), and 12% of patients had complex aspergillomas (80% in group 1, 41% in group 2). Postoperatively, there was no mortality (5% in group 1, 0% in group 2). Morbidity decreased progressively in terms of bleeding (44% in group 1, 9% in group 2, and 6% in recently, accrued patients), of pleural space problems (47%, 18% and 12%, respectively), and of prolonged hospital stay (32%, 8% and 6%, respectively). With a decreased postoperative complications rate after resection, contemporary surgery of aspergilloma is safe and offers satisfactory early and long-term results.

Intra-operative paravertebral block for postoperative analgesia in thoracotomy patients: a randomized, double-blind, placebo-controlled study.

OBJECTIVE: Epidural analgesia is the gold standard for post-thoracotomy pain relief but is contraindicated in certain patients. An alternative is paravertebral block. We investigated whether ropivacaine, administered through a paravertebral catheter placed by the surgeon, reduced postoperative pain. METHODS: In a randomized double-blind study, adult patients with a paravertebral catheter placed by the thoracic surgeon after thoracotomy were randomly assigned to receive through this catheter, either a 0.1 mlkg(-1) bolus of 0.5% ropivacaine, followed by a continuous infusion of 0.1 mlkg(-1)h(-1) for 48 h, or saline at the same scheme of administration. Patients also benefited from patient-controlled analgesia with intravenous morphine (bolus 1mg, lockout time 7 min), paracetamol, and nefopam. The primary endpoint was pain intensity on a visual analog scale at rest and on coughing. Secondary endpoints were total morphine consumption and side effects during the first 48 postoperative hours. Surgeons, anesthesiologists, and all the nurses and caring staff involved in this study were blinded. Solutions of saline and ropivacaine were prepared identically by the central pharmacy, without any possible identification of the product. RESULTS: Forty-seven patients with contraindications to epidural anesthesia were included. There were no significant differences between the groups receiving ropivacaine and saline in terms of pain severity at rest and on coughing, mean postoperative morphine consumption (45.7 mg for ropivacaine, 43.2mg in controls), and incidence of morphine-related side effects (nausea and vomiting, urinary retention, pruritus, respiratory rate, and sedation). CONCLUSIONS: Paravertebral block using a catheter placed by the thoracic surgeon was ineffective on postoperative pain after thoracotomy and did not confirm the analgesic effect that has been observed after percutaneous catheter placement. A direct comparison of these two placement methods is required.