A Randomized Controlled Study of the Use of Video Double-Lumen Endobronchial Tubes Versus Double-Lumen Endobronchial Tubes in Thoracic Surgery.

OBJECTIVE: To compare the incidence of fiberoptic bronchoscope (FOB) use (1) during verification of initial placement and (2) for reconfirmation of correct placement following repositioning, when either a double-lumen tube (DLT) or video double-lumen tube (VDLT) was used for lung isolation during thoracic surgery. DESIGN: A randomized controlled study. SETTING: Single-center university teaching hospital. PARTICIPANTS: The study comprised 80 patients who were 18 years or older requiring lung isolation for surgery. INTERVENTIONS: After institutional review board approval, patients were randomized prior to surgery to either DLT or VDLT usage. Attending anesthesiologists placed the Mallinckrodt DLT or Vivasight (ET View Ltd, Misgav, Israel) VDLT with conventional laryngoscopy or video laryngoscopy then verified correct tube position through the view provided with either VDLT external monitor or FOB. MEASUREMENTS AND MAIN RESULTS: Data collected included: sex, body mass index, successful intubation and endobronchial placement, intubation time, confirmation time of tube position, FOB use, quality of view, dislodgement of tube, and ability to forewarn dislodgement of endobronchial cuff and complications. FOB use for verification of final position of the tube (VDLT 13.2% [5/38] v DLT 100% [42/42], p < 0.0001), need for FOB to correct the dislodgement (VDLT 7.7% [1/13] v DLT 100% [14/14], p < 0.0001), dislodgement during positioning (VDLT 61.5% [8/13] v DLT 64.3% [9/14], p = ns), dislodgement during surgery (VDLT 38.5% [5/13] v DLT 21.4% [3/14], p = ns), and ability to forewarn dislodgement of endobronchial cuff (VDLT 18.4% [7/38] v DLT 4.8% [2/42], p = 0.078). CONCLUSION: This study demonstrated a reduction of 86.8% in FOB use, which was a similar reduction found in other published studies.

Video laryngoscopy versus direct laryngoscopy for double-lumen endotracheal tube intubation: a retrospective analysis.

OBJECTIVE: The authors hypothesized that video laryngoscopy (VL) facilitated double-lumen tube (DLT) insertion compared with direct laryngoscopy (DL). DESIGN: A retrospective analysis. SETTING: An academic hospital. PARTICIPANTS: Patients older than 18 years of age undergoing thoracic surgery requiring DLT placement between 2005 and 2011. INTERVENTIONS: Patients without airway predictors of difficult intubation who were intubated under DL with Macintosh (DL-MAC, n = 40) or Miller (DL-MIL, n = 44) blades and VL with McGrath MAC (Aircraft Medical, Edinburgh, UK) and C-MAC (Karl Storz, Tuttlingen, Germany) laryngoscopes (n = 46) were included in the study. Patients who were intubated with both VL devices were grouped into a VL group. MEASUREMENTS: Patients in all 3 groups had comparable preoperative demographics. Mallampati scores and ease of manual ventilation after the induction of anesthesia were also similar in all groups. The Cormack Lehane (C-L) grade views were significantly higher in patients in the DL-MAC than in the DL-MIL and VL groups (p < 0.006). The number of intubation attempts was similar in all 3 groups; however, the percentage of intubation reported to be difficult was higher in the DL-MAC than in the other 2 groups (p = 0.014). No damage to the airway was found in any of the groups. CONCLUSION: DLT placement using VL appeared to overcome some of the limitations of DL-MAC but was similar to DL-MIL. The authors speculated that the ease of placement was related to the improved visualization of the vocal cords because there was a significantly greater number of C-L views 3 and 4 in the DL-MAC group as compared with the VL and DL-MIL groups. Hence, the authors advocate using VL, particularly when the laryngoscopist is inexperienced using DL-MIL for DLT placement.

A Prospective, Randomized, Controlled Trial of Paravertebral Block versus General Anesthesia Alone for Prosthetic Breast Reconstruction.

BACKGROUND: Paravertebral blocks have gained popularity because of ease of implementation and a shift toward ambulatory breast surgery procedures. Previous retrospective studies have reported potential benefits of paravertebral blocks, including decreased narcotic and antiemetic use. METHODS: The authors conducted a prospective controlled trial of patients undergoing breast reconstruction over a 3-year period. The patients were randomized to either a study group of paravertebral blocks with general anesthesia or a control group of general anesthesia alone. Demographic and procedural data, in addition to data regarding pain and nausea patient-reported numeric scores and consumption of opioid and antiemetic medications, were recorded. RESULTS: A total of 74 patients were enrolled to either the paravertebral block (n = 35) or the control group (n = 39). There were no significant differences in age, body mass index, procedure type, or cancer diagnosis between the two groups. Patients who received a paravertebral block required less opioid intraoperatively and postoperatively combined compared with patients who did not receive paravertebral blocks (109 versus 246 fentanyl equivalent units; p < 0.001), and reported significantly lower pain scores at 0 to 1 (3.0 versus 4.6; p = 0.02), 1 to 3 (2.0 versus 3.2; p = 0.01), and 3 to 6 (1.9 versus 2.7; p = 0.04) hours postoperatively. The study group also consumed less antiemetic medication (0.7 versus 2.1; p = 0.05). CONCLUSIONS: Incorporating paravertebral blocks carries considerable potential for improving pathways for breast cancer patients undergoing breast reconstruction--with minimal procedure-related morbidity. This is the first prospective study designed to assess paravertebral blocks in the setting of prosthetic breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A possible association between aprotinin and improved survival after radical surgery for mesothelioma.

BACKGROUND: Aprotinin has been used to decrease blood loss with complicated cardiac surgery but has not been investigated in extrapleural pneumonectomy, an operation that does not use cardiopulmonary bypass. In this prospective, randomized, placebo-controlled, double-blind trial, the authors investigated whether aprotinin decreased blood loss in patients who underwent this operation. METHODS: After appropriate statistical design and institutional review board approval, eligible patients who were scheduled for extrapleural pneumonectomy were randomized to receive either aprotinin or placebo during the operation. Blood loss and survival data were obtained from electronic medical records and surgical databases. RESULTS: Of 20 patients who were enrolled, 16 patients met criteria for blood loss analysis. Four patients were excluded from the blood loss analysis: Three patients were inoperable because of tumor spread and underwent limited surgery, and 1 patient died intraoperatively because of acute, massive hemorrhage. The mean blood loss was 769 mL with aprotinin versus 1832 mL with placebo (P = .05; Wilcoxon test). All 20 patients were included in survival analyses. All 9 patients who received placebo died. In contrast, 7 of 11 patients who received aprotinin remained alive at the time of the current report. Kaplan-Meier survival curves differed significantly between the 2 groups (P = .0004). A Bayesian multivariate survival analysis of 18 patients who had complete data available on 8 prognostic variables indicated a posterior probability of .99 that aprotinin was beneficial. CONCLUSIONS: Aprotinin decreased blood loss. After accounting for covariate effects, there was a significant comparative benefit with aprotinin in postoperative survival. This finding was unexpected and could not be considered conclusive because of the small size of the current study. A confirmatory study may be warranted.