Successful treatment of neurologic injury after complex spinal surgery with hyperbaric oxygen therapy: a case report.

Background: Neurologic injury is relatively common in the context of spinal surgery, and is often treated with physiotherapy, pharmacotherapy, or surgical intervention. Emerging evidence supports a possible role for hyperbaric oxygen therapy (HBOT) in the treatment of peripheral and spinal nerve injuries. We describe the successful use of HBOT in improving neurologic recovery after complex spine surgery with new-onset postoperative unilateral foot drop. Case Description: A 50-year-old woman was found to have new right-sided foot drop and L2-S1 motor deficits following complex thoracolumbar revision spinal surgery. She received standard conservative management for a provisional diagnosis of acute traumatic nerve ischemia, but demonstrated no neurologic improvement. On postoperative day four, after other avenues of treatment were exhausted, she was referred for HBOT. The patient received a total of twelve sessions of HBOT at 2.0 absolute atmospheres (ATA) of pressure, for 90 minutes (including two air breaks) per session, before transfer to a rehabilitation facility. Conclusions: The patient displayed marked neurologic improvement after the first hyperbaric session, and further recovery thereafter. She concluded therapy with a significantly improved range of motion and lower limb power, ability to ambulate, and pain control. HBOT was associated with a rapid, sustained improvement when applied in this case as a salvage therapy for persistent postoperative neurologic deficit. Mounting evidence supports the consideration of hyperbaric therapy as a standard adjunct treatment for traumatic neurologic injury.

Dynamic hyperinflation and cardiac arrest during one-lung ventilation: a case report.

PURPOSE: Dynamic hyperinflation describes the phenomenon of progressive gas trapping that occurs in patients with severe airflow obstruction. It is associated with significant hemodynamic instability and may precipitate cardiac arrest. This report describes a case of hemodynamic collapse secondary to dynamic hyperinflation in a patient during one-lung ventilation. CLINICAL FEATURES: A 50-yr-old male with a pneumothorax secondary to a ruptured bulla was transferred to the operating room for a left bullectomy. Approximately 30 minutes after initiation of one-lung ventilation in the right lateral decubitus position, sudden ST segment elevation and hypotension occurred, which was refractory to large doses of vasopressor. This culminated in a pulseless electrical activity arrest. The patient was immediately placed supine, disconnected from the ventilator circuit, and resuscitated with chest compressions, fluids, and epinephrine. Auscultation of the right chest revealed no air entry, and needle decompression followed by chest tube insertion in the right chest did not demonstrate any evidence of a pneumothorax. Approximately three to five minutes after the onset of the arrest, the patient's hemodynamics stabilized and there was no evidence of ST elevation. The etiology of the arrest was likely due to dynamic hyperinflation. CONCLUSION: This report highlights the importance of having a high index of suspicion for dynamic hyperinflation and the key to its treatment: disconnection from the ventilator circuit and cessation of mechanical ventilation to allow the lungs to return to functional residual capacity.

Perioperative lung protection.

Perioperative pulmonary complications are known to be a major cause of morbidity and mortality, and as such, contribute a large burden to the health care system globally. Anesthesiologists have an important role during the perioperative period to identify patients at risk of these complications and intervene in order to reduce them. After describing perioperative pulmonary complications and risk factors for such, this article will address preoperative, intraoperative, and postoperative lung protective strategies to try and reduce the risk of these complications.

Anesthetic Considerations for Pneumonectomy With Left Atrial Resection on Cardiopulmonary Bypass in a Patient With Lung Cancer: A Case Report.

Cases of pneumonectomy plus atrial resection for lung cancer have been reported in the surgical literature, but not the anesthesia literature. To achieve curative resection, cardiopulmonary bypass (CPB) may be necessary. Although CPB may complicate the management of these high-risk patients, these cases should always be undertaken in a center where it is immediately available. Here, we discuss the anesthetic management of a 70-year-old man with left lower lobe lung cancer invading the left inferior pulmonary vein and left atrium.

Sevoflurane Attenuates Ischemia-Reperfusion Injury in a Rat Lung Transplantation Model.

BACKGROUND: Sevoflurane is one of the most commonly used volatile anesthetic agents with the fastest onset and offset, replacing isoflurane in modern anesthesiology. Preconditioning and postconditioning using volatile anesthetics can attenuate ischemia-reperfusion injury (IRI). However, no previous studies have evaluated the effect of sevoflurane in lung transplantation after cold ischemic injury. We aimed to study the effects of donor and recipient treatment with sevoflurane in a rat lung transplantation model. METHODS: Lewis rats were allocated to four groups: control, PreC (preconditioning), PostC (postconditioning), and PreC + PostC. Donor rats in the PreC and PreC + PostC groups were exposed to 1.5% sevoflurane for 30 minutes before donor operation. Donor lungs were flushed with Perfadex and stored for 12 hours at 4°C before transplantation. Recipients received orthotopic left lung transplantation. In the PostC and PreC + PostC groups, sevoflurane was initiated 2 minutes before reperfusion and maintained for 30 minutes. Two hours after reperfusion, lung function was evaluated, and samples were collected for histologic, inflammatory, and cell death assessment. RESULTS: Preconditioning and postconditioning using sevoflurane significantly improved the oxygenation of lung grafts (partial arterial gas pressure of oxygen: 198 mm Hg in control, 406.5 mm Hg in PreC, 472.4 mm Hg in PostC, and 409.7 mm Hg in PreC + PostC, p < 0.0001) and reduced pulmonary edema. Sevoflurane treatment reduced levels of interleukin-1ß, interleukin-6, and tumor necrosis factor-α. Moreover, sevoflurane significantly inhibited apoptotic cells by a decrease in cytochrome c release into cytosol and caspase-3 cleavage. CONCLUSIONS: Preconditioning or postconditioning of lungs using sevoflurane exhibits a significant protective effect against early phase of ischemia-reperfusion injury in a rat lung transplantation model.

Use of single-cannula venous-venous extracorporeal life support in the management of life-threatening airway obstruction.

The use of venous-venous extracorporeal life support (VV ECLS) for the endoscopic management of airway obstruction has been rarely reported. In most instances, ECLS has been used in the setting of cardiopulmonary resuscitation in which venoarterial ECLS was initiated as part of resuscitation. We report a patient with a bulky primary tumor of the tracheal carina presenting with airway obstruction who was managed with intraoperative single-cannula VV ECLS to facilitate endoscopic interventions leading to more definitive airway security.