Thoracic epidural anaesthesia for awake thoracic surgery in severely dyspnoeic patients excluded from general anaesthesia.

OBJECTIVES: General anaesthesia (GA) carries high risks of ventilator dependency with increased morbidity and mortality in patients with severe respiratory disease. It also presents an ethical dilemma if surgery remains the only treatment option for patients with advanced terminal chronic respiratory disease. Thoracic epidural anaesthesia for awake thoracic surgery (TEATS) in high-risk patients with dyspnoea at rest could avoid ventilator dependency and speed up recovery even in patients with severe dyspnoea. This retrospective observational study analysed indications, management and outcome of patients contraindicated to GA undergoing awake thoracic surgery with thoracic epidural anaesthesia. METHODS: From 716 patients requiring thoracic surgery, nine were contraindicated to GA. Eight patients [American Society of Anesthesiologists (ASA) 4] had a maximum grade four of the modified Medical Research Council dyspnea scale (MMRC). Two patients (ASA 3, grade 1 MMRC and ASA 4, grade 4 MMRC) refused GA. RESULTS: Patients (female : male ratio 1.25 : 1, age 19-76 years) had the following chronic respiratory diseases: pulmonary fibrosis (n = 2), pulmonary metastases (n = 3), chronic obstructive pulmonary disease (n = 1), alveolitis (n = 1) and myopathy (n = 2). Surgical indications were: thoracotomy (n = 6) for pleurectomy to treat recurring pneumothorax (n = 3), pleurostomy (n = 1), emphysema surgery (n = 1), lung biopsy (n = 1) and thoracoscopy (n = 3) for pleural/lung biopsy (n = 2), pneumothorax (n = 1). Lidocaine 20 mg/ml or ropivacaine 7.5 mg/ml was titrated to achieve an anaesthesia level T2-T12. No patient required GA [time of surgery: 46-128 min, mean = 76 min, standard deviation (SD) = 23 min]. Seven patients had light sedation with TCI propofol, remifentanyl or both and remained responsive. Fifty percent of patients received phenylephrine or ephedrine to maintain arterial pressure. Two patients went into hypercapnia, which was reversed with assisted mask ventilation. One patient suffered acute respiratory distress 7 days postoperatively and died of intestinal bleeding on Day 25. There were no postoperative complications in other patients. Excluding Patient 9 always remaining in a medical intensive care unit (ICU), the mean postoperative ICU stay in thoracic surgery was 4.4 days (SD 5.2). Hospital discharge was between 5 and 40 days after surgery. CONCLUSIONS: TEATS with/without sedation was an alternative to GA for thoracotomy/thoracoscopy in severely dyspnoeic patients (MMRC grade 4, ASA 4) without postoperative sequelae.

Open window thoracostomy and thoracoplasty to manage 90 postpneumonectomy empyemas.

BACKGROUND: Postpneumonectomy empyema (PPE) is a serious complication. The treatment options are similar to the management of any abscess, with drainage, ideally open, often of critical importance. After infection control, many techniques for space obliteration have been described. This study summarizes a 10-year experience in the management of PPE in our center. METHODS: From 2000 to 2010, 90 patients (83 men) with PPE were treated. Median follow-up was 5.3 years. Once the diagnosis of empyema was confirmed, chest drainage was performed through open window thoracostomy (OWT), with ensuing extramusculoperiosteal thoracoplasties if healthy tissue was present. RESULTS: Pneumonectomy was performed in 72 patients with lung cancer. Mortality after PPE was 2.2%. OWT achieved infection control in 89 patients. Seven OWT spontaneously healed, and 24 were never closed. The remaining 59 patients with OWT underwent thoracoplasty. Mortality after thoracoplasty was 5%. Empyema recurred in 3 patients. Overall success rate of PPE control after pleural obliteration was 91.5%. CONCLUSIONS: Thoracoplasty is a reliable filling procedure. It has a significantly higher success rate and a lower mortality rate than the other techniques. We believe that this procedure has a part to play in the future management of PPE.

Ultrasonographic evaluation of normal extrinsic and intrinsic carpal ligaments: preliminary experience.

OBJECTIVE: To determine normal anatomy of extrinsic and intrinsic carpal ligaments at ultrasonography (US). DESIGN AND VOLUNTEERS: In the first part of the study, two musculoskeletal radiologists retrospectively reviewed in consensus the photographs of anatomic sections and dissections derived from 20 cadaveric wrists. This cadaveric study gave the two readers the opportunity to learn the anatomy and orientation of the various extrinsic and intrinsic carpal ligaments and, thus, to develop a US protocol to facilitate the recognition of each carpal ligament. In the second part of the study, these two radiologists prospectively and independently evaluated the visibility of extrinsic and intrinsic carpal ligaments in 30 wrists of volunteers, using the same US protocol. RESULTS: With regard to extrinsic carpal ligaments, the radioscaphocapitate ligament (partially visible, 38%; completely visible, 62%), the radiolunotriquetral ligament (partially visible, 27%; completely visible, 73%), the palmar ulnotriquetral ligament (partially visible, 12%; completely visible, 88%), and the dorsal radiotriquetral ligament (partially visible, 7%; completely visible, 93%) were visualized at US. The dorsal ulnotriquetral ligament (partially visible, 21%; completely visible, 74%), the ulnolunate ligament (partially visible, 5%; completely visible, 70%), and the radial collateral ligament (partially visible, 18%; completely visible, 12%) were more difficult to recognize. The radioscapholunate ligament was never seen. With regard to intrinsic carpal ligaments, the dorsal (partially visible, 11%; completely visible, 89%) and palmar (partially visible, 38%; completely visible, 62%) scaphotriquetral ligaments as well as the dorsal scapholunate ligament (partially visible, 3%; completely visible, 97%) were visualized at US. The dorsal lunotriquetral ligament (partially visible, 39%; completely visible, 61%) and the palmar scapholunate ligaments (partially visible, 12%; completely visible, 81%) were more difficult to recognize. CONCLUSION: US may be helpful in identifying the major extrinsic and intrinsic carpal ligaments.