Lung ultrasound is non-inferior to bronchoscopy for confirmation of double-lumen endotracheal tube positioning: a randomized controlled noninferiority study.

BACKGROUND: Appropriate placement of left-sided double-lumen endotracheal tubes (LDLTs) is paramount for optimal visualization of the operative field during thoracic surgeries that require single lung ventilation. Appropriate placement of LDLTs is therefore confirmed with fiberoptic bronchoscopy (FOB) rather than clinical assessment alone. Recent studies have demonstrated lung ultrasound (US) is superior to clinical assessment alone for confirming placement of LDLT, but no large trials have compared US to the gold standard of FOB. This noninferiority trial was devised to compare lung US with FOB for LDLT positioning and achievement of lung collapse for operative exposure. METHODS: This randomized, controlled, double-blind, noninferiority trial was conducted at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand from October 2017 to July 2019. The study enrolled 200 ASA classification 1-3 patients that were scheduled for elective thoracic surgery requiring placement of LDLT. Study patients were randomized into either the FOB group or the lung US group after initial blind placement of LDLT. Five patients were excluded due to protocol deviation. In the FOB group (n = 98), fiberoptic bronchoscopy was used to confirm lung collapse due to proper positioning of the LDLT, and to adjust the tube if necessary. In the US group (n = 97), lung ultrasonography of four pre-specified zones (upper and lower posterior and mid-axillary) was used to assess lung collapse and guide adjustment of the tube if necessary. The primary outcome was presence of adequate lung collapse as determined by visual grading by the attending surgeon on scale from 1 to 4. Secondary outcomes included the time needed to adjust and confirm lung collapse, the time from finishing LDLT positioning to the grading of lung collapse, and intraoperative parameters such has hypotension or hypertension, hypoxia, and hypercarbia. The patient, attending anesthesiologist, and attending thoracic surgeon were all blinded to the intervention arm. RESULTS: The primary outcome of lung collapse by visual grading was similar between the intervention and the control groups, with 89 patients (91.8%) in the US group compared to 83 patients (84.1%) in the FOB group (p = 0.18) experiencing adequate collapse. This met criteria for noninferiority per protocol analysis. The median time needed to confirm and adjust LDLT position in the US group was 3 min (IQR 2-5), which was significantly shorter than the median time needed to perform the task in the FOB group (6 min, IQR 4-10) (p = 0.002). CONCLUSIONS: In selected patients undergoing thoracic surgery requiring LDLT, lung ultrasonography was noninferior to fiberoptic bronchoscopy in achieving adequate lung collapse and reaches the desired outcome in less time. TRIAL REGISTRATION: This study was registered at clinicaltrials.gov, NCT03314519 , Principal investigator: Kasana Raksamani, Date of registration: 19/10/2017.

Low dose intraoperative ketamine infusion with multilevel paravertebral block for pain after video-assisted thoracic surgery: a randomized-controlled study.

BACKGROUND: Intraoperative low-dose ketamine infusion has been reported to be an effective adjuvant to opioids for postoperative pain control without major side effects, but it has not been tested in video-assisted thoracic surgery (VATS). The aim of this study was to examine the effect of low-dose intraoperative intravenous ketamine infusion on 24-hour morphine requirement and acute postoperative pain following VATS for lung resection. METHODS: This study was a single center, randomized, double-blind, placebo-controlled study. Thirty-two patients undergoing elective VATS for lung resection in a university hospital were included. Patients were randomly allocated (1:1 ratio) to receive either intraoperative low-dose ketamine (0.2 mg/kg/h) or normal saline infusion starting from intubation to the beginning of chest closure. All patients received multilevel thoracic paravertebral block (TPVB) and morphine was administered postoperatively via the patient-controlled analgesia pump using the same protocol. Time to first analgesia, postoperative cumulative morphine doses at 10, 30 minutes, and the consecutive 1, 2, 6, 12, 18, and 24 hours were recorded. Pain intensity during rest and deep breathing were also assessed by numeric rating scale (NRS) score at 1- and 24-hour postoperatively. RESULTS: There was no significant difference in median (P25, P75) cumulative 24-hour morphine requirement between the ketamine and the control groups [15 (5.5, 29.5) vs. 22.5 (15.3, 40.8) mg, P=0.090]. Patients in ketamine group had significantly longer median pain free time than the control group (27 vs. 2 minutes, P=0.006). No difference in overall NRS score at rest or during deep breathing at 1- and 24-hour postoperatively was demonstrated (P=0.861). CONCLUSIONS: Intraoperative low dose ketamine infusion in addition to TPVB does not reduce postoperative morphine consumption or pain intensity but may prolong pain free time in patients undergoing VATS for lung resection.

Comparison of High-Flow Humidified Oxygen With Conventional Continuous Positive Airway Pressure in Nonventilated Lungs During Thoracic Surgery: A Randomized Cross-Over Study.

OBJECTIVE: This study assessed the efficacy of high-flow humidified oxygen (HFHO) as an alternative to continuous positive airway pressure (CPAP) for improving oxygenation while preserving nonventilated lung collapse during one-lung ventilation. DESIGN: A prospective randomized cross-over trial. SETTING: A tertiary medical center. PARTICIPANTS: The study comprised 28 patients undergoing elective thoracotomy with one-lung ventilation using a double-lumen endobronchial tube placement. INTERVENTIONS: The patients received prophylactic CPAP or HFHO to the nonventilated lung for 20 minutes and were then crossedover to the other oxygenation modality for 20 minutes, with a 20-minute recovery interval between the two modalities. MEASUREMENTS AND MAIN RESULTS: Changes in respiratory parameters and lung deflation quality were recorded. Both CPAP and HFHO increased the partial pressure of arterial oxygen in either sequence in both groups, ranging from 31.8-to-66.0 mmHg. However, the increments from these two interventions were not statistically significant (95% confidence interval -12.84 to 21.87; p = 0.597). There were no differences in other parameters. Half the patients receiving CPAP experienced worsening of the surgical condition, whereas the HFHO patients experienced no change or reported a better lung deflation (p < 0.001). CONCLUSION: HFHO could be an alternative method to CPAP for improving arterial oxygenation while preserving lung deflation during one-lung ventilation. However, additional studies are warranted in regard to its cost-effectiveness and establishment as a routine treatment.

Thoracic cancer surgery during the COVID-19 pandemic: a consensus statement from the Thoracic Domain of the Asian Society for Cardiovascular and Thoracic Surgery.

OBJECTIVES: Healthcare resources have been mobilized to combat the COVID-19 pandemic of 2020. The Thoracic Domain of the Asian Society for Cardiovascular and Thoracic Surgery reports a consensus statement on the provision of thoracic cancer surgery during this pandemic. METHODS: A Thoracic Experts Panel was convened by the Society. A consensus on the provision, safety, and setting of thoracic cancer surgery during the pandemic was obtained through a Delphi process. RESULTS: Responses were received from 26 panel members (96% response rate) from 10 regions across Asia. The Society recommended that elective thoracic cancer surgery services may need to be reduced or postponed if medical resources were needed for COVID-19 patients, especially intensive care unit beds and ventilators. However, thoracic cancer surgery should proceed as normal for all solid tumors, without restrictions based on disease stage, availability of non-surgical treatment options, or patient condition (unless there is a high likelihood of postoperative intensive care unit stay). Aerosol-forming procedures should be avoided intra- and perioperatively. The surgical approach does not make a difference in terms of safety. Services for thoracic cancer patients should be offered only in hospitals that maintain isolation wards for patients with confirmed or suspected COVID-19. CONCLUSIONS: Services for patients with thoracic cancer should be maintained during the COVID-19 pandemic. The position of the Society is that thoracic surgeons have a responsibility to perform good surgical management of thoracic cancer during the pandemic, to advocate for patients' rights to receive it, and to safeguard patients and staff from infection.

General thoracic surgery services across Asia during the 2020 COVID-19 pandemic.

The COVID-19 pandemic of 2020 posed an historic challenge to healthcare systems around the world. Besides mounting a massive response to the viral outbreak, healthcare systems needed to consider provision of clinical services to other patients in need. Surgical services for patients with thoracic disease were maintained to different degrees across various regions of Asia, ranging from significant reductions to near-normal service. Key determinants of robust thoracic surgery service provision included: preexisting plans for an epidemic response, aggressive early action to "flatten the curve", ability to dedicate resources separately to COVID-19 and routine clinical services, prioritization of thoracic surgery, and the volume of COVID-19 cases in that region. The lessons learned can apply to other regions during this pandemic, and to the world, in preparation for the next one.

Validation of EuroSCORE for coronary artery bypass grafting at Siriraj Hospital.

OBJECTIVE: To access the performance of the EuroSCORE when applied to CABG patients at Siriraj hospital. MATERIAL AND METHOD: One thousand five hundred forty nine patients diagnosed with coronary artery disease (CAD) who underwent isolated CABG between January 2007 and December 2009 was prospectively studied. RESULTS: The patients included 1,102 men and 447 women and had a mean age of 67 years old. The mean additive score in expired and survived groups were 9.65 +/- 5.14 and 3.87 +/- 3.06. In logistic, score were 25.43 +/- 26.31 and 4.88 +/- 7.88 respectively (p < 0.001). The best cut-off value of EuroSCORE for prediction of a death rate was 6 for additive score and 10 for logistic score. Area under the curve was 0.831 for the additive score and 0.823 for the logistic score. The observed overall mortality rate was 2.0% while the predict mortality was 5.27%. The difference between observed and predicted deaths was significant with additive score and logistic score (p < 0.001). CONCLUSION: Our results suggest that EuroSCORE is not valid for CABG in Thai patient due to over prediction.

Surveillance of pediatric cardiac surgical outcome using risk stratifications at a tertiary care center in Thailand.

Objectives. To determine in-hospital mortality and complications of cardiac surgery in pediatric patients and identify predictors of hospital mortality. Methods. Records of pediatric patients who had undergone cardiac surgery in 2005 were reviewed retrospectively. The risk adjustment for congenital heart surgery (RACHS-1) method, the Aristotle basic complexity score (ABC score), and the Society of Thoracic Surgeons and the European Association for Cardiothoracic Surgery Mortality score (STS-EACTS score) were used as measures. Potential predictors were analyzed by risk analysis. Results. 230 pediatric patients had undergone congenital cardiac surgery. Overall, the mortality discharge was 6.1%. From the ROC curve of the RACHS-1, the ABC level, and the STS-EACTS categories, the validities were determined to be 0.78, 0.74, and 0.67, respectively. Mortality risks were found at the high complexity levels of the three tools, bypass time >85 min, and cross clamp time >60 min. Common morbidities were postoperative pyrexia, bleeding, and pleural effusion. Conclusions. Overall mortality and morbidities were 6.1%. The RACHS-1 method, ABC score, and STS-EACTS score were helpful for risk stratification.

Pathology and etiology of 110 consecutively removed aortic valves.

OBJECTIVES: To study the pathology and determine the etiology and prevalence of aortic valve disease from surgically removed aortic valve specimens. MATERIAL AND METHOD: All the native surgically excised aortic valves (AV) received from June 1997 to March 1999 (22 months) were studied macroscopically including cuspal measurements and microscopically. By preoperative echocardiographic and macroscopic studies, they were classified into functional disorders of predominant aortic stenosis (AS), aortic stenosis with regurgitation (AS-AR) and predominant aortic regurgitation (AR). The patients' medical records were reviewed and the clinical information was extracted. The etiology was determined according to the macroscopic, microscopic and clinical findings. RESULTS: Among 110 AV (76 isolated AV and 34 with concomitant mitral valves from patients aged 15-96 years, mean age 47.54 years; male:female = 1.39:1) there were 25 AS (22.73%), 34 AS-AR (30.91%) and 51 AR (46.36%) cases. Eighty-four (76.36%) were tricuspid, 16 (14.54%) were bicuspid and 10 were undetermined. Cuspal measurements of each disease were provided and compared. All AS specimens were related to moderate to severe calcification and causes included postinflammatory disease (14 cases, 56%; age range 38-67 years, mean age 53.29 years, male:female = 0.56:1), degenerative calcific change (11 cases, 44%, age range 56-76 years, male:female = 1.2:1; mean age 69 years of 5 tricuspid AV and 60.83 years of 6 bicuspid AV). In AS-AR, 29 cases (85.29%; mean age 47.10 years; male:female = 1.23:1) were attributable to postinflammatory disease and 5 cases (mean age 70.20 years; male:female = 1.5:1) to degenerative calcific change. In pure AR, there were 21 cases (age range 15-65 years, mean age 29.76 years) of postinflammatory disease, 14 cases of infective endocarditis (IE) and postIE (age range 20-63 years, mean age 42.21 years; all 10 IE cases contained gram positive cocci), 1 case (age 55 years) of bicuspid calcific change, 8 cases of AV with dilated valve ring, 5 cases of miscellaneous causes and 2 cases of indeterminate etiology. Aschoff bodies were found in 3 AR cases. Four of 18 postinflammatory AS-AR and 4 of 14 postinflammatory disease AR cases had past history of rheumatic fever. One postinflammatory AS also had infective endocarditis from gram positive cocci without clinical sign. Severe degenerative calcific change had a higher incidence of underlying diabetes (3 of 15 cases, 20%), hypertension (8 of 14 cases, 57.14%) and dyslipoproteinemia (9 of 13 cases, 69.23%) in comparison with 3.37% (3/89) for diabetes, 9.09% (8/88) for hypertension and 30.99% (22/71) for dyslipoproteinemia in other AV diseases in combination. CONCLUSION: The three common causes of severe AV functional disorders were postinflammatory disease (58.18%), degenerative calcific change (15.45%) and IE-postIE (12.72%). Underlying diseases of severe degenerative calcific change included hypertension, dyslipoproteinemia and diabetes. Macroscopic and microscopic examinations together with clinical information, echocardiographic findings and operative details are important in evaluating the etiology of valvular diseases especially in severely calcified specimens.