Mediastinal Masses, Anesthetic Interventions, and Airway Compression in Adults: A Prospective Observational Study.

BACKGROUND: Central airway occlusion is a feared complication of general anesthesia in patients with mediastinal masses. Maintenance of spontaneous ventilation and avoiding neuromuscular blockade are recommended to reduce this risk. Physiologic arguments supporting these recommendations are controversial and direct evidence is lacking. The authors hypothesized that, in adult patients with moderate to severe mediastinal mass-mediated tracheobronchial compression, anesthetic interventions including positive pressure ventilation and neuromuscular blockade could be instituted without compromising central airway patency. METHODS: Seventeen adult patients with large mediastinal masses requiring general anesthesia underwent awake intubation followed by continuous video bronchoscopy recordings of the compromised portion of the airway during staged induction. Assessments of changes in anterior-posterior airway diameter relative to baseline (awake, spontaneous ventilation) were performed using the following patency scores: unchanged = 0; 25 to 50% larger = +1; more than 50% larger = +2; 25 to 50% smaller = -1; more than 50% smaller = -2. Assessments were made by seven experienced bronchoscopists in side-by-side blinded and scrambled comparisons between (1) baseline awake, spontaneous breathing; (2) anesthetized with spontaneous ventilation; (3) anesthetized with positive pressure ventilation; and (4) anesthetized with positive pressure ventilation and neuromuscular blockade. Tidal volumes, respiratory rate, and inspiratory/expiratory ratio were similar between phases. RESULTS: No significant change from baseline was observed in the mean airway patency scores after the induction of general anesthesia (0 [95% CI, 0 to 0]; P = 0.953). The mean airway patency score increased with the addition of positive pressure ventilation (0 [95% CI, 0 to 1]; P = 0.024) and neuromuscular blockade (1 [95% CI, 0 to 1]; P < 0.001). No patient suffered airway collapse or difficult ventilation during any anesthetic phase. CONCLUSIONS: These observations suggest a need to reassess prevailing assumptions regarding positive pressure ventilation and/or paralysis and mediastinal mass-mediated airway collapse, but do not prove that conventional (nonstaged) inductions are safe for such patients.

Update on anesthetic management for esophagectomy.

PURPOSE OF REVIEW: The article highlights the current important issues surrounding the anesthetic care of patients presenting for esophagectomy. RECENT FINDINGS: With the decline in mortality from esophagectomy in high-volume centers over the last 30 years, focus may now be on decreasing morbidity. Improving the blood supply of the esophageal anastomosis, methods to reduce the incidence of pulmonary complications and optimizing fluid management in these patients are areas in which anesthetic care may contribute. There are also the potential benefits of minimally invasive techniques, which are increasingly being utilized. SUMMARY: The incorporation of thoracic epidural analgesia, goal-directed fluid management therapy, protective ventilation during one-lung anesthesia and strategies to improve perfusion of the gastric graft are some aspects which anesthetic care may impact.

Controlled apneic tracheostomy in patients with coronavirus disease 2019 (COVID-19).

OBJECTIVE: To develop a team-based institutional infrastructure for navigating management of a novel disease, to determine a safe and effective approach for performing tracheostomies in patients with COVID-19 respiratory failure, and to review outcomes of patients and health care personnel following implementation of this approach. METHODS: An interdisciplinary Task Force was constructed to develop innovative strategies for management of a novel disease. A single-institution, prospective, nonrandomized cohort study was then conducted on patients with coronavirus disease 2019 (COVID-19) respiratory failure who underwent tracheostomy using an induced bedside apneic technique at a tertiary care academic institution between April 27, 2020, and June 30, 2020. RESULTS: In total, 28 patients underwent tracheostomy with induced apnea. The median lowest procedural oxygen saturation was 95%. The median number of ventilated days following tracheostomy was 11. There were 3 mortalities (11%) due to sepsis and multiorgan failure; of 25 surviving patients, 100% were successfully discharged from the hospital and 76% are decannulated, with a median time of 26 days from tracheostomy to decannulation (range 12-57). There was no symptomatic disease transmission to health care personnel on the COVID-19 Tracheostomy Team. CONCLUSIONS: Patients with respiratory failure from COVID-19 disease may benefit from tracheostomy. This can be completed effectively and safely without viral transmission to health care personnel. Performing tracheostomies earlier in the course of disease may expedite patient recovery and improve intensive care unit resource use. The creation of a collaborative Task Force is an effective strategic approach for management of novel disease.

Single-Session CT-Guided Percutaneous Microwave Ablation of Bilateral Adrenal Gland Hyperplasia Due to Ectopic ACTH Syndrome.

Bilateral adrenalectomy is currently the only available treatment for adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome (ectopic ACTH syndrome) that is refractory to pharmacologic therapy. We describe two patients with refractory ectopic ACTH syndrome who were treated with CT-guided percutaneous microwave ablation of both hyperplastic adrenal glands in a single session: O ne was not a surgical candidate, and the other had undergone unsuccessful surgery. Following the procedure, both patients achieved substantial decreases in serum cortisol, symptomatic improvement, and decreased anti-hypertensive medication requirements.

Anesthetic strategies for patients undergoing extrapleural pneumonectomy.

Anesthetic management of patients with extrapleural pneumonectomy may contribute to risk reduction, and it differs from management of patients with standard pneumonectomy in several respects. Hemodynamic and intravascular fluid management is complicated by the significantly greater blood loss and impairments of venous return imposed by weighty tumors and the blunt dissection process. There are greater risks of catastrophic (central) bleeding, dysrhythmias, cardiac herniation, and electrocardiographic changes. Restrictive forces increase the likelihood of dependent lung atelectasis during single-lung ventilation. Preoperative assessment of cardiopulmonary reserve remains an imprecise process. Awareness of these risks and limitations enables the anesthesiologist to understand, anticipate, and potentially preempt many intraoperative problems.

Pain management strategies for patients undergoing extrapleural pneumonectomy.

The role of anesthetic or analgesic technique in outcome remains controversial. The choice of anesthetic and postoperative analgesic plan plays a small, albeit important, role in perioperative care and a multimodal rehabilitation program. Pulmonary complications are the most important cause of morbidity and mortality after EPP. There is increasing evidence that TEA with local anesthetic agents and opioids is superior for the control of dynamic pain, plays a key role in early extubation and mobilization, reduces postoperative pulmonary complications, and has the potential to decrease the incidence of PTPS.

Perioperative anesthetic management for esophagectomy.

Esophageal resection is a formidable operation associated with high morbidity and mortality. Anesthetic management may contribute to the containment of respiratory failure and anastomotic leakage by the use of thoracic epidural analgesia, protective ventilation strategies, prevention of tracheal aspiration, and judicious fluid management.

Anesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma.

PURPOSE OF REVIEW: Extrapleural pneumonectomy is a radical and aggressive surgery that presents a great challenge to the thoracic anesthesiologist. This surgery is performed routinely by only a few centers in the world and this review represents our institution's experience in anesthetic care. RECENT FINDINGS: Prominent among the developing multimodal treatment options is the combination of extrapleural pneumonectomy with intraoperative intracavitary hyperthermic chemotherapy. Outcome survival benefits have recently been demonstrated for the less completely cytoreductive pleurectomy procedure when combined with intraoperative intracavitary hyperthermic chemotherapy and trials are well under way for extrapleural pneumonectomy plus intraoperative intracavitary hyperthermic chemotherapy. Anesthetic management of extrapleural pneumonectomy is further impacted by these developments. SUMMARY: Anesthetic management importantly contributes to containment of the perioperative complications of extrapleural pneumonectomy. An appreciation of the technical aspects and physiologic disruptions associated with extrapleural pneumonectomy is critical to effective management. While data on this relatively uncommon surgical procedure are scarce, some referral centers have accumulated extensive experience. This review summarizes relevant surgical aspects and anesthetic insights from the Brigham and Women's Hospital experience. Included are the anesthetic implications of intraoperative intracavitary hyperthermic chemotherapy in combination with extrapleural pneumonectomy - an emerging therapeutic option in the treatment of malignant pleural mesothelioma.

Evaluation of partial carbon dioxide rebreathing cardiac output measurement during thoracic surgery.

OBJECTIVE: Noninvasive partial CO2 rebreathing (NICO; Novametrix Medical Systems, Inc, Wallingford, CT) is a relatively new alternative to thermodilution (TDCO) for measurement of cardiac output. This study compares the 2 methods during thoracic surgery and one-lung ventilation. DESIGN: A prospective, observational study. SETTING: A tertiary hospital. PARTICIPANTS: Twelve adult patients undergoing elective thoracotomy and one-lung ventilation in the lateral decubitus position. INTERVENTIONS: Paired measurements of cardiac output were performed during (1) 2-lung ventilation in the supine position (postinduction of anesthesia), (2) 10 minutes after initiation of one-lung ventilation in the lateral decubitus position with the nondependent chest open, and (3) after 30 minutes on one-lung ventilation. An average of 3 consecutive (10 mL 20 degrees C saline) TDCO measurements made during end-expiration was compared with corresponding NICO measurements. MEASUREMENTS AND MAIN RESULTS: The NICO showed a tendency to underestimate cardiac output compared with TDCO at all measurement times. Overall, bias was -0.29 L/min and limits of agreement -1.69 to 1.43 L/min. CONCLUSIONS: There was a moderate agreement between cardiac output measurements obtained with the NICO and TDCO. The present data suggest that the NICO technique may be useful during thoracic surgery.

Hypoxemia during one-lung ventilation: jet ventilation of the middle and lower lobes during right upper lobe sleeve resection.

A 64-yr-old man underwent right thoracotomy and upper lobectomy for lung carcinoma. Hypoxemia on one-lung ventilation was being managed with continuous positive airway pressure to the nondependent lung when a sleeve resection had to be performed. As this positive airway pressure would no longer be maintained with the bronchus open, an alternate method of oxygenation was necessary. This report describes the successful use of jet ventilation via an airway exchange catheter placed in the bronchus intermedius through the tracheal lumen of a left-sided double-lumen endobronchial tube. Oxygenation was maintained and surgical access was good during the 15-min resection.

Effects of preemptive epidural analgesia on post-thoracotomy pain.

OBJECTIVE: The purpose of this study was to determine whether preemptive thoracic epidural analgesia (TEA) initiated before surgical incision would reduce the severity of acute post-thoracotomy pain and the incidence of chronic post-thoracotomy pain. METHOD: Meta-analysis of randomized controlled trials (RCTs). SEARCH STRATEGY: MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE were searched from 1966 to December 2004 for prospective RCTs published in all languages using the following MeSH terms: post-thoracotomy pain, epidural analgesia, chronic pain, and preemptive analgesia. SELECTION CRITERIA: All RCTs that compared thoracic epidural analgesia initiated before surgical incision (preemptive group) versus thoracic epidural analgesia initiated after completion of surgery (control group) in adult patients undergoing unilateral thoracotomy. MEASUREMENTS AND MAIN RESULTS: Three authors reviewed all citations and simultaneously extracted data on sample size, patient characteristics, surgical and analgesic interventions, methods of pain assessment, and pain scores at 24 hours, 48 hours, and 6 months postoperatively. Six studies were included with a total of 458 patients. Pooled analyses indicated that preemptive TEA was associated with a statistically significant reduction in the severity of acute pain on coughing at 24 and 48 hours (weighted mean difference -1.17 [95% confidence interval (CI) -1.50 to -0.83] and -1.08 [95% CI -1.17 to -0.99]), respectively. Acute pain was a good predictor of chronic pain. However, there was no statistically significant difference in the overall incidence of chronic pain at 6 months between the preemptive TEA group (39.6%) and the control group (48.6%). CONCLUSION: Preemptive TEA appeared to reduce the severity of acute pain but had no effect on the incidence of chronic pain.

Vallecular cyst and laryngomalacia in infants: report of six cases and airway management.

IMPLICATIONS: This report describes difficulties encountered in the airway management of six infants with concurrent vallecular cyst and laryngomalacia. It is hoped that our experience will assist others in the management of such patients.