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Left-sided double-lumen tube (LDLT) is commonly used to achieve one lung isolation in most thoracic surgical procedures. Traditionally, the LDLT is blindly placed using direct or video laryngoscopy. In this brief report, we highlight the importance of using our novel insertion depth formula to predict the appropriate LDLT insertion depth and demonstrate the current evidence supporting the efficacy of the formula. Also, we will discuss two relatively new devices of LDLTs: one with an embedded camera at the distal end of the tracheal lumen and the other with a carinal cuff between the bronchial cuff and the tracheal lumen in reducing the incidence of too deep inserted LDLT. We advocate that using our novel formula and these two new devices may reduce but not eliminate the need for FOB to check the insertion depth of LDLT.
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Anomalías de los Vasos Coronarios , Insuficiencia de la Válvula Mitral , Femenino , Humanos , Lactante , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/cirugía , Arteria Pulmonar/anomalías , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Función Ventricular Izquierda , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Resultado del Tratamiento , Anomalías de los Vasos Coronarios/complicaciones , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Anomalías de los Vasos Coronarios/cirugíaRESUMEN
ERAS programs aim to reduce the length of hospital stays and lower costs, and minimize the risk of postoperative complications and readmissions while enhancing the overall patient experience. BMC Anesthesiology has initiated a new collection on ERAS, urging investigators to conduct large-scale, high-quality studies that address the existing knowledge gap.
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Recuperación Mejorada Después de la Cirugía , Humanos , Complicaciones Posoperatorias/prevención & control , Tiempo de Internación , Recuperación de la Función , Atención PerioperativaRESUMEN
OBJECTIVES: To clarify the influence of lower tidal volume (4-7 mL/kg) compared with higher tidal volume (8-15 mL/kg) during one-lung ventilation (OLV) on gas exchange and postoperative clinical outcome. DESIGN: Meta-analysis of randomized trials. SETTING: Thoracic surgery. PARTICIPANTS: Patients receiving OLV. INTERVENTIONS: Lower tidal volume during OLV. MEASUREMENTS AND MAIN RESULTS: Primary outcome was PaO2-to-the oxygen fraction (PaO2/FIO2) ratio at the end of the surgery, after the reinstitution of two-lung ventilation. Secondary endpoints included perioperative changes in PaO2/FIO2 ratio and carbon dioxide (PaCO2) tension, airway pressure, the incidence of postoperative pulmonary complications, arrhythmia, and length of hospital stay. Seventeen randomized controlled trials (1,463 patients) were selected. Overall analysis showed that the use of low tidal volume during OLV was associated with a significantly higher PaO2/FIO2 ratio 15 minutes after the start of OLV and at the end of surgery (mean difference 33.7 mmHg [p = 0.02] and mean difference 18.59 mmHg [p < 0.001], respectively). The low tidal volume also was associated with higher PaCO2 values 15 minutes and 60 minutes after the start of OLV and with lower airway pressure, which was maintained during two-lung ventilation after surgery. Moreover, the application of lower tidal volume was associated with fewer postoperative pulmonary complications (odds ratio 0.50; p < 0.001) and arrhythmias (odds ratio 0.58; p = 0.009), with no difference in length of hospital stay. CONCLUSIONS: The use of lower tidal volume, a component of protective OLV, increases the PaO2/FIO2 ratio, reduces the incidence of postoperative pulmonary complications, and should be considered strongly in daily practice.
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Ventilación Unipulmonar , Procedimientos Quirúrgicos Torácicos , Humanos , Volumen de Ventilación Pulmonar , Ensayos Clínicos Controlados Aleatorios como Asunto , Respiración Artificial , Pulmón , Procedimientos Quirúrgicos Torácicos/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & controlRESUMEN
Objective. The competency of using video laryngoscopes (VL) for double-lumen tube (DLT) endobronchial intubations can be improved with constant training as assessed by measuring the learning curves. We hypothesized that the time to DLT intubation would be reduced over the intubation attempts. Design. A crossover manikin study. Settings. University-affiliated hospital. Participants. Forty-two novice medical students unfamiliar with DLT intubation. Interventions. Participants were randomly allocated to two sequences, including DLT intubation, using King Vision and McGrath VLs. Each participant completed 100 DLT intubation attempts on both simulated easy and difficult airways on two different mannikins using the study devices (25 attempts for each). Measurements and Main Results. The primary outcome was the time to DLT intubation. The secondary outcomes included the best glottic view, optimizing maneuvers, and intubation first-pass success. The use of King Vision VL was associated with a significantly shorter time to DLT intubation (P < 0.044 and P < 0.05, respectively) and a higher percentage of glottic opening (POGO) compared to the McGrath VL (P < 0.011 and P < 0.002, respectively) in the simulated "easy" and "difficult" over most of the intubation attempts. In the simulated "easy" airway, the first-pass success ratio was higher when using the King Vision VL (median [Minimum-Maximum] 100% [100%-100%] and 100% [88%-100%], P = 0.012). Conclusion. Novice medical students developed skills over intubation attempts, meaning achievement of a faster DLT intubation, better laryngeal exposure, and higher success rate on simulated "easy" and "difficult" airways. A median of 9 DLT intubations was required to achieve a 92% or greater DLT intubation success rate.
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Laringoscopios , Humanos , Intubación Intratraqueal/métodos , Laringoscopía/métodos , Factores de Tiempo , ManiquíesRESUMEN
INTRODUCTION: Hyperlactatemia, a problem reported in up to 30% of cardiac surgery patients, results from excessive production of or decreased clearance of lactate. It is typically a symptom of tissue hypoperfusion and may be associated with the prevalence of postoperative acute mesenteric ischemia and renal failure, or prolonged intensive care unit (ICU) and hospital stay, and increased 30-day mortality. METHODS AND MEASUREMENTS: Eighty cardiac surgery patients using cardiopulmonary bypass (CPB) were randomly assigned into either a placebo (n = 39) or norepinephrine 0.05-0.2 µg/kg/min (n = 41) as well as norepinephrine boluses during CPB to maintain mean arterial blood pressure (MAP) at 65 to 80 mm Hg. Patient assignments were done after receiving ethical approval to proceed. The primary result was the perioperative changes in lactic acid level. Secondary findings were also recorded, including hemodynamic variables, the incidence of vasoplegia, intraoperative hypotension, myocardial ischemia, the need for vasopressor support, postoperative complications, and mortality. RESULTS: The peak levels and perioperative changes in blood lactate during the first 24 postoperative hours, the number of patients who experienced early hyperlactatemia on admission to the ICU (Placebo: 46.2%, Norepinephrine: 51.2%, p = .650), vasoplegia, hemodynamic changes, incidences of intraoperative hypotension, myocardial ischemia, postoperative complications, and mortality rates were similar in the two groups. Patients in the norepinephrine group received lower intraoperative rescue norepinephrine boluses to maintain the target MAP (p = .039) and had higher MAP values during the CPB and intraoperative blood loss [mean difference [95% confidence interval]; 177 [20.9-334.3] ml, p = .027]. CONCLUSION: norepinephrine and placebo infusions during the CPB with the maintenance of MAP from 65 to 80 mmHg had comparative effects on the changes in blood lactate and incidence of vasoplegia after cardiac surgery. Norepinephrine infusion maintained higher MAP values during the CPB.
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Hiperlactatemia , Hipotensión , Isquemia Miocárdica , Vasoplejía , Humanos , Norepinefrina/uso terapéutico , Vasoplejía/tratamiento farmacológico , Vasoplejía/etiología , Ácido Láctico , Puente Cardiopulmonar/efectos adversos , Hipotensión/complicaciones , Hipotensión/tratamiento farmacológico , Complicaciones Posoperatorias/etiologíaRESUMEN
Abstract Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.
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Cuidados Críticos , AnestesiologíaRESUMEN
ABSTRACT: Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.
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Anestesia en Procedimientos Quirúrgicos Cardíacos , Cardiopatías Congénitas , Anestesiología , Atención PerioperativaRESUMEN
OBJECTIVE: To investigate the effect of volatile anesthetics on the rates of postoperative myocardial infarction (MI) and cardiac death after coronary artery bypass graft (CABG). DESIGN: A post hoc analysis of a randomized trial. SETTING: Cardiac surgical operating rooms. PARTICIPANTS: Patients undergoing elective, isolated CABG. INTERVENTIONS: Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or total intravenous anesthesia (TIVA). The primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48 hours from surgery. The secondary outcome was 1-year death due to cardiac causes. MEASUREMENTS AND MAIN RESULTS: A total of 5,400 patients were enrolled between April 2014 and September 2017 (2,709 patients randomized to the volatile anesthetics group and 2,691 to TIVA). The mean age was 62 ± 8.4 years, and the median baseline ejection fraction was 57% (50-67), without differences between the 2 groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14 of 2,530 [0.6%] v 27 of 2,501 [1.1%] in the TIVA group; p = 0.038) and as-treated analyses (16 of 2,708 [0.6%] v 29 of 2,617 [1.1%] in the TIVA group; p = 0.039), but not in the intention-to-treat analysis (17 of 2,663 [0.6%] v 28 of 2,667 [1.0%] in the TIVA group; p = 0.10). Overall, deaths due to cardiac causes were lower in the volatile group (23 of 2,685 [0.9%] v 40 of 2,668 [1.5%] than in the TIVA group; p = 0.03). CONCLUSIONS: An anesthetic regimen, including volatile agents, may be associated with a lower rate of postoperative MI with hemodynamic complication in patients undergoing CABG. Furthermore, it may reduce long-term cardiac mortality.
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Anestésicos por Inhalación , Infarto del Miocardio , Propofol , Anciano , Anestésicos Intravenosos , Puente de Arteria Coronaria/métodos , Humanos , Persona de Mediana Edad , Infarto del Miocardio/tratamiento farmacológico , Infarto del Miocardio/epidemiología , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , SevofluranoRESUMEN
OBJECTIVE: To investigate the effect of volatile anesthetics on the rates of postoperative myocardial infarction (MI) and cardiac death after coronary artery bypass graft (CABG). DESIGN: A post hoc analysis of a randomized trial. SETTING: Cardiac surgical operating rooms. PARTICIPANTS: Patients undergoing elective, isolated CABG. INTERVENTIONS: Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or total intravenous anesthesia (TIVA). The primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48 hours from surgery. The secondary outcome was 1-year death due to cardiac causes. Measurements and main Results: A total of 5,400 patients were enrolled between April 2014 and September 2017 (2,709 patients randomized to the volatile anesthetics group and 2,691 to TIVA). The mean age was 62 ± 8.4 years, and the median baseline ejection fraction was 57% (50-67), without differences between the 2 groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14 of 2,530 [0.6%] v 27 of 2,501 [1.1%] in the TIVA group; p = 0.038) and as-treated analyses (16 of 2,708 [0.6%] v 29 of 2,617 [1.1%] in the TIVA group; p = 0.039), but not in the intention-to-treat analysis (17 of 2,663 [0.6%] v 28 of 2,667 [1.0%] in the TIVA group; p = 0.10). Overall, deaths due to cardiac causes were lower in the volatile group (23 of 2,685 [0.9%] v 40 of 2,668 [1.5%] than in the TIVA group; p = 0.03). CONCLUSIONS: An anesthetic regimen, including volatile agents, may be associated with a lower rate of postoperative MI with hemodynamic complication in patients undergoing CABG. Furthermore, it may reduce long-term cardiac mortality.
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Trasplantes , Desflurano , Anestesia Intravenosa , AnestésicosRESUMEN
OBJECTIVE: The authors explored the current practice of fellowship training in cardiothoracic and vascular anesthesia and surveyed the acceptability of potential solutions to mitigate the interrupted fellowship training during the severe acute respiratory syndrome coronavirus disease 2019 (COVID-19) pandemic. DESIGN: A prospective electronic questionnaire-based survey. SETTING: The survey was initiated by the Education Committee of the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC). PARTICIPANTS: The study comprised EACTAIC fellows, EACTAIC, and non-EACTAIC subscribers to the EACTAIC newsletter and EACTAIC followers on different social media platforms. INTERVENTIONS: After obtaining the consent of participants, the authors assessed the perioperative management of COVID-19 patients, infrastructural aspects of the workplace, local routines for preoperative testing, the perceived availability of personal protective equipment (PPE), and the impact of COVID-19 on fellowship training. In addition, participants rated suggested solutions by the investigators to cope with the interruption of fellowship training, using a traffic light signal scale. MEASUREMENTS AND MAIN RESULTS: The authors collected 193 responses from 54 countries. Of the respondents, 82.4% reported cancelling or postponing elective cases during the first wave, 89.7% had provided care for COVID-19 patients, 75.1% reported staff in their center being reassigned to work in the intensive care unit (ICU), and 45% perceived a shortage of PPE at their centers. Most respondents reported the termination of local educational activities (79.6%) and fellowship assessments (51.5%) because of the pandemic (although 84% of them reported having time to participate in online teaching), and 83% reported a definitive psychological impact. More than 90% of the respondents chose green and/or yellow traffic lights to rate the importance of the suggested solutions to cope with the interrupted fellowship training during the pandemic. CONCLUSIONS: The COVID-19 pandemic led to the cancellation of elective cases, the deployment of anesthesiologists to ICUs, the involvement of anesthesiologists in perioperative care for COVID-19 patients, and the interruption of educational activities and trainees' assessments. There is some consensus on the suggested solutions for mitigation of the interruption in fellowship training.
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Anestesia , Anestesiología , COVID-19 , Electrónica , Becas , Humanos , Pandemias , Estudios Prospectivos , SARS-CoV-2 , Encuestas y CuestionariosRESUMEN
Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.
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Anestesia en Procedimientos Quirúrgicos Cardíacos , Anestesiología , Anestesiología/educación , Niño , Cuidados Críticos , Curriculum , Becas , HumanosRESUMEN
Difficult lung isolation or separation in patients undergoing thoracic surgery using one-lung ventilation might be attributed to upper airway difficulty or abnormal anatomy of the lower airway. Additionally, adequate deflation of the surgical lung can impair surgical exposure. The coronavirus disease 2019 (COVID-19) has a harmful consequence for both patients and anesthesiologists. Management of patients with difficult lung isolation can be challenging during the COVID-19 pandemic. Careful planning and preparation, preoperative routine testing, protective personal equipment, standard safety measures, proper preoxygenation, and individualize the patients care are required for successful lung separation. A systematic approach for management of difficult lung separation is centered around securing the airway and providing adequate ventilation using either a blocker or double-lumen tube. Several measures are described to expedite lung collapse.
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Continuous monitoring of clinical outcomes after thoracotomy is very important to improve medical services and to reduce complications. The use of regional analgesia techniques for thoracotomy offers several advantages in the perioperative period including effective pain control, reduced opioid consumption and associated side effects, enhanced recovery, and improved patient satisfaction. Postthoracotomy complications, such as chronic postthoracotomy pain syndrome, postthoracotomy ipsilateral shoulder pain, pulmonary complications, recurrence, and unplanned admission to the intensive care unit are frequent and may be associated with poor outcomes and mortality. The role of regional techniques to reduce the incidence of these complications is questionable. This narrative review aims to investigate the impact of regional analgesia on the long-term clinical outcomes after thoracotomy.