Rationale and Study Design for an Individualized Perioperative Open Lung Ventilatory Strategy in Patients on One-Lung Ventilation (iPROVE-OLV).

OBJECTIVE: The aim of this clinical trial is to examine whether it is possible to reduce postoperative complications using an individualized perioperative ventilatory strategy versus using a standard lung-protective ventilation strategy in patients scheduled for thoracic surgery requiring one-lung ventilation. DESIGN: International, multicenter, prospective, randomized controlled clinical trial. SETTING: A network of university hospitals. PARTICIPANTS: The study comprises 1,380 patients scheduled for thoracic surgery. INTERVENTIONS: The individualized group will receive intraoperative recruitment maneuvers followed by individualized positive end-expiratory pressure (open lung approach) during the intraoperative period plus postoperative ventilatory support with high-flow nasal cannula, whereas the control group will be managed with conventional lung-protective ventilation. MEASUREMENTS AND MAIN RESULTS: Individual and total number of postoperative complications, including atelectasis, pneumothorax, pleural effusion, pneumonia, acute lung injury; unplanned readmission and reintubation; length of stay and death in the critical care unit and in the hospital will be analyzed for both groups. The authors hypothesize that the intraoperative application of an open lung approach followed by an individual indication of high-flow nasal cannula in the postoperative period will reduce pulmonary complications and length of hospital stay in high-risk surgical patients.

Analgesia Management for Mitral Valve Repair Via Minithoracotomy - A Case Report.

INTRODUCTION: Minimally invasive cardiac surgery (MICS), via minithoracotomy, is thought to be a fast track to extubation and recovery after surgery. Chronic pain, due to intercostal nerve injury, develops in up to 50% of postthoracotomy patients.A number of regional anaesthesia and analgesia techniques may be employed, and the anaesthesiologists play a key role in facilitating optimal outcomes after surgery. METHODS: We report a case of postoperative pain management with a local anesthetic infiltration for MICS. RESULTS: A 63-year-old woman, 80kg, American Society Anaesthesiology (ASA) physical status 3 [arterial hypertension, atrial fibrillation (AF), rheumatic mitral stenosis and class II NYHA heart failure] was presented for an elective minimally invasive mitral valve repair through a minithoracotomy and cryoablation of AF. No relevant facts were found on pre-operative evaluation. Calculated EuroScore II was 1.55%. After premedication with intravenous (IV) midazolam 1.5mg, radial arterial and jugular central venous catether were placed. General anaesthesia was induced with IV remifentanil 1mcg/kg/h, propofol 50mg, rocuronium 1mg/ kg. A transesophageal echocardiography probe was inserted atraumatically, which revealed thickened mitral valve leaflets. ASA standard, invasive blood pressure, central venous pressure, depth of anaesthesia and cerebral oximetry monitoring were used. Urine output and arterial blood gas were measured periodically. A right lateral minithoracotomy was performed. After cardiopulmonary bypass (CPB) by femoral cannulation, cryoablation was performed followed by placement of the mechanical prosthesis. Total bypass time was 186min including 139min aortic cross-clamping time. At the ending of CPB, there was no need for inotropic support. Analgesia with paracetamol 1g, tramadol 100mg and morphine 10mg was performed after protamine reversion. Immediately before closure of skin, catheter was placed nearly to intercostal space (figures 1, 2) and ropivacaine 0,75% 75mg was administered. Anaesthesia and surgery were uneventful. Patient was shifted to intensive care unit (ICU), being extubated 3 hours after surgery. There was no need for additional bolus of ropivacaine during 2 days of ICU stay. She was discharged home on the 4th postoperative day, without complications. In a telephone interview 3 weeks after surgery, the patient referred no pain and good satisfaction with analgesia management. CONCLUSION: Thoracotomy incisions are associated with severe pain, leading to a decrease in pulmonary function, an increase in metabolic and hormonal activity and increased cardiac morbidity. Regional analgesia techniques have an opioid-sparing effect, reducing stress response and pain chronification. The local infiltration through catheter with local anaesthetics allows excellent analgesia for 8-12 hours, providing a route of additional analgesia according to pain control.

Rapid Pacing for Thoracic Endovascular Aortic Repair: a Case Report.

INTRODUCTION: Endovascular aortic interventions are suitable alternatives to open surgery, being less invasive and having lower mortality and complications. Accurate positioning of the stent graft is a critical point because of systolic thrush. Techniques used to prevent it include pharmacological (antihypertensive drugs, nitroglycerin, adenosine) and mechanical methods (temporary caval occlusion by balloon). Rapid Right Ventricular Pacing (RRVP) is an emerging alternative with good patient tolerance and low level of complications. METHODS: A 79 years-old male, American Society of Anaesthesiology (ASA) status 3 (hypertension, chronic obstructive pulmonary disease and hyperuricemia), with an aortic arch aneurysm previously submitted to an ascendant aortic debranching, was proposed for Thoracic Endovascular Aortic Repair (TEVAR). ASA standard, invasive blood pressure, depth of anaesthesia and cerebral oximetry monitoring were used. RESULTS: Patient was sedo-analgesiated with Midazolam 2mg and Fentanyl 100mcg. A flow directed Pacing catheter was passed through an 8.5FR introducer inserted in right internal jugular vein. RRVP was tested to a cardiac frequency of 180 without patient complaint. Two vascular Valiant Thoracic endoprosthesis were placed through a femoral access. At the time of testing position and prothesis deployment, RRVP was started and systolic blood pressure dropped to 50mmHg. After stopping the RRVP in both placements, normal rhythm and blood pressure were observed. No relevant changes in cerebral monitoring were found. Final angiography showed no endoleak of prosthesis. The patient was admitted at Post- -Anaesthetic Care Unit and discharged after 24hours. CONCLUSION: RRVP results in accelerated heart rate, with consequent decrease of intra-aortic blood flow, allowing more precise graft deployment without displacement, which is associated with lower incidence of endoleak. The faster onset of RRVP and rapid return to normal values can shorten the duration of the procedure. The procedure is done with minimal sedation, important in individuals with poor clinical status. This also allows to continually monitor the patient's neurologic status, possibly detecting any prosthetic displacement or acute event. Most complications are puncture- related. Rhythm-associated complications can occur in patients with heart diseases. In this case, no cardiac events were found. RRVP has been used in TEVAR with reliable results and is a good option for difficult cases. It's associated with a lower incidence of complications and less secondary effects than traditional measures, allowing to maintain patients with mild sedation, shortening hospital's length of stay. RRVP seems to be advantageous over traditional methods of controlling blood pressure in patients submitted to TEVAR.