One lung ventilation management in a patient with Reinke's edema.

INTRODUCTION: Reinke's edema (RE) is a benign laryngeal disease. We describe the case of a patient with history of bilateral RE requiring surgical treatment, that came to our attention for a lung lobectomy due to adenocarcinoma. In consideration of the possible complications at the time of extubation and of the probable difficult control of the airways, the patient underwent intervention of microflap surgery for the RE at the same time of lobectomy. We opted for Bronchial Blocker (BB) using a Viva-sight™ Single Lumen Tube (SLT) Internal Diameter (ID) 7.0 mm (Ambu A/S, Baltorpbakken 13, DK-2750 Ballerup, Denmark) with integrated high-resolution camera. PRESENTATION OF CASE: The patient (female, 67 years old, BMI 28) was a candidate for lung lobectomy. She reported a RE requiring surgical treatment. An armoured Endo Tracheal Tube (ETT) ID 5.0 mm was positioned and microflap surgery was performed. Once this surgery ended, the armoured ETT was removed after placing an airway guide wire exchanger and a SLT ID 7.0 mm was placed. ​VivaSight-endoblocher™ (EB) was positioned in the right bronchus. DISCUSSION: We opted for double intervention, the risk that could result from the delay persuaded the patient to perform surgery for the RE. Postponing the lobectomy was dangerous for the oncological situation. The Viva-Sight SLT represented the right compromise. CONCLUSION: Even after the microflap, the space available for the ETT was reduced and, in order not to traumatize a tissue already stressed by surgery and to facilitate the tracheal intubation, we opted for BB using a Viva-sight™.

Erector spine plane block as postoperative rescue analgesia in thoracic surgery.

OBJECTIVE: Erector spine plane block (ESPB) is a newly defined regional anesthesia technique performed by injection of local anesthetic beneath the erector spine muscle. We tested ESPB as a regional rescue analgesia bedside technique to be performed in the thoracic surgical ward, reporting a 7-patient case series. METHODS: We report our experience in rescue analgesia after thoracic surgery. During the postoperative stay, numeric rating scale (NRS) score >3 and inability to perform physiotherapy or effective cough due to postoperative pain represented the criteria for proposing rescue analgesia with ESPB. NRS at rest and during movements was recorded; blood gas analysis and spirometry were performed to evaluate PaO2/FiO2 (P/F), forced vital capacity (FVC), and forced expiratory volume in 1 second (FEV1) before ESPB execution. After performing the ESPB, static and dynamic NRS, P/F, and FVC and FEV1 were recorded at 40 minutes and 80 minutes. RESULTS: NRS had a reduction at rest and in dynamic assessment. The P/F did not improve but spirometric measures improved. FVC had a relevant improvement only after 80 minutes; FEV1 was increased after 40 minutes. CONCLUSION: The use of ESPB as postoperative rescue analgesia can offer several advantages due to effective rescue analgesia and safety that makes it easy to perform in the thoracic surgical ward or in an outpatient clinic setting.

Management of chest impalement injury.

PRESENTATION OF CASE: We will describe the case of a man who impaled himself on a greenhouse pole by falling off a ladder. DISCUSSION: The belated radiological exclusion of any spine and neck lesions forced the surgeons to operate with the patient supine and on a spine board, which prevented them from performing the classic thoracotomy and reaching the entry hole in the right scapula area. CONCLUSION: A double thoracotomy and the expedient of a haemostatic plug, positioned simultaneously with the extraction of the pole, allowed to control bleeding with absolute safety margins.

Preoperative optimization with levosimendan in heart failure patient undergoing thoracic surgery.

INTRODUCTION: We present the case of a patient with dilatative cardiomyopathy waiting for heart transplantation with pleural effusion to be subjected to pleural biopsy, treated with preoperative infusion of levosimendan to improve heart performances. PRESENTATION OF CASE: A 56-year-old man (BMI 22,49) with dilatative cardiomyopathy (EF 18%) presented right pleural effusion. The levosimendan treatment protocol consisted of 24h continuous infusion (0,1ug/kg/min), without bolus. The patient was under continuous hemodynamic monitoring prior, during and after levosimendan administration. The surgery for pleural biopsy was performed with uniportal Video Assisted Thoracoscopic approach (VATS). DISCUSSION: A significant increase of Cardiac Index (CI) and Stroke Volume Index (SVI) were observed at 4h after infusion initiation and was sustained during the next 24h after the end of infusion. Levosimendan administration was safe. CONCLUSION: In this case the prophylactic preoperative levosimendan administration is safe and effective in cardiac failure patient undergoing thoracic surgery, but prophylactic preoperative levosimendan treatment in these patients merits further study.

Intraoperative Extracorporeal Carbon Dioxide Removal During Apneic Oxygenation with an EZ-Blocker in Tracheal Surgery.

Tracheal surgery requires continued innovation to manage the anesthetic during an open airway phase. A common approach is apneic oxygenation with continuous oxygen flow, but the lack of effective ventilation causes hypercapnia, with respiratory acidosis. We used extracorporeal carbon dioxide removal for intraoperative decapneization during apneic oxygenation in a 64-year-old woman who was scheduled for tracheal surgery because of tracheal stenosis caused by long-term intubation. Our findings demonstrate that even after 40 minutes of total apnea, using an EZ-blocker for oxygenation and external decapneization, hemodynamic and gas exchange variables never demonstrated any dangerous alterations.

Major thoracic surgery in Jehovah's witness: A multidisciplinary approach case report.

INTRODUCTION: A bloodless surgery can be desirable also for non Jehovah's witnesses patients, but requires a team approach from the very first assessment to ensure adequate planning. PRESENTATION OF THE CASE: Our patient, a Jehovah's witnesses, was scheduled for right lower lobectomy due to pulmonary adenocarcinoma. Her firm denies to receive any kind of transfusions, forced clinicians to a bloodless management of the case. DISCUSSION: Before surgery a meticulous coagulopathy research and hemodynamic optimization are useful to prepare patient to operation. During surgery, controlled hypotension can help to obtain effective hemostasis. After surgery, clinicians monitored any possible active bleeding, using continuous noninvasive hemoglobin monitoring, limiting the blood loss due to serial in vitro testing. The optimization of cardiac index and delivery of oxygen were continued to grant a fast recovery. CONCLUSION: Bloodless surgery is likely to gain popularity, and become standard practice for all patients. The need for transfusion should be targeted on individual case, avoiding strictly fixed limit often leading to unnecessary transfusion.

Long-term cardiovascular effects of levothyroxine therapy in young adults with congenital hypothyroidism.

CONTEXT: Congenital hypothyroidism (CH) is the most prevalent endocrine disorder in the newborn and is routinely treated with life-long levothyroxine replacement therapy. Although several studies have demonstrated that such therapy may impact on the cardiovascular system, little is known with regard to the effects of long-term levothyroxine administration in patients with CH. OBJECTIVE: The aim of the current study was to evaluate whether long-term levothyroxine replacement therapy in young adults with CH is associated with cardiovascular abnormalities. PATIENTS AND METHODS: Thirty young adults with CH aged 18.1 +/- 0.2 yr and 30 age- and sex-matched controls underwent cardiac and carotid Doppler ultrasound and symptom-limited cardiopulmonary exercise testing. Hypothyroidism was diagnosed by neonatal screening, and levothyroxine treatment was initiated within the first month of life and carefully adjusted to maintain TSH levels in the normal range and free T(4) in the high-normal range. RESULTS: Compared with controls, hypothyroid patients exhibited left ventricular diastolic dysfunction, impaired exercise capacity, and increased intima-media thickness. At multiple regression analysis, the number of episodes of plasma TSH levels less than 0.5 mU/liter and greater than 4.0 mU/liter from the age of 1 yr onward, and mean TSH plasma levels during puberty were independent predictors of diastolic filling and cardiopulmonary performance indexes (multiple r values: 0.61-0.75). CONCLUSIONS: Long-term levothyroxine treatment in young adults with congenital hypothyroidism is associated with impaired diastolic function and exercise capacity and increased intima-media thickness.