External tracheal manipulation for bronchial blocker placement in children undergoing thoracic surgery requiring one lung ventilation: A case report.

Limited options exist for pediatric one lung ventilation (OLV). Compared to adults, pediatric OLV can be more challenging due to physiological/anatomical differences, various pathologies, and size limitations of lung isolation devices. Fiberoptic bronchoscopy can be harder due to the restricted tube sizes through which bronchial blockers (BB) and scopes can appropriately fit, while providing adequate oxygenation and ventilation. Recent literature is sparse concerning facilitation of BB placement in children. A 2-, 8-, and 10-year-old presented for thoracic surgeries requiring OLV. External tracheal manipulation (ETM) facilitated BB placement in each case and can potentially offer unique advantages in pediatric OLV.

Sugammadex-Associated Hypotension, Bradycardia, Asystole, and Death.

On December 16, 2015, the Food and Drug Administration (FDA) in the United States approved sugammadex (Bridion, Merck and Co), a modified gamma-cyclodextrin, to be used as a reversal agent. It is a first and unique selective nondepolarizing steroidal muscle relaxant (NDSMR) binding agent with a great affinity for rocuronium and vecuronium. However, there have been several recently published case reports of bradycardia and asystole immediately after sugammadex administration for the reversal. This report presents a case of sugammadex administration followed by rapidly progressing bradycardia leading to asystole and subsequent death. The family has provided the written consent to share this case report.

Case report on intravenous octreotide for the treatment of intraoperative vasoplegia following thymoma resection.

Octreotide is a somatostatin analog known for its role in the treatment of acute variceal bleeding, enterocutaneous fistula and carcinoid syndrome. The reduction of portal pressure from splanchnic vasoconstriction has been attributed to the inhibition of nitric oxide synthesis, guanylate cyclase and release of glucagon. Octreotide has many therapeutic applications as a result of the ubiquitous nature of somatostatin receptors throughout the body. The effects of octreotide on vascular tone make it potentially useful in the treatment of intraoperative vasoplegia, hypotension with low systemic vascular resistance with preserved cardiac output that is refractory to adrenergic agonists. We present a case in which a patient undergoing thymoma resection developed vasoplegia that was effectively treated with octreotide. We believe that this case illustrates the need for further investigation on the potential efficacy of octreotide as an adjunct for the treatment of vasoplegia and other forms of shock.

A retrospective evaluation of the use of video-capable double-lumen endotracheal tubes in thoracic surgery.

OBJECTIVE: The objective of this study was to evaluate whether the use of a video double-lumen tube reduced the need for fiberoptic bronchoscopy for (1) verification of initial tube placement and for (2) reverification of correct placement after repositioning for thoracotomy. DESIGN: A single-center retrospective study. SETTING: Thoracic surgery in a medical university hospital. PARTICIPANTS & INTERVENTIONS: After institutional review board approval, 29 patients who underwent thoracic surgical procedures using video double-lumen tubes were included in the final retrospective analysis. MEASUREMENTS AND MAIN RESULTS: For 27 (93.2%) patients, the use of fiberoptic bronchoscopy was not needed either for initial placement or for verification of correct video double-lumen tube placement upon final positioning of the patient. However, for two patients, fiberoptic bronchoscopy was needed: for (1) one patient with severe left mainstem bronchus distortion as a result of a large left upper lobe tumor, and (2) a second patient with secretions that were difficult to clear. CONCLUSION: This study demonstrates that the video double-lumen tube requires significantly less (6.8%) fiberoptic use for both initial placement and verification of final position, in stark contrast to standard practice in which bronchoscopy is always used to verify final positioning of the double-lumen tube. As opposed to intermittent bronchoscopy, the continuous visualization offered by an embedded camera may confer an added measure of safety.

Perioperative beta-blocker use and survival in lung cancer patients.

STUDY OBJECTIVE: To assess the effect of perioperative beta blockers on recurrence and overall survival after non-small cell lung cancer surgery. DESIGN: Retrospective study. SETTING: Academic medical center. MEASUREMENTS: The medical records of patients with stage 1, 2, and 3a non-small cell lung cancer were divided into three different groups: those patients who never received beta blockers perioperatively, those receiving nonselective beta blockers within 60 days of surgery, and those taking selective beta blockers within 60 days of surgery. Recurrence-free survival and overall survival were the main clinical endpoints. Univariate log-rank tests and multivariate Cox proportional hazards models were used to assess the effects of selective beta blockers, nonselective beta blockers, or no beta blockers on recurrence-free survival and overall survival. MAIN RESULTS: The analysis included records of 435 patients. Univariate analyses showed that the use of both selective and nonselective beta blockers was associated with decreased recurrence-free survival (P = 0.014) and overall survival (P = 0.009). However, these findings were not sustained after adjusting for possible confounding variables in the multivariate analysis. The hazard ratios for recurrence-free survival (selective beta blockers vs no beta blocker use were: 1.304; 95% confidence intervals [CI] 0.973 - 1.747; P = 0.075; for nonselective beta blockers vs no beta blockers: 0.989; 95% CI 0.639 - 1.532; P = 0.962. The hazard ratios for overall survival were: selective beta blocker use vs no beta blockers: 1.335; 95% CI 0.966 - 1.846; P = 0.080; nonselective beta blocker use vs no beta blocker use: 1.108; 95% CI 0.678 - 1.812; P = 0.682. CONCLUSION: Administration of beta blockers during the perioperative period did not improve recurrence-free or overall survival in patients undergoing resection of non-small cell lung cancer.

Effects of postoperative epidural analgesia on recurrence-free and overall survival in patients with nonsmall cell lung cancer.

STUDY OBJECTIVE: To determine whether postoperative epidural analgesia is associated with better recurrence-free survival and overall survival after lung cancer surgery. DESIGN: Retrospective study. SETTING: Academic hospital. MEASUREMENTS: Data of patients with stage 1, stage 2, and stage 3 nonsmall cell lung cancer, who underwent tumor resection surgery, were studied. Patient data were grouped into three different postoperative pain management interventions: intravenous patient-controlled analgesia, patient-controlled epidural analgesia, and their combination. Univariate and multicovariate Cox proportional hazards models were applied to assess the effects of covariates of interest on overall survival and recurrence-free survival. MAIN RESULTS: The type of postoperative analgesia used for patients who underwent surgery for nonsmall cell lung cancer did not affect recurrence-free survival or overall survival. However, certain variables, including age ≥ 65 years, male gender, body mass index ≥ 25 kg/m(2), ASA physical status 4, and the need for preoperative blood transfusions, pneumonectomy, and postoperative radiation, were associated with decreased recurrence-free survival and overall survival. CONCLUSIONS: The type of postoperative analgesia used after surgery for nonsmall cell lung cancer is not associated with better 2-year or 5-year recurrence-free survival or overall survival rates.

A possible association between aprotinin and improved survival after radical surgery for mesothelioma.

BACKGROUND: Aprotinin has been used to decrease blood loss with complicated cardiac surgery but has not been investigated in extrapleural pneumonectomy, an operation that does not use cardiopulmonary bypass. In this prospective, randomized, placebo-controlled, double-blind trial, the authors investigated whether aprotinin decreased blood loss in patients who underwent this operation. METHODS: After appropriate statistical design and institutional review board approval, eligible patients who were scheduled for extrapleural pneumonectomy were randomized to receive either aprotinin or placebo during the operation. Blood loss and survival data were obtained from electronic medical records and surgical databases. RESULTS: Of 20 patients who were enrolled, 16 patients met criteria for blood loss analysis. Four patients were excluded from the blood loss analysis: Three patients were inoperable because of tumor spread and underwent limited surgery, and 1 patient died intraoperatively because of acute, massive hemorrhage. The mean blood loss was 769 mL with aprotinin versus 1832 mL with placebo (P = .05; Wilcoxon test). All 20 patients were included in survival analyses. All 9 patients who received placebo died. In contrast, 7 of 11 patients who received aprotinin remained alive at the time of the current report. Kaplan-Meier survival curves differed significantly between the 2 groups (P = .0004). A Bayesian multivariate survival analysis of 18 patients who had complete data available on 8 prognostic variables indicated a posterior probability of .99 that aprotinin was beneficial. CONCLUSIONS: Aprotinin decreased blood loss. After accounting for covariate effects, there was a significant comparative benefit with aprotinin in postoperative survival. This finding was unexpected and could not be considered conclusive because of the small size of the current study. A confirmatory study may be warranted.

Use of deep intravenous sedation with propofol and the laryngeal mask airway during transesophageal echocardiography.

OBJECTIVE: To describe the use of either deep intravenous sedation with propofol or light sedation with midazolam and topical anesthesia during transesophageal echocardiography (TEE) and to report the incidence of respiratory complications and their management. DESIGN: Retrospective study from March 2000 through August 2002. SETTING: Single institution, specialized cancer center. PARTICIPANTS: All patients undergoing TEE examination in the specified time period (n = 42). MAIN RESULTS: Eight patients received light sedation and 34 patients received deep intravenous sedation with propofol. An airway event occurred in one patient in the light sedation group and in six patients in the deep sedation group. The patient in the light sedation group was managed with the use of a face-mask and a manual resuscitation bag. All airway events in the deep sedation group were managed successfully using the laryngeal mask airway (LMA). CONCLUSION: Deep sedation with intravenous propofol can provide both excellent patient comfort and optimal conditions for TEE examination, particularly in patients who may require more lengthy procedures or in whom other techniques have failed. Although the incidence of respiratory depression was higher in patients receiving deep sedation with propofol than in patients who were lightly sedated (17.6% versus 12.5%, respectively), all six patients who had respiratory depression while under deep sedation with propofol were successfully ventilated using the LMA trade mark, without the need to remove the TEE probe and without terminating the examination prematurely. In contrast, in the one patient in the light sedation group who had respiratory depression, the TEE probe had to be removed to ventilate the patient via a face mask, and the procedure was cancelled.