Immediate postoperative extubation in bilateral lung transplantation: predictive factors and outcomes.

BACKGROUND: We reviewed our experience with tracheal extubation in the operating room (E-OR) among cystic fibrosis patients requiring bilateral lung transplantation to evaluate safety and determine predictive factors of E-OR. METHODS: The charts of 89 recipients (from May 2007 to June 2013) were analysed. Patients were divided into E-OR and E-ICU (intensive care unit extubation) groups. Data are expressed as numbers (percentages) or medians [25th-75th percentiles]. RESULTS: There were 41 patients in the E-OR group (46%). Donor and recipient characteristics were similar between groups. Intraoperative complications occurred less frequently in the E-OR group, and fluid and transfusion requirements were lower. Postoperative courses were different in the E-OR group, including a lower rate of grade 3 primary graft dysfunction (0 compared with 19 patients, P<0.0001) and shorter ICU (5.0 [3.7-7.2] compared with 11.5 [7.0-15.5] days) and hospital stays (22.0 [18.0-25.5] compared with 33.0 [25.0-56.5] days, respectively; P<0.0001 for both). The 1 yr survival rates were similar: 95% in the E-OR group and 98% in the E-ICU group. A statistical model built on a development cohort of 60 randomly selected patients predicted 95% of E-OR instances in this cohort and 82% of E-OR instances in the validation cohort (28 patients). Predictive factors were complications during single-lung ventilation (second graft implantation), complications during bipulmonary ventilation (end of surgery), and the ratio of arterial partial pressure of oxygen to fractional inspired oxygen (end of surgery). CONCLUSIONS: Our protocol allowed for extubation of 46% of bilateral lung transplant patients without increased postoperative risks.

[One-lung ventilation in a patient with a tracheal bronchus]. / Ventilation unipulmonaire chez une patiente présentant une trifurcation bronchique.

We report a patient in whom a tracheal bronchus was discovered intraoperatively during an endoscopy control. This observation led us to a focus on what to do in such cases.

[Blood-patch treatment of headache occurring after post-dural puncture at the thoracic level]. / Traitement par blood patch des céphalées après brèche dure-mérienne au niveau thoracique.

A 23-year-old woman experienced headache following a high thoracic epidural analgesia to control postoperative pain after thoracoscopic treatment of a recurrent pneumothorax. On fourth postoperative day, a blood patch has been sited with 17 mL of autologous blood, injected into the thoracic epidural space at T1-T2 level, which was immediately effective. Except a mild and transient cervical pain during the procedure, no other complication occurred. The technique of thoracic blood patch is similar to the lumbar one, except some minor modifications. According to this case of a thoracic epidural blood patch which is seemingly the first one reported in the literature and our expertise with two other unpublished cases, a volume of 10 mL of blood may be sufficient and free of adverse effects.

[Total pulmonary atelectasis after epidural anesthesia]. / Atélectasie pulmonaire totale au décours d'une anesthésie péridurale.

A case is reported of a 69-year-old man who sustained a total atelectasis of his right lung while undergoing ilio-tibial bypass surgery. This patient had a history of chronic obstructive pulmonary disease. The plain chest film showed a possible right-sided segmental atelectasis as well as pleural thickening on the same side. Lung function tests showed up a small obstructive syndrome, with mild hypoxaemia (Pao2 60.5 mmHg). The procedure was performed under epidural anaesthesia, carried out with 20 ml of 0.5% bupivacaine and 0.1 mg fentanyl. The upper level of anaesthesia was T4. The patient was sedated with flunitrazepam. He was given oxygen because arterial blood appeared to be somewhat dark. Despite this, the patient became grey, agitated, and had tachypnoea, together with absent breath sounds on the right side. A chest X-ray confirmed the diagnosis of total atelectasis of the right lung. Fiberoptic bronchoscopy was carried out, and a purulent mucous plug was removed. The patient improved and recovered from this episode totally. Blood gases were measured 1 month later; there was no difference with the preoperative values, except for correction of the hypoxaemia (Pao2 76 mmHg). The different factors possibly involved in the pathogenesis of the plug are discussed. It is likely that general anaesthesia would not have avoided this complication.