One-Lung Ventilation and Postoperative Pulmonary Complications After Major Lung Resection Surgery. A Multicenter Randomized Controlled Trial.

OBJECTIVES: The effect of one-lung ventilation (OLV) strategy based on low tidal volume (TV), application of positive end-expiratory pressure (PEEP), and alveolar recruitment maneuvers (ARM) to reduce postoperative acute respiratory distress syndrome (ARDS) and pulmonary complications (PPCs) compared with higher TV without PEEP and ARM strategy in adult patients undergoing lobectomy or pneumonectomy has not been well established. DESIGN: Multicenter, randomized, single-blind, controlled trial. SETTING: Sixteen Italian hospitals. PARTICIPANTS: A total of 880 patients undergoing elective major lung resection. INTERVENTIONS: Patients were randomized to receive lower tidal volume (LTV group: 4 mL/kg predicted body weight, PEEP of 5 cmH2O, and ARMs) or higher tidal volume (HTL group: 6 mL/kg predicted body weight, no PEEP, and no ARMs). After OLV, until extubation, both groups were ventilated using a tidal volume of 8 mL/kg and a PEEP value of 5 cmH2O. The primary outcome was the incidence of in-hospital ARDS. Secondary outcomes were the in-hospital rate of PPCs, major cardiovascular events, unplanned intensive care unit (ICU) admission, in-hospital mortality, ICU length of stay, and in-hospital length of stay. MEASUREMENTS AND MAIN RESULTS: ARDS occurred in 3 of 438 patients (0.7%, 95% CI 0.1-2.0) and in 1 of 442 patients (0.2%, 95% CI 0-1.4) in the LTV and HTV group, respectively (Risk ratio: 3.03 95% CI 0.32-29, p = 0.372). Pulmonary complications occurred in 125 of 438 patients (28.5%, 95% CI 24.5-32.9) and in 136 of 442 patients (30.8%, 95% CI 26.6-35.2) in the LTV and HTV group, respectively (risk ratio: 0.93, 95% CI 0.76-1.14, p = 0.507). The incidence of major complications, in-hospital mortality, and unplanned ICU admission, ICU and in-hospital length of stay were comparable in both groups. CONCLUSIONS: In conclusion, among adult patients undergoing elective lung resection, an OLV with lower tidal volume, PEEP 5 cmH2O, and ARMs and a higher tidal volume strategy resulted in low ARDS incidence and comparable postoperative complications, in-hospital length of stay, and mortality.

Dexamethasone and postoperative analgesia in minimally invasive thoracic surgery: a retrospective cohort study.

BACKGROUND: Dexamethasone is commonly used for the prevention of postoperative nausea and vomiting (PONV), and recent reviews suggest a role for dexamethasone in postoperative analgesia. The aim of this study is to evaluate the efficacy of dexamethasone as an analgesic adjuvant in minimally invasive thoracic surgery. Primary outcome was morphine consumption 24 h after surgery; secondary outcomes were pain control, measured as numeric rating scale (NRS), glycemic changes, PONV, and surgical wound infection. RESULTS: We performed a retrospective cohort study considering 70 patients who underwent elective lobectomy, segmentectomy, or wedge resection surgery with a mini-thoracotomy approach or video-assisted thoracoscopic surgery (VATS). All patients received the same locoregional techniques and short-acting opioids during surgery; 46 patients received dexamethasone at induction. There were no significant differences in morphine consumption at 24 h (p = 0.09) and in postoperative pain scores. Nevertheless, a higher frequency of rescue therapy (p = 0.01) and a tendency for a higher attempted-PCA pushes count were observed in patients who did not receive dexamethasone. No cases of surgical wound infections were detected, and the incidence of PONV was similar in the two groups. Postoperative glycemia was transiently higher in the dexamethasone group (p = 0.004), but the need of hypoglycemic therapy was not significantly different. CONCLUSIONS: Preoperative administration of dexamethasone did not cause a significant reduction in morphine consumption, but appears to be safe and plays a role in a multimodal anesthesia approach for patients undergoing elective minimally invasive thoracic surgery.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care.

INTRODUCTION: Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care. METHODS: A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria. RESULTS: Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery). CONCLUSIONS: These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care.

INTRODUCTION: Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. METHODS: A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria. RESULTS: Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. CONCLUSIONS: These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Anesthesia and fast-track in video-assisted thoracic surgery (VATS): from evidence to practice.

In thoracic surgery, the introduction of video-assisted thoracoscopic techniques has allowed the development of fast-track protocols, with shorter hospital lengths of stay and improved outcomes. The perioperative management needs to be optimized accordingly, with the goal of reducing postoperative complications and speeding recovery times. Premedication performed in the operative room should be wisely administered because often linked to late discharge from the post-anesthesia care unit (PACU). Inhalatory anesthesia, when possible, should be preferred based on protective effects on postoperative lung inflammation. Deep neuromuscular blockade should be pursued and carefully monitored, and an appropriate reversal administered before extubation. Management of one-lung ventilation (OLV) needs to be optimized to prevent not only intraoperative hypoxemia but also postoperative acute lung injury (ALI): protective ventilation strategies are therefore to be implemented. Locoregional techniques should be favored over intravenous analgesia: the thoracic epidural, the paravertebral block (PVB), the intercostal nerve block (ICNB), and the serratus anterior plane block (SAPB) are thoroughly reviewed and the most common dosages are reported. Fluid therapy needs to be administered critically, to avoid both overload and cardiovascular compromisation. All these practices are analyzed singularly with the aid of the most recent evidences aimed at the best patient care. Finally, a few notes on some of the latest trends in research are presented, such as non-intubated video-assisted thoracoscopic surgery (VATS) and intravenous lidocaine.

Enhanced recovery pathways in thoracic surgery from Italian VATS Group: perioperative analgesia protocols.

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive technique that allows a faster recovery after thoracic surgery. Although enhanced recovery after surgery (ERAS) principles seem reasonably applicable to thoracic surgery, there is little literature on the application of such a strategy in this context. In regard to pain management, ERAS pathways promote the adoption of a multimodal strategy, tailored to the patients. This approach is based on combining systemic and loco-regional analgesia to favour opioid-sparing strategies. Thoracic paravertebral block is considered the first-line loco-regional technique for VATS. Other techniques include intercostal nerve block and serratus anterior plane block. Nonsteroidal anti-inflammatory drugs and paracetamol are essential part of the multimodal treatment of pain. Also, adjuvant drugs can be useful as opioid-sparing agents. Nevertheless, the treatment of postoperative pain must take into account opioid agents too, if necessary. All above is useful for careful planning and execution of a multimodal analgesic treatment to enhance the recovery of patients. This article summarizes the most recent evidences from literature and authors' experiences on perioperative multimodal analgesia principles for implementing an ERAS program after VATS lobectomy.

Postoperative analgesia after pulmonary resection with a focus on video-assisted thoracoscopic surgery.

Video-assisted thoracoscopic surgery is a widespread technique that has been linked to improved postoperative respiratory function, reduced hospital length of stay and a higher level of tolerability for the patients. Acute postoperative pain is of considerable significance, and the late development of neuropathic pain syndrome is also an issue. As anaesthesiologists, we have investigated the available evidence to optimize postoperative pain management. An opioid-sparing multimodal approach is highly recommended. Loco-regional techniques such as the thoracic epidural and peripheral blocks can be performed. Several adjuvants have been employed with varying degrees of success both intravenously and in combination with local anesthetics. Opioids with different pharmacodynamic and pharmacokinetic profiles can be used, either through continuous infusion or on demand. Non-opioid analgesics are also beneficial. Finally, perioperative gabapentinoids may be implemented to prevent the onset of chronic neuropathic pain.

Lumbar microdiscectomy under epidural anaesthesia with the patient in the sitting position: a prospective study.

In a prospective study we compared the surgical outcome, length of hospital stay, complications and patient satisfaction for patients undergoing lumbar microdiscectomy (LM) under spinal anaesthesia (SA) in the sitting position (23 patients) to those of another cohort who underwent LM under general anaesthesia (GA) in the prone or genu-pectoral position during the same time period (238 patients). We aimed to determine: (i) if epidural anaesthesia is safe for lumbar microdiscectomy; and (ii) if placing the patient in a sitting position confers an advantage in performing the operation. For all patients we calculated the time from the end of the operation to the first spontaneous urination and to the first administration of analgesic drugs. Before being discharged, patients were asked to give an opinion on the quality of analgesia obtained by epidural anaesthesia and on the sitting position used. No patient had any complications linked to epidural anaesthesia and only one patient experienced a small dural tear as a surgical complication. Twenty of 23 patients expressed satisfaction with the level of analgesia obtained and only three considered it poor. All patients found the sitting position comfortable. Advantages of the sitting position for surgery include better comfort for the patient, potential to recreate a load condition similar to the one that takes place during orthostasis and a "cleaner" operative field that uses gravity to drain blood. Of greatest concern is the possibility of the patient developing a dural tear and subsequent leaking of cerebrospinal fluid, which could also be a source of surgical complications. Currently, epidural anaesthesia allows a reduction in anaesthetic and surgical times, anaesthetic complications and, consequently, hospitalization period. Further analysis of the sitting position for the patient during surgery is required to fully assess the advantages and disadvantages of this method.