Should fluid management in thoracic surgery be goal directed?

PURPOSE OF REVIEW: To find a reliable answer to the question in the title: Should fluid management in thoracic surgery be goal directed? RECENT FINDINGS: 'Moderate' fluid regimen is the current recommendation of fluid management in thoracic anesthesia, however, especially in more risky patients; 'Goal-Directed Therapy' (GDT) can be a more reliable approach than just 'moderate'. There are numerous studies examining its effects in general anesthesia; albeit mostly retrospective and very heterogenic. There are few studies of GDT in thoracic anesthesia with similar drawbacks. SUMMARY: Although the evidence level is low, GDT is generally associated with fewer postoperative complications. It can be helpful in decision-making for volume-optimization, timing of fluid administration, and indication of vasoactive agents.

Thoracic Paravertebral Block Achieves Better Pain Control Than Erector Spinae Plane Block and Intercostal Nerve Block in Thoracoscopic Surgery: A Randomized Study.

OBJECTIVES: The objective of this study was to compare analgesic efficacy of erector spinae plane block (ESPB), thoracic paravertebral block (TPVB), and intercostal nerve block (ICNB) after video-assisted thoracoscopic surgery (VATS). DESIGN: Prospective, randomized, single-blind study. SETTING: University hospital, single institution. PARTICIPANTS: Adult patients undergoing VATS. INTERVENTIONS: Ultrasonography-guided ESPB, ultrasonography-guided TPVB, or ICNB. MEASUREMENTS AND MAIN RESULTS: Patients were enrolled into the following three groups according to analgesia technique as ESPB, TPVB, or ICNB, respectively, group erector spinae plane block (GESP) (n = 35), group thoracic paravertebral block (GTPV) (n = 35), and group intercostal nerve block (GICN) (n = 36). Multimodal analgesia was achieved with paracetamol, tenoxicam, and intravenous morphine (via patient-controlled analgesia) for all study groups. Pain scores were assessed by visual analog scale, and morphine consumption, rescue analgesic requirement, and side effects were recorded postoperatively. Dynamic visual analog scale at the first hour as primary outcome was determined five (two-seven), four (one-six) and (two-six) in GESP, GTPV, and GICN, respectively. Dynamic pain scores were significantly lower in GTPV compared with GESP and GICN at 24 hours (p < 0.017). Dynamic pain scores in GICN were significantly lower at 12 hours compared with GESP (p < 0.017). Morphine consumption for the first 24 hours was similar in GICN and GTPV, and it was significantly lower in GICN and GTPV in comparison to GESP (p < 0.017). Rescue analgesic requirement and side effects were similar among groups. CONCLUSIONS: All three blocks can obtain sufficient analgesia after VATS; however, TPVB appeared to be the preferable method compared with ESPB and ICNB, with a more successful analgesia and less morphine consumption.

Thoracic Anesthesia during the COVID-19 Pandemic: 2021 Updated Recommendations by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Subspecialty Committee.

The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority, and there is an increasing need to fully define the optimal oncologic management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Healthcare providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer; an imminent spike due to mortality from acute coronavirus disease 2019 (COVID-19) infection, and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were deemed less urgent, delayed, or cancelled. The European Association of Cardiothoracic Anaesthesiology and Intensive Care Thoracic Anesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectious period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

Thoracic Anesthesia of Patients With Suspected or Confirmed 2019 Novel Coronavirus Infection: Preliminary Recommendations for Airway Management by the European Association of Cardiothoracic Anaesthesiology Thoracic Subspecialty Committee.

The novel coronavirus has caused a pandemic around the world. Management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. The thoracic subspecialty committee of European Association of Cardiothoracic Anaesthesiology (EACTA) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. It should be emphasized that both the management of the infected patient with COVID-19 and the self-protection of the anesthesia team constitute a complicated challenge. The text focuses therefore on both important topics.

Anaesthesia for thymectomy in adult and juvenile myasthenic patients.

PURPOSE OF REVIEW: Myasthenia gravis, a chronic disease of the neuromuscular junction, is associated with an interaction with neuromuscular blocking agents (NMBAs). As thymectomy is often the method of choice for its treatment, anaesthetic management requires meticulous preoperative evaluation, careful monitoring, and adequate dose titration. The frequency of video-assisted thoracoscopic extended thymectomy (VATET) is also increasing, making the use of NMBA obligatory. The number of cases of the juvenile form has also increased over years; airway management in juvenile one-lung ventilation is another challenge. RECENT FINDINGS: Sugammadex appears to be a safe choice to avoid prolonged action of NMBA also in patients with myasthenia gravis, although this information has to be confirmed in further series. The number of VATETs is increasing so that the experience with sugammadex will also increase in time. In non-VATET operations, use of NMBA should and can be avoided as much as possible. New scoring systems are defined to predict a postoperative myasthenic crisis. For VATET in juvenile cases, blockers can be a good option for the airway management. SUMMARY: Anaesthetic management of thymectomy in myasthenia gravis requires experience concerning different approaches. Sugammadex should be considered as a possible further step toward postoperative safety.

Open Lung in Lateral Decubitus With Differential Selective Positive End-Expiratory Pressure in an Experimental Model of Early Acute Respiratory Distress Syndrome.

OBJECTIVE: After lung recruitment, lateral decubitus and differential lung ventilation may enable the titration and application of optimum-selective positive end-expiratory pressure values for the dependent and nondependent lungs. We aimed at compare the effects of optimum-selective positive end-expiratory pressure with optimum global positive end-expiratory pressure on regional collapse and aeration distribution in an experimental model of acute respiratory distress syndrome. DESIGN: Prospective laboratory investigation. SETTING: University animal research laboratory. SUBJECTS: Seven piglets. INTERVENTIONS: A one-hit injury acute respiratory distress syndrome model was established by repeated lung lavages. After replacing the tracheal tube by a double-lumen one, we initiated lateral decubitus and differential ventilation. After maximum-recruitment maneuver, decremental positive end-expiratory pressure titration was performed. The positive end-expiratory pressure corresponding to maximum dynamic compliance was defined globally (optimum global positive end-expiratory pressure) and for each individual lung (optimum-selective positive end-expiratory pressure). After new maximum-recruitment maneuver, two steps were performed in randomized order (15 min each): ventilation applying the optimum global positive end-expiratory pressure and the optimum-selective positive end-expiratory pressure. CT scans were acquired at end expiration and end inspiration. MEASUREMENTS AND MAIN RESULTS: Aeration homogeneity was evaluated as a nondependent/dependent ratio (percent of total gas content in upper lung/percent of total gas content in lower lung) and tidal recruitment as the difference in the percent mass of nonaerated tissue between expiration and inspiration. At the end of the 15-minute optimum-selective positive end-expiratory pressure, compared with the optimum global positive end-expiratory pressure, resulted in 1) decrease in the percent mass of collapse in the lower lung at expiratory CT (19% ± 15% vs 4% ± 5%; p = 0.03); 2) decrease in the nondependent/dependent ratio between the optimum global positive end-expiratory pressure-expiratory-CT and optimum-selective positive end-expiratory pressure-expiratory-CT (3.7 ± 1.2 vs 0.8 ± 0.5; p = 0.01); 3) decrease in the nondependent/dependent ratio between the optimum global positive end-expiratory pressure-inspiratory-CT and optimum-selective positive end-expiratory pressure-inspiratory-CT (2.8 ± 1.1 vs 0.6 ± 0.3; p = 0.01); and 4) less tidal recruitment (p = 0.049). CONCLUSIONS: After maximum lung recruitment, lateral decubitus and differential lung ventilation enabled the titration of optimum-selective positive end-expiratory pressure values for the dependent and the nondependent lungs, made possible the application of an optimized regional open lung approach, promoted better aeration distribution, and minimized lung tissue inhomogeneities.

Comparison of efficacy of erector spinae plane block, thoracic paravertebral block, and erector spinae plane block and thoracic paravertebral block combination for acute pain after video-assisted thoracoscopic surgery: a randomized controlled study.

BACKGROUND: The aim of this study was to compare the efficacy of ultrasound-guided erector spinae plane block (ESPB), thoracic paravertebral block (TPVB), and ESPB and TPVB combination on acute pain after video-assisted thoracoscopic surgery (VATS). METHODS: Seventy-five patients were evaluated (three groups: ESPB, TPVB, or combined ESPB-TPVB [comb-group], each 25 patients). All interventions were performed with the same volume of bupivacaine (20 mL). Primary outcome was VAS (Visual Analog Scale) during the first 24 hours. Secondary outcomes were postoperative morphine consumption and rescue analgesic requirements. RESULTS: VAS during rest and coughing of TPVB was significantly higher compared to other groups (in all measurements compared to comb-group; and in all but 24 hours measurement to ESPB) ESPB and comb-group had similar VAS in all measurements (e.g., median VAS in ESPB, TPVB and comb-group at 8th hour: 3-4-2 [P=0.014] during coughing and 2-3-1 in rest [P<0.001], respectively). Morphine consumption was statistically significantly higher in TPVB than comb-group (ESPB: 15.28 mg; TPVB: 19.30 mg; ESPB+TPVB: 10.00 mg) (P=0.003). Rescue analgesic requirement was statistically significantly higher in the TPVB group than comb-group (P=0.009). CONCLUSIONS: ESPB alone and the combination of ESPB and TPVB provided superior primary outcomes compared to TPVB alone. Morphine and rescue analgesic consumptions were higher in TPVB than comb-group. ESPB and comb-group were statistically similar in terms of primary and secondary outcomes. This study is one of the first studies using the combination of ESBP and TPVB for pain after VATS, and shows the efficacy of this approach.

Patient-centred care in thoracic surgery: a holistic approach-A review of the subjects of enhanced recovery after surgery, rehabilitation, pain management and patient-reported outcome measures in thoracic surgery.

The symposium Patient-centered care in thoracic care: a holistic approach was held on June 22, 2021, as a virtual event in the context of the European conference on general thoracic surgery. Its aim was to explore how to improve patient outcomes in thoracic surgery by using enhanced recovery after surgery (ERAS®) frameworks and collaboration within healthcare. During the four presentations, topics on patient mobilization and physical rehabilitation, pain management, and the role of chest drainage in facilitating perioperative care were discussed. Strategies to minimize opioid consumption and incorporate patients' experiences as quality indicators were described. There were two main ideas that were considered pivotal to achieve optimal care: (I) the use of simple, easily implementable perioperative protocols and practices to improve compliance from both patients and the healthcare team, and (II) promote a better recovery with early mobilization and reducing the patient's levels of pain. Among the key learnings that emerged from the presentations are the importance of taking the patient's experiences into account, including what they value the most after surgery, and how technology can enable better care. The use of digital chest drainage systems emerged as a way for improving patient outcomes and experiences across several key indicators.

Ventilatory protective strategies during thoracic surgery: effects of alveolar recruitment maneuver and low-tidal volume ventilation on lung density distribution.

BACKGROUND: The increased tidal volume (V(T)) applied to the ventilated lung during one-lung ventilation (OLV) enhances cyclic alveolar recruitment and mechanical stress. It is unknown whether alveolar recruitment maneuvers (ARMs) and reduced V(T) may influence tidal recruitment and lung density. Therefore, the effects of ARM and OLV with different V(T) on pulmonary gas/tissue distribution are examined. METHODS: Eight anesthetized piglets were mechanically ventilated (V(T) = 10 ml/kg). A defined ARM was applied to the whole lung (40 cm H(2)O for 10 s). Spiral computed tomographic lung scans were acquired before and after ARM. Thereafter, the lungs were separated with an endobronchial blocker. The pigs were randomized to receive OLV in the dependent lung with a V(T) of either 5 or 10 ml/kg. Computed tomography was repeated during and after OLV. The voxels were categorized by density intervals (i.e., atelectasis, poorly aerated, normally aerated, or overaerated). Tidal recruitment was defined as the addition of gas to collapsed lung regions. RESULTS: The dependent lung contained atelectatic (56 ± 10 ml), poorly aerated (183 ± 10 ml), and normally aerated (187 ± 29 ml) regions before ARM. After ARM, lung volume and aeration increased (426 ± 35 vs. 526 ± 69 ml). Respiratory compliance enhanced, and tidal recruitment decreased (95% vs. 79% of the whole end-expiratory lung volume). OLV with 10 ml/kg further increased aeration (atelectasis, 15 ± 2 ml; poorly aerated, 94 ± 24 ml; normally aerated, 580 ± 98 ml) and tidal recruitment (81% of the dependent lung). OLV with 5 ml/kg did not affect tidal recruitment or lung density distribution. (Data are given as mean ± SD.) CONCLUSIONS: The ARM improves aeration and respiratory mechanics. In contrast to OLV with high V(T), OLV with reduced V(T) does not reinforce tidal recruitment, indicating decreased mechanical stress.

Effects of volatile and intravenous anesthesia on the alveolar and systemic inflammatory response in thoracic surgical patients.

BACKGROUND: One-lung ventilation (OLV) results in alveolar proinflammatory effects, whereas their extent may depend on administration of anesthetic drugs. The current study evaluates the effects of different volatile anesthetics compared with an intravenous anesthetic and the relationship between pulmonary and systemic inflammation in patients undergoing open thoracic surgery. METHODS: Sixty-three patients scheduled for elective open thoracic surgery were randomized to receive anesthesia with 4 mg · kg⁻¹ · h⁻¹ propofol (n = 21), 1 minimum alveolar concentration desflurane (n = 21), or 1 minimum alveolar concentration sevoflurane (n = 21). Analgesia was provided by remifentanil (0.25 µg · kg⁻¹ · min⁻¹). After intubation, all patients received pressure-controlled mechanical ventilation with a tidal volume of approximately 7 ml · kg ideal body weight, a peak airway pressure lower than 30 cm H2O, a respiratory rate adjusted to a Paco2 of 40 mmHg, and a fraction of inspired oxygen lower than 0.8 during OLV. Fiberoptic bronchoalveolar lavage of the ventilated lung was performed immediately after intubation and after surgery. The expression of inflammatory cytokines was determined in the lavage fluids and serum samples by multiplexed bead-based immunoassays. RESULTS: Proinflammatory cytokines increased in the ventilated lung after OLV. Mediator release was more enhanced during propofol anesthesia compared with desflurane or sevoflurane administration. For tumor necrosis factor-α, the values were as follows: propofol, 5.7 (8.6); desflurane, 1.6 (0.6); and sevoflurane, 1.6 (0.7). For interleukin-8, the values were as follows: propofol, 924 (1680); desflurane, 390 (813); and sevoflurane, 412 (410). (Values are given as median [interquartile range] pg · ml⁻¹). Interleukin-1ß was similarly reduced during volatile anesthesia. The postoperative serum interleukin-6 concentration was increased in all patients, whereas the systemic proinflammatory response was negligible. CONCLUSIONS: OLV increases the alveolar concentrations of proinflammatory mediators in the ventilated lung. Both desflurane and sevoflurane suppress the local alveolar, but not the systemic, inflammatory responses to OLV and thoracic surgery.

Enhanced recovery after thoracic anesthesia.

In recent years, the concept of "Perioperative Medicine" has been evolved to a more concrete and sophisticated approach called "Enhanced Recovery After Surgery" (ERAS). ERAS has been first introduced in colorectal surgery by a dedicated leading ERAS® society, ERAS-criteria has been subsequently extended into several types of surgery, including thoracic surgery. Anesthesiology has always been one of the most important components of the multidisciplinary perioperative approaches, which is also valid for ERAS. There are several guidelines published on the enhanced recovery after thoracic surgery (ERATS). This article focuses on the "official" ERATS protocols of a joint consensus of two different societies. Regarding thoracic anesthesia, there are some challenges to be dealt with. The first challenge, although there is a large number of studies published on thoracic anesthesia, only a very few of them have studied the overall outcome and quality of recovery; and only few of them were powered enough to provide sufficient evidence. This has led to the fact that some components of the protocol are debatable. The second challenge, the adherence to individual elements and the overall compliance are poorly reported and also hard to apply even in the best organized centers. This article explains and discusses the debatable viewpoints on the elements of the ERATS protocol published in 2019 aiming to achieve a list for the future steps required for a more effective and evidence-based ERATS protocol.

Impact of regional analgesia techniques on the long-term clinical outcomes following thoracic surgery.

Continuous monitoring of clinical outcomes after thoracotomy is very important to improve medical services and to reduce complications. The use of regional analgesia techniques for thoracotomy offers several advantages in the perioperative period including effective pain control, reduced opioid consumption and associated side effects, enhanced recovery, and improved patient satisfaction. Postthoracotomy complications, such as chronic postthoracotomy pain syndrome, postthoracotomy ipsilateral shoulder pain, pulmonary complications, recurrence, and unplanned admission to the intensive care unit are frequent and may be associated with poor outcomes and mortality. The role of regional techniques to reduce the incidence of these complications is questionable. This narrative review aims to investigate the impact of regional analgesia on the long-term clinical outcomes after thoracotomy.

Effects of short-term hyperoxic ventilation on lung, kidney, heart, and liver in a rat model: A biochemical evaluation.

BACKGROUND: Despite studies on the adverse effects of hyperoxia, its use is still recommended by the World Health Organization. The aim of this study was to test the possible harmful effects of hyperoxia on the lung, kidney, heart, and liver in a rat mechanical ventilation model. METHODS: Male Wistar rats were randomly assigned into two groups (n=6/group): Normoxic (FiO2: 0.3) or hyperoxic (FiO2: 1.0) ventilation for 4 h. The injury was evaluated in bronchoalveolar lavage (BAL), blood, lung, liver, kidney, and heart was evaluated in terms of cell surface integrity, extracellular matrix (sialic acid, syndecan-1), osmotic stress (free hemoglobin), and redox homeostasis-lipid peroxidaation (malondialdehyde). BAL and wet/dry weight ratio were also evaluated for cellular permeability. RESULTS: Four hours of hyperoxic ventilation did not lead to significant changes in (1) sialic acid, syndecan-1, (2) malondialdehyde levels and wet/dry weight ratio in liver, kidney, heart, and lung compared to normoxic ventilation. CONCLUSION: Mechanical ventilation with hyperoxia seems to have almost similar effects compared to ventilation with normoxia. However, the long term effect of hyperoxia should be evaluated.

Comparison of epidural analgesia combined with general anesthesia and general anesthesia for postoperative cognitive dysfunction in elderly patients.

BACKGROUND: Cognitive dysfunction in the early postoperative course is common for the elderly population. Anesthetic management may affect postoperative cognitive decline. Effective analgesia, early recovery and modulation of the stress response are advantages of neuraxial blocks. This study aims to compare the effects of general anesthesia and the combination of general anesthesia with epidural analgesia for postoperative cognitive dysfunction (POCD). We hypothesized that neuraxial block combined with general anesthesia (GA) would have a favorable influence on POCD prevention. METHODS: Patients above 60 years undergoing non-cardiac surgery were included in this randomized, prospective study and randomized into two groups. Patients in the first group (GI) were treated under GA, whereas in the second group (GII), epidural analgesia was combined with GA. Patients' cognitive function was assessed before and one week after surgery using a neuropsychological test battery. POCD was defined as a drop of one standard deviation from baseline on two or more tests. RESULTS: A total of 116 patients were allocated for the final analysis. Demographic and operative data were similar between groups, except maximum pain scores, which were significantly higher in GI than GII (4.9±2.8 vs. 1.7±1.7; p<0.001, respectively). The incidence of POCD was comparable between groups (26% in GI and 24% in GII). Memory performance, visuospatial functions, and language skills tests were significantly higher in GII compared to GI. CONCLUSION: General anesthesia and epidural analgesia combined with general anesthesia resulted in similar POCD in elderly patients undergoing abdominal surgery. However, in combined anesthesia group memory, language skills and visuospatial functions appeared to be better preserved. Effective pain control might contribute to preventing cognitive decline in some domains.

Videothoracoscopic thymectomy for nonthymomatous myasthenia gravis: results of 90 patients.

BACKGROUND: Videothoracoscopic thymectomy is an alternative surgical procedure for patients with nonthymomatous myasthenia gravis. The aim of this study is to present our experience and to analyze the factors contributing to the operative morbidity. METHODS: Ninety myasthenia gravis patients were operated through right-sided videothoracoscopy from June 2002 to September 2006. Prospective data recording was performed. Surgeon-related conversion to open surgery, length of the operation, chest tube duration time, duration of hospital stay, amount of drainage, pain score, and complications were evaluated. Factors contributing to longer operation time and longer postoperative stay were studied. RESULTS: The mean length of chest tube duration and postoperative hospital stay was 26.7 +/- 18.6 hours and 2.2 days +/- 1.1 days respectively. Visual analogue scale (VAS) values for pain evaluation were 2.0 +/- 1.4. Surgeon-related open conversion occured in two patients (2.2%). Body mass index (BMI) was the sole significant factor for longer operation time. (23.04 +/- 2.93 versus 25.61 +/- 2.70 (p = 0.001). The amount of pyridostigmine was the only significant factor for longer hospital stay (213.3 +/- 101.5 mg versus 270. 0 +/- 122.6 mg (p = 0.044). CONCLUSIONS: This study demonstrates the right-sided videothoracoscopy is a safe procedure. The only contributing factors were: BMI >25.61 for longer operation time, and pyridostigmine level >270 mg for duration of postoperative stay.

[Effects of cerebral oxygen changes during coronary bypass surgery on postoperative cognitive dysfunction in elderly patients: a pilot study]. / Efeitos das alterações no oxigênio cerebral durante cirurgia de revascularização do miocárdio sobre a disfunção cognitiva no pós­operatório em pacientes idosos: estudo piloto.

BACKGROUND AND OBJECTIVES: Postoperative cognitive dysfunction is common after cardiac surgery. Adequate cerebral perfusion is essential and near infrared spectroscopy (NIRS) can measure cerebral oxygenation. Aim of this study is to compare incidence of early and late postoperative cognitive dysfunction in elderly patients treated with conventional or near infrared spectroscopy monitoring. METHODS: Patients undergoing coronary surgery above 60 years, were included and randomized to 2 groups; control and NIRS groups. Peroperative management was NIRS guided in GN; and with conventional approach in control group. Test battery was performed before surgery, at first week and 3 rd month postoperatively. The battery comprised clock drawing, memory, word list generation, digit spam and visuospatial skills subtests. Postoperative cognitive dysfunction was defined as drop of 1 SD (standard deviation) from baseline on two or more tests. Mann-Whitney U test was used for comparison of quantitative measurements; Chi-square exact test to compare quantitative data. RESULTS: Twenty-one patients in control group and 19 in NIRS group completed study. Demographic and operative data were similar. At first week postoperative cognitive dysfunction were present in 9 (45%) and 7 (41%) of patients in control group and NIRS group respectively. At third month 10 patients (50%) were assessed as postoperative cognitive dysfunction; incidence was 4 (24%) in NIRS group (p:0.055). Early and late postoperative cognitive dysfunction group had significantly longer ICU stay (1.74+0.56 vs. 2.94+0.95; p<0.001; 1.91+0.7 vs. 2.79+1.05; p<0.01) and longer hospital stay (9.19+2.8 vs. 11.88+1.7; p<0.01; 9.48+2.6 vs. 11.36+2.4; p<0.05). CONCLUSION: In this pilot study conventional monitoring and near infrared spectroscopy resulted in similar rates of early postoperative cognitive dysfunction. Late cognitive dysfunction tended to ameliorate with near infrared spectroscopy. Early and late cognitive declines were associated with prolonged ICU and hospital stays.

Non-analgesic effects of thoracic epidural anesthesia.

Thoracic epidural anaesthesia is selected usually to provide adequate postoperative analgesia; however with administration of local anaesthetics to epidural space selective sympatolysis ensues. The effects of this transient sympathectomy on cardivascular, respiratory and other systems deserve certainly some interest as it may influence postoperative morbidity or mortality. Thoracic epidural anaesthesia has succesfully been used in cardiac, thoracic and major abdominal surgery. It provides dynamic analgesia, rapid mobilization, blunted stress response, early extubation with reduced pulmonary complications and also rapid recovery of bowel function. In cardiac surgery where thoracic sympathetic blockade is expected to be most useful, there is no difference in morbidity and mortality. Despite the superior quality of pain control, the beneficial aspect of thoracic epidural anaesthesia is not reflected on outcome in meta-analysis. Recent papers has still demonstrated positive effects on each system. So thoracic epidural anaesthesia is increasingly used and it seems that it will be discussed more in near future.

Fluid management in thoracic anesthesia.

Fluid management during thoracic anesthesia remains as a challenge for the anesthesiologists. The "safe zone" between volume overload (risk of pulmonary edema) and hypovolemia (potential risk of renal failure) is hard to determine and narrow. Relationship between perioperative fluid administration and postoperative lung injury has been clearly demonstrated but lung injury can even occur after the most restrictive management. Multiple hit hypothesis and endothelial glycocalyx in addition to revised Starling equation can help us understand this dilemma. Although a "liberal" fluid strategy is out of question for thoracic surgery, evidence on "restrictive" and "goal-directed" fluid strategies are missing. New monitors with dynamic parameters can help to evaluate if the patient will respond to a fluid challenge. However, "volume responsiveness" should not be equated with volume deficiency, especially in a patient with thoracic epidural catheter. Fluid type (crystalloids or colloids) is also another unclear point, although balanced solutions should be preferred for crystalloids. Minimal discontinuation of oral hydration, early feeding and mobilization should be encouraged. This review summarizes current evidence on the topic and highlights unanswered questions.

[The effect of two different glycemic management protocols on postoperative cognitive dysfunction in coronary artery bypass surgery]. / Efeito de dois protocolos de controle glicêmico diferentes sobre a disfunção cognitiva após cirurgia de revascularização do miocárdio.

INTRODUCTION: Postoperative cognitive dysfunction (POCD) is an adverse outcome of surgery that is more common after open heart procedures. The aim of this study is to investigate the role of tightly controlled blood glucose levels during coronary artery surgery on early and late cognitive decline. METHODS: 40 patients older than 50 years undergoing elective coronary surgery were randomized into two groups. In the "Tight Control" group (GI), the glycemia was maintained between 80 and 120mg·dL-1 while in the "Liberal" group (GII), it ranged between 80-180mg·dL-1. A neuropsychological test battery was performed three times: baseline before surgery and follow-up first and 12th weeks, postoperatively. POCD was defined as a drop of one standard deviation from baseline on two or more tests. RESULTS: At the postoperative first week, neurocognitive tests showed that 10 patients in the GI and 11 patients in GII had POCD. The incidence of early POCD was similar between groups. However the late assessment revealed that cognitive dysfunction persisted in five patients in the GII whereas none was rated as cognitively impaired in GI (p=0.047). CONCLUSION: We suggest that tight perioperative glycemic control in coronary surgery may play a role in preventing persistent cognitive impairment.