Clinically-guided placement of fogarty catheter for lung isolation in video-assisted thoracoscopic surgery for spontaneous pneumothorax

Over the past decade, video assisted thoracic surgery [VATS] has changed the way spontaneous pneumothorax [SP] is managed. During VATS one-lung ventilation [OLV] is strictly indicated. Successful use of Fogarty occlusion embolectomy catheters has been reported. This study aimed to evaluate the efficiency and safety of Fogarty catheters as bronchial blockers for patients undergoing VATS for spontaneous pneumothorax and using the fiberoptic bronchoscope to assess the successful placement of such catheters when inserted depending on clinically-guided technique including initial temporary deliberate endobrinchial intubation. Eleven patients with SP for VATSbuulectomy and pleural abrasion were enrolled. All patients received standardized balanced general anesthetic technique and VATS technique by a single anesthesiologist and surgein.The lung isolation technique depends on deliberate temporary intubation of the main bronchusin the ipsilateral surgical side with a single-lumen endotracheal tube and advancing a 8/22F Fogarty catheter past the tip of the endobronchial tube. The endobronchial tube is then removed and a new endotracheal tube is placed alongside the Fogarty catheter. We measured the success rate and time needed to achieve placement of the Fogarty catheter. W e also confirmed proper positioning with fiberoptic bronchoscope and recorded results. Verbal analog scale was used to describe the surgical satisfaction about lung isolation. One left sided case failed to be intubated without bronchoscopy. Success was significantly higher in right sided cases [100% versus80% in left sided] and needed significantly shorter time to be achieved [328.2 +/- 23. 2 seconds versus 757.9 +/- 51.5 seconds respectively]. Verbal analog scale scored a mean of 78.5 +/- 13mm out of 100mm. This study showed that Fogarty catheter can be placed in a clinically-guided technique safely with satisfactory lung isolation in patients undergoing video-assisted thoracoscopic surgery for spontaneous pneumothorax

Lung volume reduction surgery by bilateral bullectomy through median sternotomy

Emphysematous bullae represent a form of emphysematous lung destruction. Surgical resection has traditionally been indicated when there is hyperexpansion of the chest, compromised pulmonary function, and evidence of underlying, relatively normal compressed lung. Different approaches to LVRS have been proposed; these include median sternotomy, thoracosternotomy and video-assisted thoracoscopic surgery [VATS] technique. Nine patients underwent resection of emphysematous bullae at Kasr Elaini hospital between February 2006 and July 2007. All had limiting dyspnea and radiological evidence of hyperinflated bullae compressing adjacent lung parenchyma. All the patients had bilateral lesions. We did median sternotomy, with one-lung ventilation under a standard general anesthetic technique to avoid rupture of bulla, in all patients to do resections bilaterally in the same sitting. Intraoperative complications included arrhythmia in 2 casesm hypoxia in 3 patients and uncontrolled air leak in all patients but with no cases of cardiac arrest or hyperinflation leading to rupture bulla prior to chest opening. Postoperative complications included persistent air-leak, failure of early extubation, readmission to ICU and chest infection. We had two mortalities one due to ARDS and the other due to chest infection. In conclusion we recommend the use of this approach in highly selected patients as it is only subject the patient for one procedure instead of two and we can avoid the possibility of spontaneous pnemothorax on the contralateral side, while doing bulletomy in lateral position through thoracotomy. The described surgical and anesthetic technique in our experience case series showed acceptable outcome compared to the literature and with adequate exposure and accessibility

Comparative study between the effects of clevidipine and nitroglycerine in patients with pulmonary hypertension undergoing mitral valve replacement

Pulmonary hypertension [PHT] is commonly found in patients undergoing mitral valve replacement [MVR]. Various pharmacologic agents have been used to decrease the pulmonary artery pressure in pulmonary hypertensive patients. Clevidipine is a third-generation IV dihydropyridine calcium channel blocker, specific arterial dilator, with rapid onset and offset. The aim of the present study was to compare between the effects of clevidipine and nitroglycerine on pulmonary and systemic hemodynamics as well as pulmonary oxygenation. Thirty patients with PHT scheduled for elective MVR were enrolled in this study and randomly allocated into 2 groups. Patients received either nitroglycerin infusion at 0.25-10 microg/kg/min [NTG group] or clevidipine infusion at 0.4-8 microg/kg/min [CLV group]. Pulmonary and systemic hemodynamic parameters as well as oxygenation data were measured after induction of anesthesia, after weaning from CPB before the start of the study medication, and after 30 minutes, 2 hours, and 4 hours from the start of the study medication. The incidence of postoperative atrial fibrillation and total ICU and hospital length of stays were also recorded. The mean pulmonary artery pressure [MPAP], pulmonary vascular resistance [PVR], pulmonary capillary wedge pressure [PCWP], mean arterial blood pressure [MAP], and systemic vascular resistance [SVR] were significantly lower in the CLV group compared to the NTG group. In both groups, these parameters were significantly lower at 30 min, 2 hours, and 4 hours after drug administration compared to pre-drug administration values. There was no statistical significant change in the heart rate [HR] in the CLV group, however, it was significantly increased at 30 min, 2 hours, and 4 hours after drug administration compared to pre-drug administration values in the NTG group. The cardiac index [Cl] was significantly increased at 30 min, 2 hours, and 4 hours after drug administration compared to pre-drug administration values in CLV group and was statistically higher than NTG group. There was a non significant decrease in the PaO[2]/Fi0[2] and no significant change in PaCO[2] and SvO[2] at 30 min, 2 hours, and 4 hours after drug administration compared to pre-drug administration values in both groups with no statistical difference between the two groups. Clevidipine is a valuable alternative to nitroglycerine in the treatment of PHT in patients undergoing MVR as it showed better pulmonary and systemic hemodynamic profiles and did not worsen pulmonar] oxygenation