Choosing the Correct?Sized Adult Double?Lumen Tube: Quest for the Holy Grail

Appropriate size selection of double?lumen tubes (DLTs) for one?lung ventilation (OLV) in adults is still a humongous task. Several important factors are to be considered like patient height, gender, tracheal diameter, left main bronchial diameter, and cricoid cartilage transverse diameter. In addition to radiological assessment of the airway diameters, the manufacturing details of the particular DLT being used also play a significant role in size selection. Optimal positioning of the appropriately sized DLT is indispensable to avoid complications like airway trauma, cuff rupture, hypoxemia, and tube displacement. It is imperative to know whether the one?size?fits?all dictum holds for DLT size selection as claimed by certain studies. Further randomized studies are required for crystallizing standard protocols ascertaining the correct DLT size. This systematic review article highlights the various parameters employed for DLT size selection and explores the newer DLTs used for adult OLV.

Effects of pressure controlled ventilation-volume guaranteed mode on intraoperative pulmonary ventilation and postoperative pulmonary complications in elderly patients undergoing thoracoscopic lobectomy / 肿瘤研究与临床

Objective:To explore the effects of pressure controlled ventilation-volume guaranteed (PCV-VG) mode on intraoperative pulmonary ventilation and postoperative pulmonary complications (PPC) in elderly patients undergoing thoracoscopic lobectomy.Methods:Sixty patients of American Society of Anesthesiologists (ASA) classification Ⅱor Ⅲ, aged 65-80 years old, with body mass index (BMI) 18-30 kg/m 2, received thoracoscopic lobectomy under general anesthesia from November 2021 to June 2022 in the Second Hospital of Shanxi Medical University were recruited. The patients were divided into PCV-VG and volume-controlled ventilation (VCV) groups using the randomized number table method, with 30 patients in each group. The ventilatory parameters of two-lung ventilation were set to respiratory rate (RR) at 10-12 breaths/min, with a tidal volume (VT) of 8 ml/kg (ideal body weight). The ventilatory parameters of one-lung ventilation (OLV) were set at 12-16 breaths/min, with a VT of 6 ml/kg (IBW). The peak airway pressure (Ppeak), plateau airway pressure (Pplat), driving pressure (ΔP), dynamic lung compliance (Cdyn), end-tidal carbon dioxide (ETCO 2), heart rate (HR), mean arterial pressure (MAP), partial pressure of oxygen (PaO 2) and partial pressure of carbon dioxide (PaCO 2) were obtained at 1 min before OLV (T 0), 30 min after OLV (T 1) and 60 min after OLV (T 2). The incidence and severity of PPC, chest tube duration time and postoperative hospital stay time were recorded. Results:The Ppeak, Pplat and ΔP were higher and Cdyn was lower in both groups at T 1-T 2 than at T 0 (all P<0.001). The Ppeak, Pplat and ΔP were higher and Cdyn was lower in PCV-VG group than in VCV group (all P<0.05). There were no statistical differences in HR, MAP, ETCO 2, PaO 2 and PaCO 2 between the two groups (all P > 0.05). There were no statistical differences in the incidence of PPC [43.3% (13/30) vs. 30.0% (9/30)] and chest tube duration time [(4.4±0.9) d vs. (4.2±1.2) d] between VCV group and PCV-VG group (all P>0.05). Compared with VCV group, the proportion of patients with ≥grade 2 PPC was lower in PCV-VG group [10.0% (3/30) vs. 36.7% (11/30), χ2=5.96, P<0.05]. The postoperative hospital stay time in PCV-VG group was shorter than that in VCV group [(6.4±1.3) d vs. (8.0±1.9) d, t = 4.85, P<0.05]. Conclusions:PCV-VG mode can effectively reduce the severity of PPC, shorten the postoperative hospital stay time and improve the prognosis in elderly patients undergoing thoracoscopic lobectomy.

Optimization efficacy of individualized LPVS based on P-V curve combined with PCV-VG mode for OLV in elderly patients undergoing radical resection of lung cancer / 中华麻醉学杂志

Objective:To evaluate the optimization efficacy of pressure-volume (P-V) curve-based individualized lung-protective ventilation strategy combined with pressure-controlled ventilation-volume guaranteed (PCV-VG) mode (LPVS+ PCV-VG) for one-lung ventilation (OLV) in elderly patients undergoing radical resection of lung cancer.Methods:Seventy American Society of Anesthesiologists Physical Status classificationⅡ-Ⅲ patients, aged 65-74 yr, with body mass index of 18-24 kg/m 2, undergoing elective thoracoscopic radical resection of lung cancer, were divided into 2 groups ( n=35 each) using a random number table method: PCV-VG group and LPVS+ PCV-VG group. Blood samples were collected from the radial artery for blood gas analysis before induction of general anesthesia (T 0), at 5 min of two lung ventilation after endotracheal intubation (T 1), at 30 min of OLV (T 2), at the end of OLV (T 3), and at 5 min of two lung ventilation in supine position (T 4). Ppeak, mean airway pressure (Pmean) and dynamic lung compliance (Cdyn) were recorded. The use of antibiotics, lung-related complications and rehabilitation were recorded within 7 days after operation. Results:Compared with PCV-VG group, PaO 2, PaCO 2 and Cdyn were significantly increased at T 2-4, Ppeak was decreased at T 2, 3, Pmean was increased at T 3, the requirement for antibiotics within 7 days after operation was decreased, the incidence of 1 grade lung-related complications was decreased, and the thoracic drainage tube indwelling time and length of hospital stay were shortened in LPVS+ PCV-VG group ( P<0.05). Conclusions:Individualized LPVS based on P-V curve combined with PCV-VG mode provides better efficacy for OLV in elderly patients undergoing radical resection of lung cancer.

Anesthetic management of an adult patient with hypertrophic obstructive cardiomyopathy and chronic kidney disease for minimally invasive video-assisted thoracoscopic surgery

It is not an uncommon situation to encounter a patient with anesthesia having multiple co-morbidities. Here, we report the successful anesthetic management of an immunosuppressed 53-year-old female patient with hypertrophic obstructive cardiomyopathy, stage IV chronic kidney disease, and chronic lung infection who was posted for minimally invasive video-assisted thoracoscopy requiring one lung ventilation. Intraoperative hemodynamic stability was maintained with etomidate, fentanyl, cisatracurium, desflurane, and dexmedetomidine with accurate bispectral depth for sedation and precise fluid guidance with transesophageal echocardiography. The entire anesthetic conduct was planned to avoid the left ventricular outflow tract obstruction and maintain a steady-state hemodynamic balance. This case report is a learning experience of how close vigilance with appropriate use of monitoring and knowledge about disease per se resulted in an uneventful perioperative period.

Bronchial Blocker and Double?Lumen Endotracheal Tube Combination to Facilitate Lung Isolation during Esophagectomy

Lung isolation is an essential anesthetic technique utilized in thoracic surgeries. We present a patient undergoing esophagectomy that developed an iatrogenic injury to the left mainstem bronchus that damaged the bronchial cuff of a left?sided double?lumen endotracheal tube (DLETT). A bronchial blocker (BB) was placed in the tracheal lumen of the DLETT as a rescue method to facilitate continued lung isolation. This unusual combination of a DLETT and a BB proved useful once the bronchial cuff was compromised and may serve as a viable solution to maintain lung isolation in similar circumstances

Effect of apneic oxygen insufflation on phenotypic transformation of alveolar macrophage in non-ventilated lung during one-lung ventilation / 中华麻醉学杂志

Objective:To evaluate the effect of apneic oxygen insufflation (AOI) on phenotypic transformation of alveolar macrophage (AM) in the non-ventilated lung during one-lung ventilation (OLV).Methods:A total of 60 patients of either sex, aged 40-64 yr, weighing 45-85 kg, undergoing elective thoracoscopic lobectomy, were recruited and divided into 2 groups using a computer-generated table of random numbers: test group and control group, with 30 cases in each group.At the beginning of OLV, the non-ventilated lung received 3 L/min of AOI in test group and no AOI in control group.Radial artery blood samples were collected for blood gas analysis before operation, immediately after anesthesia induction, 30 min, 1 h and 2 h after the start of OLV, and oxygenation index (OI) was calculated.The resected normal lung tissues around the lung lobe were excised at 2 h after the start of OLV for microscopic examination of the pathological changes after HE staining, and the lung injury score was assessed.Bronchoalveolar lavage fluid (BALF) was collected at 2 h after the start of OLV, AM was sorted by flow cytometry, and the apoptotic rate was calculated.The levels of intracellular Ca 2+ and reactive oxygen species (ROS, a marker of M1 AM phenotype) in cells were determined.The concentrations of M1 phenotype AM markers inducible nitric oxide synthase (iNOS), interleukin 6 (IL-6), and tumor necrosis factor alpha (TNF-α) and of M2 phenotype AM markers arginase 1 (Arg-1) and interleukin 10 (IL-10) in BALF were measured by enzyme-linked immunosorbent assay. Results:Compared with control group, SpO 2, PaO 2 and OI were significantly increased, PaCO 2 and lung injury score were decreased, the survival rate of AM was increased, the apoptotic rate in the early and late stages was decreased, the concentrations of iNOS, IL-6 and TNF-α in BALF were decreased, and the concentrations of Arg-1 and IL-10 in BALF were increased, the level of ROS in AM was decreased, and the level of Ca 2+ in AM was increased in test group ( P<0.05). Conclusions:The mechanism by which implementing AOI in the non-ventilated lung reduces lung injury may be related to promotion of transformation of AM from M1 phenotype to M2 phenotype and inhibition of inflammatory responses during OLV in the patients undergoing thoracoscopic lobectomy.

Effect of ventilation mode on pulmonary complications after thoracoscopic lung resection: A retrospective cohort study / 中国胸心血管外科临床杂志

@#Objective     To evaluate the association between pressure-controlled ventilation-volume guaranteed (PCV-VG) mode and volume-controlled ventilation (VCV) mode on postoperative pulmonary complications (PPCs) in patients undergoing thoracoscopic lung resection. Methods     A retrospective cohort analysis of 329 patients undergoing elective thoracoscopic lung resection in West China Hospital of Sichuan University between September 2020 and March 2021 was conducted, including 213 females and 116 males, aged 53.6±11.3 years. American Society of Anesthesiologists (ASA) grade wasⅠ-Ⅲ. The patients who received lung-protective ventilation strategy during anesthesia were divided into a PCV-VG group (n=165) and a VCV group (n=164) according to intraoperative ventilation mode. Primary outcome was the incidence of PPCs during hospitalization. Results     A total of 73 (22.2%) patients developed PPCs during hospitalization. The PPCs incidence of PCV-VG and VCV was 21.8% and 22.6%, respectively (RR=0.985, 95%CI 0.569-1.611, P=0.871). Multivariate logistic regression analysis showed that there was no statistical difference in the incidence of PPCs between PCV-VG and VCV mode during hospitalization (OR=0.846, 95%CI 0.487-1.470, P=0.553). Conclusion     Among patients undergoing thoracoscopic lung resection, intraoperative ventilation mode (PCV-VG or VCV) is not associated with the risk of PPCs during hospitalization.

Lung protective effect of driving pressure-guided lung protective ventilation strategy combined with pressure-controlled ventilation in elderly patients undergoing thoracoscopic radical resection of lung cancer / 肿瘤研究与临床

Objective:To investigate the lung protective effect of driving pressure-guided lung protective ventilation strategy (LPVS) combined with pressure-controlled ventilation (PCV) in elderly patients undergoing thoracoscopic radical resection of lung cancer.Methods:One hundred elderly patients scheduled for thoracoscopic radical resection of lung cancer from April 2021 to April 2022 in the Second Hospital of Shanxi Medical University were selected. Patients were aged 60-80 years old and American Society of Anesthesiologists (ASA) classification Ⅰ-Ⅱ. All patients were divided into 4 groups by using the random number table method, with 25 cases in each group. Group A received volume-controlled ventilation (VCV) + 5 cm H 2O (1 cm H 2O = 0.098 kPa) PEEP, group B received PCV+5 cm H 2O PEEP, group C received VCV+driving pressure-guided individualized PEEP, and group D received PCV+driving pressure-guided individualized PEEP. The arterial oxygen partial pressure (PaO 2) was recorded before one-lung ventilation (OLV) (T 0), 30 min after OLV (T 1) and 60 min after OLV (T 2). The serum concentrations of neutrophil elastase (NE) in radial artery blood samples of patients were measured at T 0 and 10 min after the end of OLV (T 3). The occurrence of postoperative pulmonary complications (PPC) within 5 d after surgery was recorded. Results:The PaO 2 of group A and B at T 1 [(135±50), (146±51) mmHg (1 mmHg = 0.133 kPa)] and T 2 [(137±46), (143±47) mmHg] were lower than those of group C and group D at T 1 [(168±27), (190±30) mmHg] and T 2 [(180±30), (183±24) mmHg] (all P < 0.05). The incidence of PPC within 5 d after surgery in group A was higher than that in group D [36% (9/25) vs. 4% (1/25)] ( P = 0.005). The concentration of NE at T 3 in group A [(202.8±9.7) ng/ml] was lower than that in group B, C and D [(182.5±12.0), (180.0±10.3), (160.6±13.0) ng/ml] ( P < 0.05). Conclusions:During OLV, driving pressure-guided LPVS combined with PCV can not only improve oxygenation, but also show obvious advantages in reducing inflammatory response. It is a safe and effective intraoperative ventilation strategy for elderly patients undergoing thoracoscopic radical resection of lung cancer.

Strategic ventilation reduces non-ventilated contralateral lung injury induced by one-lung ventilation in rabbits / [Ventilação estratégica reduz lesão pulmonar contralateral não ventilada induzido pela ventilação pulmonar unilateral em coelhos]

One lung ventilation (OLV) often results in trauma to the unventilated contralateral lung. This study aims to evaluate the effects of different OLV regimens on the injury of the unventilated contralateral lung to identify the best conditions for OLV. Forty rabbits were divided into five groups: a sham group, OLV group I (fraction of inspired oxygen (FIO2) 1.0, tidal volume (VT) 8mL/kg, respiratory rate (R) 40 breaths/min and inspiratory/expiratory ratio (I:E) 1:2), OLV group II (FIO2=1.0, VT 8mL/kg, R 40 breaths/min, I:E 1:2, and positive end-expiratory pressure (PEEP) 5 cm H2O), OLV group III (FIO2 1.0, VT 6mL/kg, R 40 breaths/min, I:E 1:2 and PEEP 5 cm H2O) and OLV group IV (FIO2 0.8, VT 6mL/kg, R 40 breaths/min, I:E 1:2 and PEEP 5 cm H2O). Animals from all OLV groups received two-lung ventilation (TLV) to establish a baseline, followed by one of the indicated OLV regimens. The rabbits in the sham group were intubated through trachea and ventilated with fresh air. Arterial blood gas samples were collected, lung injury parameters were evaluated, and the concentrations of TNF-α and IL-8 in bronchoalveolar lavage fluid (BALF) and pulmonary surfactant protein A (SPA) in the unventilated lung were also measured. In OLV group I, the unventilated left lung had higher TNF-α, IL-8 and lung injury score but lower SPA than the ventilated right lung. In OLV groups I to III, the concentrations of TNF-α, IL-8 and lung injury score in the left lung decreased but SPA increased. No differences in these parameters between OLV groups III and IV were observed. Strategic ventilation designed for OLV groups III and IV reduced OLV-induced injury of the non-ventilated contralateral lung in rabbits.(AU)

Ventilação pulmonar unilateral (OLV) frequentemente resulta em trauma no pulmão contralateral não ventilado. Este estudo visa avaliar os efeitos de diferentes regimes de OLV sobre a lesão do pulmão contralateral não ventilado para identificar as melhores condições para OLV. Quarenta coelhos foram divididos em cinco grupos: um grupo falso, OLV grupo I (fração de oxigênio inspirado (FIO2) 1.0, volume corrente (VT) 8mL/kg, frequência respiratória (R) 40 respirações/min e relação inspiração/expiração (I:E) 1:2), OLV grupo II (FIO2=1.0, VT 8mL/kg, R 40 respirações/min, I:E 1:2, e pressão positiva expiratória final (PEEP) 5 cm H2O), OLV grupo III (FIO2 1.0, VT 6mL/kg, R 40 respirações/min, I:E 1:2 e PEEP 5 cm H2O) e OLV grupo IV (FIO2 0.8, VT 6mL/kg, R 40 respirações/min, I:E 1:2 e PEEP 5 cm H2O). Os animais de todos os grupos OLV receberam ventilação nos dois pulmões (TLV) para estabelecer uma linha de base, seguida por um dos regimes OLV indicados. Os coelhos do grupo falso foram intubados através da traqueia e ventilados com ar fresco. Amostras de gases no sangue arterial foram coletadas, parâmetros de lesão pulmonar foram avaliados e as concentrações de TNF-α e IL-8 no fluido de lavagem bronco alveolar (BALF) e proteína A do surfactante pulmonar (SPA) no pulmão não ventilado também foram medidas. No grupo OLV I, o pulmão esquerdo não ventilado tinha maior índice de TNF-α, IL-8 e lesão pulmonar, mas menor SPA do que o pulmão direito ventilado. Nos grupos OLV I a III, as concentrações de TNF-α, IL-8 e a pontuação de lesão pulmonar no pulmão esquerdo diminuíram, mas o SPA aumentou. Não foram observadas diferenças nestes parâmetros entre os grupos OLV III e IV. A ventilação estratégica projetada para os grupos OLV III e IV reduziu a lesão induzida por OLV do pulmão contralateral não ventilado em coelhos.(AU)

Esofagectomía minimamente invasiva / Minimally invasive esophagectomy

INTRODUCTION: Minimally invasive esophagectomy aims to reduce complications compared to open esophagectomy. In this report of the first patient undergoing this procedure at Hospital Pasteur, we highlight the importance of multidisciplinary management, and the main anesthesiological objectives. OBJECTIVE: To present the case report highlighting the anesthetic management, together with the bibliographic review carried out in order to update the anesthetic action protocols, with the main objective of reducing the appearance of perioperative complications. MATERIAL AND METHOD: Bibliographic search in PubMed bibliographic databases. Initially, 67 articles were obtained, selecting 20 considered relevant by the authors. CLINICAL CASE: It was a 46-year-old patient coordinated for esophagectomy for squamous neoplasm. Rapid sequence induction, selective endobronchial intubation and anesthetic maintenance with Isoflurane and epidural analgesia were performed. The hydroelectric replacement was restricti- ve. The surgical technique was performed in 3 stages: thoracic time by thoracoscopy; a second laparoscopic abdominal stage and a third stage for left cervicotomy. Extubation was carried out in the operating room with transfer to the ICU where she remained for 6 days to manage analgesia and due to the presence of a mild infectious complication, with good subsequent evolution. CONCLUSION: The use of perioperative multidisciplinary management protocols has fundamental importance as a strategy aimed at reducing morbidity and mortality. Advances in surgical technique added to anesthetic management constitute strategies that aim to reduce perioperative complications.

INTRODUCCIÓN: La esofagectomía minimamente invasiva tiene como objetivo disminuir las complicaciones en comparación con la esofagectomía abierta. En este reporte del primer paciente sometido a este procedimiento en el Hospital Pasteur destacamos la importancia del manejo multidisciplinario, y los principales objetivos anestesiológicos. OBJETIVO: Presentar el reporte de caso destacando el manejo anestésico, junto con la revisión bibliográfica realizada en vistas a la actualización de protocolos de actuación anestésica, con objetivo principal de disminuir la aparición de complicaciones perioperatorias. MATERIAL Y MÉTODO: Búsqueda bibliográfica en las bases bibliográficas PubMed. Inicialmente se obtuvieron 67 artículos, seleccionando 20 considerados relevantes por los autores. CASO CLÍNICO: Se trató de una paciente de 46 años coordinada para esofagectomía por neoplasma epidermoide. Se realizó inducción en secuencia rápida, intubación endobronquial selectiva y mantenimiento anestésico con Isofluorano y analgesia peridural. La reposición hidroelectrolítica fue restrictiva. La técnica quirúrgica se realizó en 3 tiempos: tiempo torácico por toracoscopía; un segundo tiempo abdominal laparoscópico y un tercer tiempo para cervicotomía izquierda. La extubación se realizó en sala de operaciones con traslado a CTI donde permaneció por 6 días para manejo de la analgesia y por presencia de complicación infecciosa leve, con buena evolución posterior. CONCLUSIÓN: Resulta de fundamental importancia el uso de protocolos de manejo multidisciplinario perioperatorio como estrategia destinada a disminuir la morbimortalidad. Los avances en cuanto a la técnica quirúrgica sumado al manejo anestésico constituyen estrategias que apuntan a disminuir las complicaciones perioperatorias.

Effects of Lidocaine Aerosol Inhalation on Perioperative Pulmonary Function ，Inflammatory Factors and Related Complication of Patients with One-lung Ventilation / 中国药房

OBJECTIVE：To investigate the effects of lidocaine aerosol inhalation on perioperative pulmonary function ， inflammation factor and related complications of patients with one-lung ventilation. METHODS ：A total of 120 patients who were admitted to the Affiliated Hospital of Panzhihua University from January 2018 to May 2020 and planned to undergo partial pneumonectomy under general anesthesia and one-lung ventilation were selected. According to random number table method ，they were divided into lidocaine aerosol inhalation group （group L ）and sterile water aerosol inhalation group （group N ），with 60 cases in each group. Two groups were given Midazolam injection 0.1 mg/kg+Propofol injectable emulsion 2.0 mg/kg+Sufentanil citrate injection 0.4 μg/kg to induce anesthesia. After the insertion of the double-lumen tracheal tube ，group L was given aerosol inhalation of Lidocaine hydrochloride injection 1.5 mg/kg diluted to 20 mL with sterile water ；group N was given aerosol inhalation of sterile water 20 mL at the flow rate of 2 L/min. Patients in both groups were continuously pumped with Propofol injectable emulsion 4-12 mg/（kg·h）+Remifentanil hydrochloride for injection 0.2-1 μg（/ kg·min）+Cisatracurium besilate for injection 0.05-0.1 mg/（kg·h）for anesthesia maintenance. Eight hours after operation ，group L inhaled of Lidocaine hydrochloride injection 1.5 mg/kg diluted to 20 mL with sterile water again ，and group N inhaled of sterile water 20 mL again. Arterial blood gas analysis indexes [arterial partial pressure of oxygen （PaO2），partial pressure of carbon dioxide （PaCO2），lactic acid （Lac），oxygenation index （P/F）]，serum inflammatory factors [interleukin 6 （IL-6），tumor necrosis factor α（TNF-α）and nuclear factor κB（NF-κB）] were observed in 2 groups before anesthesia（T1），60 min of one-lung ventilation （T2），and 12 h after extubation （T3）. Respiratory and circulatory parameters [extravascular lung water（EVLW），pulmonary vascular permeability index （PVPI），heart rate （HR），stroke volume （SV）] were also observed 5 min after anesthesia （t1），T2 and 15 min after surgery （t3）. Extubation time ，visual analogue scale （VAS） score of 12 h after extubation，time of getting out of bed ，the incidence of throat pain of 12 h after extubation and the occurrence of ADR were recorded in 2 groups. RESULTS ：There was no significant difference in arterial blood gas analysis indexes ，serum inflammatory factor levels ，respiratory and circulatory parameters between the two groups at T 1 or t 1（P＞0.05）. The levels of PaO 2，PaCO2， Lac，IL-6，TNF-α and NF-κB in 2 groups at T 2 and T 3 were significantly higher than at T 1，P/F at T 2 and T 3 was significantly lower than at T 1；in group L ，the levels of PaCO 2，Lac，IL-6，TNF-α，NF-κB were significantly lower than group N，and PaO 2 and P/F were significantly higher than group N （P＜0.05）. EVLW and PVPI of 2 groups at T 2and t 3，SV of group L ，HR of group N were significantly higher than corresponding group at T 1，while EVLW ，PVPI and HR of group L were significantly lower than group N，SV was significantly higher than group N at corresponding period （P＜0.05）. The extubation time ，VAS score of 12 h after extubation，time to get out of bed after surgery ，the incidence of throat pain of 12 h after extubation in group L were significantly shorter or lower than group N （P＜0.05）. No obvious and serious ADR occurred during recovery. CONCLUSIONS：Lidocaine aerosol inhalation can effectively improve ventilation and oxygenation function of patients undergoing one-lung ventilation ，inhibit the release of inflammatory factors ，and reduce the incidence of postoperative complications with good safety.

Effect of electroacupuncture at Neiguan (PC 6) on pulmonary function during one-lung ventilation in patients with lobectomy / 中国针灸

OBJECTIVE@#To observe the protective effect of electroacupuncture (EA) at Neiguan (PC 6) on pulmonary function during one-lung ventilation (OLV) in patients with lobectomy, and explore its action mechanism.@*METHODS@#Sixty patients with lobectomy were randomly divided into an observation group and a control group, 30 cases in each one. The patients in the control group were treated with general anesthesia, and OLV was given when surgery began; when the surgery finished, air was removed from the thoracic cavity and two-lung ventilation was performed. On the basis of the treatment in the control group, the patients in the observation group were treated with EA (disperse-dense wave, 2 Hz/100 Hz of frequency) at Neiguan (PC 6) 30 min before anesthesia induction until the end of the surgery. The pulmonary function indexes [arterial partial pressure of oxygen (PaO@*RESULTS@#Compared with T@*CONCLUSION@#EA at Neiguan (PC 6) has protective effects on lung injury induced by OLV after lobectomy, and its mechanism may be related to the improvement of oxidative stress and inflammatory response.

Inverse ratio ventilation combined with PEEP in infants undergoing thoracoscopic surgery with one lung ventilation for lung cystadenomas: a randomized control trial of 63 cases / 南方医科大学学报

OBJECTIVE@#To investigate the effect of inverse ratio ventilation (IRV) combined with positive end-expiratory pressure (PEEP) in infants undergoing thoracoscopic surgery with single lung ventilation (OLV) for lung cystadenomas.@*METHODS@#A total of 66 infants undergoing thoracoscopic surgery with OLV for lung cystadenomas in our hospital from February, 2018 to February, 2019 were randomized into conventional ventilation groups (group N, =33) and inverse ventilation group (group R, =33). Hemodynamics and respiratory parameters of the infants were recorded and arterial blood gas analysis was performed at 15 min after two lung ventilation (TLV) (T), OLV30 min (T), OLV60 min (T), and 15 min after recovery of TLV (T). Bronchoalveolar lavage fluid was collected before and after surgery to detect the expression level of advanced glycation end product receptor (RAGE).@*RESULTS@#Sixty-three infants were finally included in this study. At T and T, Cdyn, PaO and OI in group R were significantly higher ( < 0.05) and Ppeak, PaCO and PA-aO were significantly lower than those in group N ( < 0.05). There was no significant difference in HR or MAP between the two groups at T and T ( > 0.05). The level of RAGE significantly increased after the surgery in both groups ( < 0.05), and was significantly lower in R group than in N group ( < 0.05).@*CONCLUSIONS@#In infants undergoing thoracoscopic surgery with OLV for pulmonary cystadenoma, appropriate IRV combined with PEEP does not affect hemodynamic stability and can increases pulmonary compliance, reduce the peak pressure, and improve oxygenation to provide pulmonary protection.

Will ultrasound replace the stethoscope?: a case report on neonatal one-lung ventilation / O ultrassom substituirá o estetoscópio?: relato de caso sobre ventilação monopulmonar neonatal

Abstract Background and objectives: One-lung ventilation and selective intubation in neonates can be challenging due to intrinsic physiological specificities and material available. Ultrasound (US) is being increasingly used in many extents of anaesthesiology including confirmation of endotracheal tube position. Case report: We present a case report of a neonate proposed for pulmonary lobectomy by thoracoscopy in which lung exclusion was confirmed by ultrasound. Conclusion: US is a rapid, more sensitive and specific method than auscultation to evaluate tracheal intubation and lung exclusion.

Resumo Justificativa e objetivos: A ventilação monopulmonar e a intubação seletiva em recém-nascidos podem ser um desafio devido às especificidades fisiológicas intrínsecas e ao material disponível. O aparelho de ultrassom tem sido cada vez mais usado em muitas situações no campo da anestesia, incluindo a confirmação da posição do tubo endotraqueal. Relato de caso: Apresentamos o relato do caso de um recém-nascido proposto para lobectomia pulmonar por toracoscopia em que a exclusão pulmonar foi confirmada por ultrassom. Conclusão: O ultrassom é um método rápido, mais sensível e específico do que a ausculta para avaliar a intubação traqueal e a exclusão pulmonar.

Predictive value of plasma cytokines for acute kidney injury following lung resection surgery: prospective observational study / Valor preditivo das citocinas plasmáticas para lesão renal aguda após cirurgia de ressecção pulmonar: estudo observacional prospectivo

Abstract Background and objectives: Patients undergoing lung resection surgery are at risk of developing postoperative acute kidney injury. Determination of cytokine levels allows the detection of an early inflammatory response. We investigated any temporal relationship among perioperative inflammatory status and development of acute kidney injury after lung resection surgery. Furthermore, we evaluated the impact of acute kidney injury on outcome and analyzed the feasibility of cytokines to predict acute kidney injury. Methods: We prospectively analyzed 174 patients scheduled for elective lung resection surgery with intra-operative periods of one-lung ventilation periods. Fiberoptic broncho-alveolar lavage was performed in each lung before and after one-lung ventilation periods for cytokine analysis. As well, cytokine levels were measured from arterial blood samples at five time points. acute kidney injury was diagnosed within 48 h of surgery based on acute kidney injury criteria. We analyzed the association between acute kidney injury and cardiopulmonary complications, length of intensive care unit and hospital stays, intensive care unit re-admission, and short-term and long-term mortality. Results: The incidence of acute kidney injury in our study was 6.9% (12/174). Acute kidney injury patients showed higher plasma cytokine levels after surgery but differences in alveolar cytokines were not detected. Although no patient required renal replacement therapy, acute kidney injury patients had higher incidence of cardiopulmonary complications and increased overall mortality. Plasma interleukin-6 at 6 h was the most predictive cytokine of acute kidney injury (cut-off point at 4.89 pg.mL-1). Conclusions: Increased postoperative plasma cytokine levels are associated with acute kidney injury after lung resection surgery in our study, which worsens the prognosis. Plasma interleukin-6 may be used as an early indicator for patients at risk of developing acute kidney injury after lung resection surgery.

Resumo Justificativa e objetivos: Os pacientes submetidos à cirurgia de ressecção pulmonar apresentam risco de desenvolver lesão renal aguda pós-operatória. A determinação dos níveis de citocinas permite detectar uma resposta inflamatória precoce. Investigamos a relação temporal entre o estado inflamatório perioperatório e o desenvolvimento de lesão renal aguda após cirurgia de ressecção pulmonar. Além disso, avaliamos o impacto da lesão renal aguda no desfecho e analisamos a viabilidade das citocinas para prever este tipo de lesão. Métodos: No total, foram analisados prospectivamente 174 pacientes agendados para cirurgia eletiva de ressecção pulmonar com períodos intraoperatórios de ventilação monopulmonar. Lavado bronco-alveolar com fibra óptica foi realizado em cada pulmão antes e após os períodos de ventilação monopulmonar para análise das citocinas. Os níveis de citocina foram medidos a partir de amostras de sangue arterial em cinco momentos. A lesão renal aguda foi diagnosticada dentro de 48 horas após a cirurgia, com base nos critérios para sua verificação. Analisamos a associação entre lesão renal aguda e complicações cardiopulmonares, tempo de internação em unidade de terapia intensiva e de internação hospitalar, reinternação em unidade de terapia intensiva e mortalidade a curto e longo prazos. Resultados: A incidência de lesão renal aguda no estudo foi de 6,9% (12/174). Os pacientes com lesão renal aguda apresentaram níveis mais altos de citocinas plasmáticas após a cirurgia, mas não foram detectadas diferenças nas citocinas alveolares. Embora nenhum paciente tenha precisado de terapia renal substitutiva, os com lesão renal aguda apresentaram maior incidência de complicações cardiopulmonares e aumento da mortalidade geral. A interleucina-6 plasmática em seis horas foi a citocina mais preditiva de lesão renal aguda (ponto de corte em 4,89 pg.mL-1). Conclusões: O aumento dos níveis plasmáticos de citocinas no pós-operatório está associado à lesão renal aguda após cirurgia de ressecção pulmonar no estudo, o que piora o prognóstico. A interleucina-6 plasmática pode ser usada como um indicador precoce para pacientes com risco de desenvolver lesão renal aguda após cirurgia de ressecção pulmonar.

The feasibility study of stroke volume variability for evaluating ventilation-volume of one lung ventilation in patients with elderly coronary heart disease / 中华老年医学杂志

Objective To observe the relationship between Flo Trac/Vigileo monitor-assessed stroke volume variability(SVV) and changes in ventilation volume during one lung ventilation(OLV),and to evaluate the feasibility of SVV reflecting changes in lung ventilation volume during OLV in patients with elderly coronary heart disease.Methods A total of 40 patients with ASA grade Ⅱ or Ⅲ,aged 60-82 years,undergoing elective thoracoscopic surgery were enrolled in this study.A doublelumen endobronchial tube was inserted,and 6％ hydroxyethyl starch(HES 130/0.4)was infused intravenously for five dosage-infusion-stage of(T0)2 ml/kg,(T1)4 ml/kg,(T2)6 ml/kg,(T3)8 ml/kg,(T4)10 ml/kg.And the infusion was suspended until starting next infusion stage.After the data reached the stability,the mean arterial pressure(MAP),heart rate(HR),central venous pressure (CVP),cardiac output(CO)and SVV were recorded.The test was stopped after stage of(T4)10 ml/kg.Then,we observed and analyzed the changes of MAP,HR,CVP,CO and SVV at different time points.Results The statistically significant difference was not found in MAP(F =2.089,P =0.130),but was definitely found in SVV,HR,CO and CVP between five different time points(F =23.380,15.205,14.990,4.726,P=0.000,0.060,0.000 and 0.001,respectively).SVV(％) was 12.6 ± 1.8 at T0,10.7 ± 1.7 at T1,9.7 ± 1.3 at T2,8.6 ± 1.2 at T3,7.8 ± 1.2 at T4,with a gradually decreased trend(P =0.000,0.000,0.042,0.033,between any two adjacent time points,respectively).While CVP had no significant difference between any two adjacent time points (P =0.093,0.161,0.261 and 0.051,respectively).HR was lower in T1 vs.in T0,and in T2 vs.in T1 (P =0.015 and 0.028,respectively).There was no significant difference in HR between the other time points (P =0.149 and 0.335,respectively).The CO was higher at T4 than at T3(P =0.005),and there was no significant difference among any other time points(T0 vs.T1,T1 vs.T2,T2 vs.T3,P =0.547,0.441 and 0.400,respectively).In Spearman correlation analysis,the amount of HES infusion was positively correlated with MAP(r =0.921,P =0.021),negatively correlated with SVV and HR(r =-0.988,-0.984,P=0.001,0.002,respectively),and not correlated with CVP and CO(r =0.872 and 0.871,P =0.054 and 0.055,respectively).Conclusions SVV can effectively evaluate the volume responsiveness in elderly CHD patients with OLV.

Development of alveolar-pleural fistula during hepatectomy: A case report

BACKGROUND: An Alveolar-pleural fistula is communication between the alveoli and the pleural space that may result in intractable pneumothorax, severe infection, respiratory failure, physical weakness, and even death.CASE: A 70-year-old male underwent right hepatectomy with a cystic mass of the liver. During the operation, peak airway pressure abruptly increased and a serous fluid was regurgitated through the endotracheal tube. Lung isolation was immediately performed with a double-lumen endotracheal tube. Approximately 1,000 ml of exudate was drained through endotracheal tube. Thoracostomy was performed at right lung. Analysis of fluid from endotracheal tube and pleural effusion consistent with parapneumonic effusion.CONCLUSIONS: We presented a case of alveolar-pleural fistula caused by pneumonia presenting with massive exudate fluid regurgitated from the endotracheal tube that was managed with bronchial suction, lung isolation, and thoracostomy and improved without surgical repair of the fistula.

The change of stroke volume variation during thoracotomy or one lung ventilation

BACKGROUND: Stroke volume variation (SVV) is based on cyclic changes of intrathoracic pressure during respiratory cycle. Thoracotomy and one-lung ventilation (OLV) can lead to changes in airway and intrathoracic pressure. The aim of this study was to determine whether thoracotomy and converting from two lung ventilation to OLV could affect SVV values. METHODS: Thirty patients who were scheduled for pulmonary lobectomy or pneumonectomy requiring OLV were enrolled. Induction and maintenance of anesthesia were performed with propofol and remifentanil via total intravenous anesthesia. Hemodynamic variables including mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), and SVV were measured at intervals of 1 min for 10 min after thoracotomy and OLV, respectively. RESULTS: MAP and HR increased from baseline at intervals between 3 and 10 min and between 4 and 10 min after thoracotomy, respectively (P < 0.001). CI increased between 4 and 10 min (P < 0.001). SVV did not change for 10 min after thoracotomy. After OLV, MAP decreased between 4 and 10 min (P = 0.112). SVV was the highest at 1 min after OLV. It returned to the baseline value at 7 min (P < 0.001). CI decreased between 8 and 10 min after OLV (P < 0.001). CONCLUSIONS: SVV can increase after OLV temporarily. Transient increase of SVV may be considered when fluid responsiveness is predicted by SVV during early period after OLV.

Comparison of displacement of polyvinyl chloride and silicone left-sided double-lumen tubes during lateral positioning / 대한마취과학회지

BACKGROUND: Compared to an equivalent sized polyvinyl chloride (PVC) double-lumen tube (DLT), a silicone DLT has a shorter endobronchial segment. The aim of this study was to compare the incidence of clinically significant displacement of left-sided PVC and silicone DLTs after a positional change to a lateral position from a supine position and determine its effect on the need for DLT repositioning for successful lung separation in patients undergoing thoracic surgery. METHODS: One hundred eight adult patients requiring one-lung ventilation were randomly divided into group P (PVC DLT, n = 54) and group S (Silicone DLT, n = 54). The position of the DLT was observed before and after lateral positioning to assess the effect of the position change. The incidence of clinically significant displacement (>10 mm) of DLT was compared between the groups. RESULTS: DLTs were clinically significantly displaced in group P (17/48, 35.4%) and group S (18/52, 34.6%) after lateral positioning (p = 0.933). A proximal displacement (31.3% [group P] and 25.0% [group S]) was more common than distal displacement (4.2% [group P] and 9.6% [group S]), with no significant intergroup difference (p = 0.494). After lateral positioning, critical malposition of DLT with bronchial herniation to the right main bronchus was 8.3% (group P) and 7.9% (group S, p = 0.906). CONCLUSION: Left-sided PVC and silicone DLTs produced comparable incidences of clinically significant displacement and, consequently, required similar rates of repositioning for successful lung separation after lateral positioning.

Anesthetic Experience of Unexpected Change to One-Lung Ventilation with Bronchial Blocker

One-lung ventilation is an anesthesiological technique to accomplish surgical visualization during thoracic surgical procedures, and is often required unexpectedly during surgery. Traditionally the double lumen tube is considered the gold standard for lung separation. Despite being equally feasible for standard situations, there are special populations and circumstances requiring the use of a bronchial blocker to establish one-lung ventilation. We have experienced unexpected change to one-lung ventilation with bronchial blocker. A 40-year-old (158 cm, 48 kg) woman was scheduled for emergency exploratory laparotomy due to panperitonitis. A sudden diaphragmatic perforation occurred during the operation. Since oxygen saturation was reduced, intraoperative tube change was not available. Therefore, one-lung ventilation was done with bronchial blockers. After the bronchial blocker was placed, one-lung ventilation was well maintained and the operation was terminated successfully.