Momento da extubação e evolução pós-operatória de toracotomia / Time of extubation and postoperative outcome after thoracotomy

OBJETIVO: A extubação traqueal precoce após cirurgias favorece a evolução dos pacientes e reduz o tempo de internação em Unidade de Terapia Intensiva (UTI), reduzindo custos hospitalares. Em cirurgias de ressecção pulmonar, tradicionalmente o pós-operatório imediato é realizado em UTI com pacientes entubados. Nesse estudo avaliou-se prontuários de pacientes submetidos a toracotomia e estabeleceu-se correlação entre o momento da extubação, a evolução pós-operatória e a internação em UTI. MÉTODOS: Estudo tipo coorte retrospectivo de prontuários de 121 pacientes submetidos a cirurgias de ressecção pulmonar. Foram relacionados o tempo de internação em UTI e o momento da extubação traqueal. A evolução pós-operatória foi classificada em boa ou ruim de acordo com a ausência ou a presença de: infecções, problemas respiratórios (reintubação, broncospasmo, edema agudo de pulmão, necessidade de traqueostomia, atelectasias, fístulas), reabordagem por sangramento, óbito. Entre os grupos foram analisadas as condições pré-operatórias, classificação de estado físico anestésico (critério da American Society of Anesthesyologists - ASA), presença de comorbidades, avaliação funcional respiratória e duração do procedimento cirúrgico. Utilizou-se o risco relativo para avaliar o efeito do tempo de extubação na evolução pós-operatória dos pacientes. RESULTADOS: A distribuição dos pacientes quanto ao tempo de extubação foi: 81 por cento extubações imediatas, 15 por cento não imediatas e 4 por cento não-extubados. Em relação ao destino, 73 por cento foram encaminhados à UTI e 27 por cento à sala de recuperação anestésica. A incidência de comorbidades (hipertensão arterial, diabetes melito, distúrbio ventilatório restritivo ou obstrutivo e cardiopatias) entre o grupo extubado imediatamente e aquele com extubação não imediata foi de 37 por cento e 41,6 por cento, respectivamente. Quanto ao estado físico (ASA), observou-se: pacientes ASA 1 ou 2 - 62 por cento no ...

OBJECTIVE: Early tracheal extubation following surgical procedures favors clinical evolution of patients and reduces incidence and time of stay in the Intensive Care Unit (ICU), minimizing hospital costs. Immediate postoperative period of pulmonary resections often takes place in the ICU and patients are kept intubated. This study evaluated hospital records of patients submitted to thoracotomy and a correlation between extubation time, postoperative evolution and ICU stay was established. METHODS: Retrospective cohort study of records of 121 patients submitted to pulmonary parenchyma resection (not biopsies) was carried out. Stay in the ICU and time of tracheal extubation were related. Postoperative evolution was classified as good or bad according to occurrence of some of the following conditions: infections, respiratory disorders (reintubation, bronchospasm, acute pulmonary edema, need of tracheotomy, atelectasis, fistulae), re-operation due to bleeding and death. Among the two groups preoperative conditions, anesthetic physical status (American Society of Anesthesyologists - ASA criteria), presence of associated diseases, respiratory functional evaluation and duration of surgery were analyzed. Relative risk was used to evaluate effect of time of extubation (immediate or non-immediate) on the postoperative evolution of patients. RESULTS: Patient distribution related to extubation time was: 81 percent immediate extubation, 15 percent non-immediate extubation and 4 percent not extubated. Destination after surgery was: 73 percent ICU and 27 percent post-anesthetic recovery room. Incidence of associated diseases (arterial hypertension, diabetes, obstructive or restrictive pulmonary disease and cardiopaty) among the immediately extubated group and non-immediately extubated group was 37 percent and 41.6 percent, respectively. Related to ASA physical status: 62 percent ASA 1 or 2 in the immediately extubated group and 58.3 percent ASA 1 or ...

Video-assisted thoracoscopic surgery (VATS) combined with auxiliary mini-incision for the treatment of 54 patients with thoracic injury / 中国微创外科杂志

Objective To explore the possibility of expending indications of VATS though auxiliary mini-incision. Methods 54 patients with thoracic injury underwent pulmonary lobectomy or pulmonary wedge resection or pulmonary rupture repair or diaphragm rupture repair using VATS combined with auxiliary mini-incition. Results All of 54 patients were cured. with primary wound healing .Hospital stay was 8d~10d with a mean of 10d.. No complication occurred. Conclusions VATS combined with auxiliary mini-incision could provide a possibility of simultaneous diagnosis and treatment and obtains as the same therapeutic result as conventional open surgery and expends indication of VATS.

Role of Fiberoptic Bronchoscopy in Conjunction with the Use of a Single Lumen Tube with Bronchial Blocker for Thoracic Anesthesia / 대한마취과학회지

BACKGROUND: Fiberoptic bronchoscopy has been recommended to verify the position of single lumen tubes with bronchial blockers (Univent(R) tube), but this remains controversial. The authors studied the role of a bronchoscopy for placing and monitoring bronchial blockers (BB) after blind intubation and after positioning the patient. METHODS: One hundred patients having thoracic surgery requiring a Univent tube insertion were prospectively studied. After "blind" tracheal intubations with Univent tubes, BB were advanced in the left-side mainstem bronchus for 60 patients and the right-side for 40 patients. A bronchoscopy was performed after conventional clinical verification of correct placement and after patient positioning for a thoracotomy. A BB was considered malpositioned when it had to be moved < 0.5 cm to correct its position. RESULTS: After "blind" BB intubation, clinical evidence of malpositioning was found in 5 patients. This was confirmed by fiberoptic assessment. In 95 patients in whom placement was judged correct by clinical assessment, malpositioning was detected by bronchoscopy in 39 cases. After patient positioning, BB were found to be displaced in 29 patients. Right-side BB were significantly more likely to be malpositioned than were left-side BB. CONCLUSIONS: After blind intubation and patient positioning, more than one third of BB required repositioning. A routine bronchoscopy is therefore recommended after intubation and after patient positioning.

A Comparison of Epidural Fentanyl-Bupivacaine and Intravenous Morphine Using Patient-Controlled Analgesia after Thoracic Surgery / 대한마취과학회지

BACKGROUND: Epidural and intravenous (IV) administration of opioids are commonly used for postoperative pain management. However, studies that compare the epidural and IV routes of opiate administration show conflicting results. The purpose of this study was to determine the superior route of analgesics by comparing the effect of epidural fentanyl-bupivacaine with IV morphine using patient-controlled analgesia (PCA) system in the management of posterior thoracic surgery pain. METHODS: Sixty patients undergoing elective thoracic surgery were randomly assigned to receive either Epiural-PCA (Epi-PCA, n=30) or IV-PCA (n=30) when postoperative pain first increased to 40/100 mm (by visual analogue scale; VAS). Epi-PCA group received epidural bolus of 0.1% bupivacaine 10 ml containing fentanyl 100 microgram and then followed by Epi-PCA with 0.1% bupivacaine 100 ml containing fentanyl 800 microgram (basal infusion 2 ml/hr, PCA dose 1 ml, lock-out interval 30 min), IV-PCA group received repeated IV boluses of 3 mg of morphine until postoperative pain decreased to 40/100 mm and then followed by a IV-PCA with morphine (basal infusion 0.005 mg/kg/hr, PCA dose 0.02 mg/kg, lock-out interval 8 min). Analgesic efficacy, degree of patient satisfaction and pain, analgesics consumptions, forced vital capacity (FVC), forced expired volume in one second (FEV1) and side effects were evaluated. RESULTS: There were no significant differences in analgesic efficacy and degree of patient satisfaction and pain in both group. But the PHS were significantly lower (p<.05), and FEV1 higher (p<.05) in Epi-PCA group, signifying better analgesia during movement (cough and deep breaths). CONCLUSIONS: We concluded that an epidural PCA with mixture of fentanyl and bupivacaine administration is superior to that of intravenous PCA with morphine in the management of pain after thoracic surgery.

The Neuroprotective Effect and Inflammatory Gene Expression of Hypothermia and Lamotrigine in Transient Spinal Ischemia in the Rat / 대한마취과학회지

BACKGROUND: Although rare, paralysis secondary to spinal cord ischemia after aortic aneurysm surgery is a devastating complication. Many papers have been published on this topic but without a clear consensus on the best way of minimizing the problem. Mild hypothermia and lamotrigine have been neuroprotective in several models of cerebral ischemia. In this study we compared the effects of mild hypothermia and the lamotrigine on neurologic and histopathologic outcomes, and inflammatory gene expression in transient spinal ischemia. METHODS: Rats were anesthetized with halothane, and divided into 4 groups; the Sham-operated (S) group; the Normothermic ischemic (N) group; the Hypothermic ischemic (H) group; and the Lamotrigine- treated (L) group. Spinal ischemia was produced by induced hypotension and thoracic aortic cross clamping. After spinal ischemia neurologic scores were assessed at 1, 2, 3, 24, and 48 hours after reperfusion. After 48 hours the rats were euthanized and their spinal cords were removed for histopathologic assessment. Also, spinal cords were removed at 1, 3, and 48 hours after reperfusion for the assay of TNF-alpha, IL-1 mRNA. RESULTS: The neurologic scores of the H group were significantly lower than from the N group. There was no significant difference between the L group and the N group. The histopathologic scores in the H and L groups were significantly lower than in the N group, and the histopathologic scores of the L group were higher than those of the H group. The TNF-alpha and IL-1 gene expression was increased in the N group. In the H group, the gene expression was significantly less than in the N group. The L group was not significantly different than N group in gene expression. CONCLUSIONS: The inflammatory gene expressions were increased in transient spinal ischemia. Hypothermia was neuroprotective in transient spinal ischemia. However, the lamotrigine showed only partial neuroprotective effects in transient spinal ischemia.

Airway Obstruction Immediately after Endotracheal Intubation for Removal of Cervico-Mediastinal Cystic Hygroma: A case report / 대한마취과학회지

Abrupt increase in the size of cervico-mediastinal tumor due to infection or spontaneous hemorrhage into cyst can induce severe tracheal compression and therefore sudden death. A 5 year old boy, who had a history of URI, had an enlarging cystic hygroma on the right side of the neck and anterior mediastinum. Under diagnosis of the cervico-mediastinal cystic hygroma, surgical removal was scheduled. After induction of anesthesia, intubation was done without any difficulty. A few minutes later, signs of partial airway obstruction were appeared. And within a very short period, total airway occlusion occurred. The tracheal tube was removed and manual ventilation was performed with positive airway pressure, but ineffective. We attempted to puncture cricothyroid membrane with 14 Gauge needle in order to ventilate manually. As soon as we puncture cricothyroid membrane, straw-colored fluid, not air, gushed out through a needle. After aspiration of about 200ml of cystic fluid, the obstructive signs disappeared and the patency of the airway was maintained. Intraoperatively, no more airway problems occured and vital signs were stable. And postoperatively, patient had no specific complications and discharged on the 7th day after operation.

Anesthetic Management for Repair of Delayed Presentation of Congenital Diaphragmatic Hernia: A case report / 대한마취과학회지

Congenital diaphragmatic hernia (CDH) associated with pulmonary hypoplasia usually presents in early neonatal life. Despite recent advances in perioperative intensive care and neonatal pharmacology, there is still a 53-62% mortality rate. CDH presenting outside of the neonatal period is called CDH delayed presentation, and it is uncommon and the diagnosis is difficult due to misleading clinical signs and symptoms. The prognosis in delayed presentation is determined by complications as strangulation or incarceration of the herniated bowel or stomach, mediastinal shift. A 3 month-old male infant was visited to pediatric department because of irritability. Breath sound were decreased over the left hemithorax and blood gas examination showed hypoxemia. Plain chest X-rays demonstrated intestinal bowel gas shadow in the left hemithorax and had done revealed CDH. An immediate operation was performed. The post-operative course was uneventful and the postoperative chest X-ray returned to normal. She was discharged on the 8th post-opertive day.