Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery?

Thanks to the experience gained through the improvement of video-assisted thoracoscopic surgery (VATS) technique, and the enhancement of surgical instruments and high-definition cameras, most pulmonary resections can now be performed by minimally invasive surgery. The future of the thoracic surgery should be associated with a combination of surgical and anaesthetic evolution and improvements to reduce the trauma to the patient. Traditionally, intubated general anaesthesia with one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections. However, thanks to the advances in minimally invasive techniques, the non-intubated thoracoscopic approach has been adapted even for use with major lung resections. An adequate analgesia obtained from regional anaesthesia techniques allows VATS to be performed in sedated patients and the potential adverse effects related to general anaesthesia and selective ventilation can be avoided. The non-intubated procedures try to minimize the adverse effects of tracheal intubation and general anaesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and postoperative nausea and vomiting. Anaesthesiologists should be acquainted with the procedure to be performed. Furthermore, patients may also benefit from the efficient contraction of the dependent hemidiaphragm and preserved hypoxic pulmonary vasoconstriction during surgically induced pneumothorax in spontaneous ventilation. However, the surgical team must be aware of the potential problems and have the judgement to convert regional anaesthesia to intubated general anaesthesia in enforced circumstances. The non-intubated anaesthesia combined with the uniportal approach represents another step forward in the minimally invasive strategies of treatment, and can be reliably offered in the near future to an increasing number of patients. Therefore, educating and training programmes in VATS with non-intubated patients may be needed. Surgical techniques and various regional anaesthesia techniques as well as indications, contraindications, criteria to conversion of sedation to general anaesthesia in non-intubated patients are reviewed and discussed.

Uniportal video-assisted thoracoscopic left upper lobectomy under spontaneous ventilation.

Intubated general anesthesia with one-lung ventilation was traditionally considered necessary for thoracoscopic major pulmonary resections. However, non-intubated thoracoscopic lobectomy can be performed by using conventional and uniportal video-assisted thoracoscopic surgery (VATS). These non-intubated procedures try to minimize the adverse effects of tracheal intubation and general anesthesia but these procedures must only be performed by experienced anesthesiologists and skilled thoracoscopic surgeons. Here we present a video of a uniportal VATS left upper lobectomy in a non-intubated patient, maintaining the spontaneous ventilation.

[Off-pump coronary artery bypass grafting and other minimally invasive techniques]. / Cirugía coronaria sin circulación extracorpórea y otras técnicas mínimamente invasivas.

Although coronary surgery was first carried out without the use of extracorporeal circulation more than 40 years ago, it was not until the second half of the 1990s and thanks to an important technological development that it became a standardized reproducible technique. There is significant terminological confusion between the different forms of so-called minimally invasive technique. There are even important technical variations in off-pump coronary surgery involving median sternotomy. The present article reviews the reasons for this renaissance, the terminology used, current progress, key technical requirements, and new developments in anesthesia and postoperative management. Our approach to the technique has resulted in us carrying out full arterial revascularization in the beating heart using both internal mammary arteries. Part of this article is devoted to the specific technical details of this form of revascularization and to the results obtained in our first 1000 patients. Finally, we comment on the scientific evidence concerning coronary surgery without extracorporeal circulation that was reviewed at the ISMICS Consensus Conference in Paris in 2004: in expert hands, coronary surgery without extracorporeal circulation is just as safe and effective as conventional surgery, reduces some forms of morbidity, and, according to nonrandomized but adjusted studies, decreases mortality in high-risk patients.

Cirugía coronaria sin circulación extracorpórea y otras técnicas mínimamente invasivas / Off-pump coronary artery bypass grafting and other minimally invasive techniques

Aunque la cirugía coronaria sin el uso de circulación extracorpórea (CEC) se realizó por primera vez hace más de 40 años, no ha sido hasta la segunda mitad de la década de los noventa y merced a un importante desarrollo tecnológico cuando se ha convertido en una técnica estandarizada y reproducible. A pesar de todo, hay una importante confusión terminológica entre las diferentes variantes de las llamadas «técnicas mínimamente invasivas». Hay incluso importantes diferencias técnicas en la cirugía coronaria sin CEC por esternotomía media. En el presente artículo se analizan las razones para su resurgimiento, la terminología, su evolución, las nuevas posibilidades de manejo anestésico y postoperatorio y los requerimientos técnicos clave. Nuestra concepción del problema nos ha llevado a la revascularización arterial completa con ambas arterias mamarias internas sin CEC. A sus particulares aspectos técnicos y a nuestros resultados con los 1.000 primeros pacientes se dedican apartados del artículo. Finalmente, se comentan las evidencias científicas sobre sus resultados analizadas en la Conferencia de Consenso de París ISMICS-2004: la cirugía coronaria sin CEC, en manos expertas, es igual de segura y efectiva que la convencional, reduce algunos aspectos de la morbilidad y, en estudios no aleatorizados pero sí ajustados, la mortalidad en pacientes de alto riesgo

Although coronary surgery was first carried out without the use of extracorporeal circulation more than 40 years ago, it was not until the second half of the 1990s and thanks to an important technological development that it became a standardized reproducible technique. There is significant terminological confusion between the different forms of so-called minimally invasive technique. There are even important technical variations in off-pump coronary surgery involving median sternotomy. The present article reviews the reasons for this renaissance, the terminology used, current progress, key technical requirements, and new developments in anesthesia and postoperative management. Our approach to the technique has resulted in us carrying out full arterial revascularization in the beating heart using both internal mammary arteries. Part of this article is devoted to the specific technical details of this form of revascularization and to the results obtained in our first 1000 patients. Finally, we comment on the scientific evidence concerning coronary surgery without extracorporeal circulation that was reviewed at the ISMICS Consensus Conference in Paris in 2004: in expert hands, coronary surgery without extracorporeal circulation is just as safe and effective as conventional surgery, reduces some forms of morbidity, and, according to nonrandomized but adjusted studies, decreases mortality in high-risk patients

Remifentanil versus fentanyl for analgesia based sedation to provide patient comfort in the intensive care unit: a randomized, double-blind controlled trial [ISRCTN43755713].

INTRODUCTION: This double-blind, randomized, multicentre study was conducted to compare the efficacy and safety of remifentanil and fentanyl for intensive care unit (ICU) sedation and analgesia. METHODS: Intubated cardiac, general postsurgical or medical patients (aged >/= 18 years), who were mechanically ventilated for 12-72 hours, received remifentanil (9 microgram/kg per hour; n = 77) or fentanyl (1.5 microgram/kg per hour; n = 75). Initial opioid titration was supplemented with propofol (0.5 mg/kg per hour), if required, to achieve optimal sedation (i.e. a Sedation-Agitation Scale score of 4). RESULTS: The mean percentages of time in optimal sedation were 88.3% for remifentanil and 89.3% for fentanyl (not significant). Patients with a Sedation-Agitation Scale score of 4 exhibited significantly less between-patient variability in optimal sedation on remifentanil (variance ratio of fentanyl to remifentanil 1.84; P = 0.009). Of patients who received fentanyl 40% required propofol, as compared with 35% of those who received remifentanil (median total doses 683 mg and 378 mg, respectively; P = 0.065). Recovery was rapid (median time to extubation: 1.1 hours for remifentanil and 1.3 hours for fentanyl; not significant). Remifentanil patients who experienced pain did so for significantly longer during extubation (6.5% of the time versus 1.4%; P = 0.013), postextubation (10.2% versus 3.6%; P = 0.001) and post-treatment (13.5% versus 5.1%; P = 0.001), but they exhibited similar haemodynamic stability with no significant differences in adverse event incidence. CONCLUSION: Analgesia based sedation with remifentanil titrated to response provided effective sedation and rapid extubation without the need for propofol in most patients. Fentanyl was similar, probably because the dosing algorithm demanded frequent monitoring and adjustment, thereby preventing over-sedation. Rapid offset of analgesia with remifentanil resulted in a greater incidence of pain, highlighting the need for proactive pain management when transitioning to longer acting analgesics, which is difficult within a double-blind study but would be quite possible under normal circumstances.