Intraoperative Glycemic Variability and Mean Glucose are Predictors for Postoperative Delirium After Cardiac Surgery: A Retrospective Cohort Study.

PURPOSE: Postoperative delirium (POD) is a common but serious complication after cardiac surgery and is associated with various short- and long-term outcomes. In this study, we investigated the effects of intraoperative glycemic variability (GV) and other glycemic variables on POD after cardiac surgery. PATIENTS AND METHODS: A retrospective single-center cohort analysis was conducted using data from electronic medical record from 2018 to 2020. A total of 705 patients undergoing coronary artery bypass graft surgery and/or valve surgery, and/or aortic replacement surgery were included in the analysis. Intraoperative GV was assessed with a coefficient of variation (CV), which was defined as the standard deviation of five intraoperative blood glucose measurements divided by the mean. POD assessment was performed three times a day in the ICU and twice a day in the ward until discharge by trained medical staff. POD was diagnosed if any of the Confusion Assessment Method for the Intensive Care Unit was positive in the ICU, and the Confusion Assessment Method was positive in the ward. Multivariable logistic regression was used to identify associations between intraoperative GV and POD. RESULTS: POD occurred in 306 (43.4%) patients. When intraoperative glycemic CV was compared as a continuous variable, the delirium group had higher intraoperative glycemic CV than the non-delirium group (22.59 [17.09, 29.68] vs 18.19 [13.00, 23.35], p < 0.001), and when intraoperative glycemic CV was classified as quartiles, the incidence of POD increased as intraoperative glycemic CV quartiles increased (first quartile 29.89%; second quartile 36.67%; third quartile 44.63%; and fourth quartile 62.64%, p < 0.001). In the multivariable logistic regression model, patients in the third quartile of intraoperative glycemic CV were 1.833 times (OR 1.833, 95% CI: 1.132-2.967, p = 0.014), and patients in the fourth quartile of intraoperative glycemic CV were 3.645 times (OR 3.645, 95% CI: 2.235-5.944, p < 0.001) more likely to develop POD than those in the first quartile of intraoperative glycemic CV. CONCLUSION: Intraoperative blood glucose fluctuation, manifested by intraoperative GV, is associated with POD after cardiac surgery. Patients with a higher intraoperative GV have an increased risk of POD.

Comparison of early postoperative cytokine changes in patients undergoing intubated and non-intubated thoracic surgery: a randomized controlled trial.

OBJECTIVES: The inflammatory response after surgery is associated with patient prognosis. Patients who undergo thoracic surgery exhibit a profound systemic inflammatory response due to the surgical procedures used and application of one-lung ventilation. The aim of this study was to compare perioperative inflammatory changes in patients after intubated and non-intubated thoracic surgery for primary lung cancer resection. METHODS: This prospective randomized controlled study included forty patients who underwent surgical resection for stage I non-small-cell lung cancer. Blood samples for cytokine analysis were collected just before induction, at 1 and 24 h after surgery. Levels of the pro-inflammatory cytokine and anti-inflammatory cytokines were measured using quantitative sandwich enzyme immunoassay kits. RESULTS: The basal values of cytokines were comparable between 2 groups. Within each group, the postoperative levels of interleukin (IL)-1, IL-6 and tumour necrosis factor-α increased, while those of IL-4 and IL-10 did not change significantly. The levels of IL-6 and tumour necrosis factor-α were significantly lower in group NI at 1 and 24 h postoperatively. Other cytokines did not differ in both groups during postoperative period. The IL-6/IL-10 ratio at 1 h after surgery was lower in non-intubated patients than in intubated patients, but there was no difference at 24 h after surgery. CONCLUSIONS: Non-intubated thoracic surgery may attenuate the early inflammatory cytokine changes following major resection for primary lung cancer compared with intubated conventional surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov registry number NCT04007354.

The Effects of Iloprost on Oxygenation During One-Lung Ventilation for Lung Surgery: A Randomized Controlled Trial.

Hypoxemia can occur during one-lung ventilation (OLV) in thoracic surgery, leading to perioperative complications. Inhaled iloprost is a selective pulmonary vasodilator with efficacy in patients with pulmonary hypertension. The purpose of this study was to evaluate the effects of off-label inhaled iloprost on oxygenation during OLV in patients undergoing lung surgery. Seventy-two patients who were scheduled for elective video-assisted thoracoscopic lobectomy were assigned to receive an inhaled nebulizer of distilled water (control group), 10 µg iloprost (IL10 group), or 20 µg iloprost (IL20 group). Arterial and venous blood gas and hemodynamic analyses were obtained. Changes in partial pressure of oxygen in arterial blood (PaO2), after the initiation of OLV and the resumption two-lung ventilation (TLV), were similar in all three groups. However, PaO2 in the IL10 group was comparable to that in the control group, whereas PaO2 in the IL20 group was significantly higher than that in the control group at 10, 20, and 30 min after administration of iloprost (275.1 ± 50.8 vs. 179.3 ± 38.9, p < 0.0001; 233.9 ± 39.7 vs. 155.1 ± 26.5, p < 0.0001; and 224.6 ± 36.4 vs. 144.0 ± 22.9, p < 0.0001, respectively). The shunt fraction in the IL20 group was significantly higher than that in the control group after administration of iloprost (26.8 ± 3.1 vs. 32.2 ± 3.4, p < 0.0001; 24.6 ± 2.2 vs. 29.9 ± 3.4, p < 0.0001; and 25.3 ± 2.0 vs. 30.8 ± 3.1, p < 0.0001, respectively). Administration of inhaled iloprost during OLV improves oxygenation and decreases intrapulmonary shunt.

Non-intubated thoracoscopic surgery: initial experience at a single center.

BACKGROUND: Non-intubated thoracoscopic surgery is an evolving form of minimally-invasive thoracic surgery. We commenced performing non-intubated thoracoscopic surgery at our center in August 2016. We would like to report our initial experience, over a period of 1 year, with this procedure. METHODS: From August 2016 to August 2017, non-intubated thoracoscopic surgery was performed in a series of consecutive patients who underwent thoracoscopic surgery in those who did not meet any of the following exclusion criteria: body mass index (BMI) >30, expected difficult airway, expected extensive pleural adhesion, severe cardiopulmonary dysfunction, persistent cough or excessive airway secretion, high risk of gastric reflux, and underlying neurological disorder. RESULTS: A total of 115 consecutive patients underwent non-intubated thoracoscopic surgery. Of these, 83 (72.2%) of patients had lung cancers that had undergone pulmonary resection and the other 32 (27.8%) patients were diagnosed with pulmonary metastasis, benign lung diseases, thymic tumor or other conditions. The mean time of anesthesia was 172.4 min and time of operation was 130 min. The mean postoperative chest tube duration was 3.9 days and time of hospital stay was 6.0 days. There were 9 conversions (7.8%) to intubation, due to increased respiratory movement with intraoperative hypoxemia or severe pleural adhesion. There were 16 complications (13.9%) following surgery, but all of these were successfully managed during the period of hospital stay. There was no postoperative mortality. In multivariate analysis, old age and high BMI were significant risk factors for conversion to intubation (hazard ratio =1.122, P=0.038; hazard ratio =1.408, P=0.042, respectively). CONCLUSIONS: Non-intubated thoracoscopic surgery can safely be performed in selected patients.

Comparison of postoperative sore throat and hoarseness between two types of double-lumen endobronchial tubes: a randomized controlled trial.

OBJECTIVE: Two types of material are used to manufacture double-lumen endobronchial tubes (DLTs): Polyvinylchloride (PVC) and silicon. PVC DLTs (Broncho-Cath) and silicon DLTs (Silbroncho) not only differ in material, but also subtly differ in structure. The goal of this study was to determine whether the incidences of postoperative sore throat and hoarseness differed between PVC DLTs and silicon DLTs. DESIGN: Prospective, single-blind, balanced (1:1), randomized, controlled trial. SETTING: Single university hospital. PARTICIPANTS: Sixty ASA I-II patients, aged 20 to 65 years, scheduled for thoracoscopic pulmonary lobectomy. INTERVENTIONS: Patients were randomized into the Broncho-cath group (group B, n = 30) and the Silbroncho group (group S, n = 30). Intubation was performed with DLT according to the allocated group by an anesthesiologist. MEASUREMENTS AND MAIN RESULTS: The incidence of sore throat and hoarseness was evaluated at 1 hour and 24 hours after DLT extubation. The intensity of sore throat was assessed by visual analog scale (VAS<0-10) at 1, 2, 4, 12, and 24 hours after DLT extubation. The incidence of sore throat was significantly lower in group S compared with that in group B at 1 h (30% v 66.7%, p = 0.018) and 24 hours (10% v 43.3%, p = 0.014). No significant difference was observed in the incidence of hoarseness between the 2 groups. The VAS scores for sore throat in group B were significantly higher than those in group S throughout the study (p< 0.05). CONCLUSIONS: The use of silicon DLTs resulted in a lower incidence of postoperative sore throat than did the use of PVC DLTs.

Videothoracoscopic management of a perforated central vein and pleura after ultrasound-guided internal jugular vein cannulation: a case report.

A 23-year-old male underwent a left internal jugular vein catheterization during extended surgery for treatment of multiple fractures due to a traffic accident. Although the catheterization was performed under ultrasound (US) guidance, iatrogenic perforation of the central vein and pleura occurred. The catheter was removed, and the perforated site was addressed under thoracoscopy rather than an open thoracotomy. This case suggests that using US does not completely guarantee a complication-free outcome, and that catheter placement should be carefully confirmed. In addition, this case suggests that thoracoscopy may be an ideal method of resolving a perforation of the central vein and pleura.