The right ventricular response to lung resection.

OBJECTIVES: Lung cancer is a leading cause of cancer death and in suitable cases the best chance of cure is offered by surgery. Lung resection is associated with significant postoperative cardiorespiratory morbidity, with dyspnea and reduced functional capacity as dominant features. These changes are poorly associated with deterioration in pulmonary function and a potential role of right ventricular (RV) dysfunction has been hypothesized. Cardiovascular magnetic resonance imaging is a reference method for noninvasive assessment of RV function and has not previously been applied to this population. METHODS: We used cardiovascular magnetic resonance imaging to assess the RV response to lung resection. Cardiovascular magnetic resonance imaging with volume and flow analysis was performed on 27 patients preoperatively, on postoperative day 2 and at 2 months. Left ventricular ejection fraction and RV ejection fraction, the ratio of stroke volume to end systolic volume, pulmonary artery acceleration time, and distensibility of main and branch pulmonary arteries were studied. RESULTS: Mean ± standard deviation RV ejection fraction deteriorated from 50.5% ± 6.9% preoperatively to 45.6% ± 4.5% on postoperative day 2 and remained depressed at 44.9% ± 7.7% by 2 months (P = .003). The ratio of stroke volume to end systolic volume deteriorated from median 1.0 (quartile 1, quartile 3: 0.9, 1.2) preoperatively to median 0.8 (quartile 1, quartile 3: 0.7, 1.0) on postoperative day 2 (P = .011). On postoperative day 2 there was a decrease in pulmonary artery acceleration time and operative pulmonary artery distensibility (P < .030 for both). There were no changes in left ventricular ejection fraction during the study period (P = .621). CONCLUSIONS: These findings suggest RV dysfunction occurs following lung resection and persists 2 months after surgery. The deterioration in the ratio of stroke volume to end systolic volume suggests a mismatch between afterload and contractility. There is an increase in indices of pulsatile afterload resulting from the operative pulmonary artery.

B-type natriuretic peptide predicts deterioration in functional capacity following lung resection.

OBJECTIVES: Following lung resection, there is a decrease in the functional capacity and quality of life, which is not fully explained by changes in pulmonary function. Previous work demonstrates that B-type natriuretic peptide (BNP) is associated with short- and long-term complications following lung resection, leading to the suggestion that cardiac dysfunction may contribute to functional deterioration. Our aim was to investigate any relationship between BNP and subjective and objective indices of functional deterioration following lung resection surgery. METHODS: Twenty-seven patients undergoing lung resection had serum BNP measured preoperatively, on postoperative day (POD)1 and POD2, and at 2 months postoperatively. The functional deterioration was assessed using 6-min walk tests and the Medical Research Council dyspnoea scale. 'Deterioration in functional capacity' was defined as either an increase in the Medical Research Council dyspnoea score or a significant decrease in the 6-min walk test distance. RESULTS: BNP increased over time (P < 0.01) and was significantly elevated on POD1 and POD2 (P < 0.02 for both). Seventeen patients demonstrated functional deterioration 2 months postoperatively. At all perioperative time points, BNP was significantly higher in patients showing deterioration (P < 0.05 for all). Preoperative BNP was predictive of functional deterioration at 2 months with an area under the receiver-operating characteristic curve of 0.82 (P = 0.01, 95% confidence interval 0.65-0.99). CONCLUSIONS: This study has demonstrated, using subjective and objective measures, that preoperative BNP is a predictor of functional deterioration following lung resection. BNP may have a role in preoperative risk stratification in this population, allowing therapy in future to be targeted towards high-risk patients with the aim of preventing postoperative cardiac dysfunction. CLINICAL TRIAL REGISTRATION NUMBER: NCT01892800.

Ventricular assist devices as rescue therapy in cardiogenic shock after subarachnoid hemorrhage.

We review the journey to myocardial and neurologic recovery of a 42-year-old mother with severe acute cardiogenic shock and multiorgan failure after extensive subarachnoid hemorrhage, who was salvaged successfully using a CentriMag short-term biventricular assist device.

Anesthesia for thoracic surgery: a survey of middle eastern practice.

PURPOSE: The main objective of this survey is to describe the current practice of thoracic anesthesia in the Middle Eastern (ME) region. METHODS: A prospective online survey. An invitation to participate was e-mailed to all members of the ME thoracic-anaesthesia group. A total of 58 members participated in the survey from 19 institutions in the Middle East. Questions concerned ventilation strategies during one-lung ventilation (OLV), anesthesia regimen, mode of postoperative analgesia, use of lung isolation techniques, and use of i.v. fluids. RESULTS: Volume-controlled ventilation was favored over pressure-controlled ventilation (62% vs 38% of respondents, P<0.05); 43% report the routine use of positive end-expiratory pressure. One hundred percent of respondents report using double-lumen tube (DLT) as a first choice airway to establish OLV. Nearly a third of respondents, 31.1%, report never using bronchial blocker (BB) in their thoracic anesthesia practice. Failure to pass a DLT and difficult airway are the most commonly cited indications for BB use. Regarding postoperative analgesia, the majority 61.8% favor thoracic epidural analgesia over other techniques (P<0.05). CONCLUSIONS: Our survey provides a contemporary snapshot of the ME thoracic anesthetic practice.

Anesthesia for thoracic surgery: a survey of UK practice.

OBJECTIVE: The authors sought to provide a snapshot of contemporary thoracic anesthetic practice in the United Kingdom and Ireland. DESIGN: An online survey. SETTING: United Kingdom. PARTICIPANTS: An invitation to participate was e-mailed to all members of the Association of Cardiothoracic Anaesthetists. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: A total of 132 responses were received; 2 were excluded because they did not originate from the United Kingdom. Values are number (percent). ANESTHETIC TECHNIQUE: The majority of respondents (109, 85%) maintain anesthesia with a volatile anesthetic agent, with a lesser proportion (20, 15%) reporting use of a total intravenous anesthetic technique. The majority of respondents (78, 61%) favor pressure control ventilation over volume control (50, 39%); just under half (57, 45%) report the routine use of positive end-expiratory pressure (median = 5 cmH(2)O [interquartile range (IQR), 4-5]). Fifty-two (40%) respondents report ventilating to a target tidal volume (median = 6 mL/kg [IQR, 5-7]). Most (114, 89%) respondents routinely ventilate with an F(I)O(2) less than 1.0. Thoracic epidural blockade (TEB) is favored by nearly two thirds of respondents (80, 62%) compared with paravertebral block (39, 30%) and other analgesic techniques (10, 8%). Anesthesiologists favoring TEB are significantly less likely to prescribe systemic opioids (17, 21% v 39, 100% [p < 0.001]). Proponents of TEB are significantly more likely to "routinely" use vasopressor infusions both intra- and postoperatively (16, 20% v 0, 0% [p = 0.003] and 28, 35% v 4, 11% [p =0.013], respectively). Most respondents (127, 98%) report a double-lumen tube as their first choice. Many (82, 64%) report "rarely" using bronchial blockers. CONCLUSIONS: The authors hope this survey both provides interest and serves as a useful resource reflecting the current practice of thoracic anesthesia.

Guidelines on the radical management of patients with lung cancer.

A joint initiative by the British Thoracic Society and the Society for Cardiothoracic Surgery in Great Britain and Ireland was undertaken to update the 2001 guidelines for the selection and assessment of patients with lung cancer who can potentially be managed by radical treatment.

Inadvertent total spinal anesthesia after intercostal nerve block placement during lung resection.

Intercostal nerve block is a recognized way of providing analgesia at thoracotomy. There is a rare association between intercostal nerve block and the complication of total spinal anesthesia. This may arise inadvertently by injection into a dural cuff extending outside the intervertebral foramen. We report our experience with a patient who sustained this life-threatening complication. The patient required postoperative ventilation until the neurologic deficits resolved. The operator must be aware that intercostal nerve block runs the rare but potentially fatal risk of total spinal block.