Cytoreductive Pleurectomy and Intrathoracic Chemohyperthermia for Pleural Relapse of Thymomas.

Several surgical procedures, from debulking to extrapleural pneumonectomy, may be applied for stage IVa Masaoka thymomas, but their efficiency is still controversial. Case studies have favored R0 resection as the cornerstone of multimodal therapy for locoregional metastatic extension. This report describes a standardized procedure combining a cytoreductive surgical procedure and intrathoracic chemohyperthermia on a 46-year-old patient presenting with B2 thymoma and synchronous unilateral pleural metastasis.

Extracorporeal Life Support for Refractory Cardiac Arrest: A 10-Year Comparative Analysis.

BACKGROUND: Cardiopulmonary resuscitation of cardiac arrest has poor outcomes. Extracorporeal life support (ECLS) could represent a salvage option. This study aimed to analyze the outcomes of ECLS used for refractory cardiac arrest. METHODS: In this observational analysis, patients were divided into an in-hospital cardiac arrest group (IHCA) and an out-of-hospital (OHCA) cardiac arrest group. The primary end point was survival to hospital discharge with good neurologic outcome. Both groups were compared after propensity score matching. Risk factors were searched with multivariate analyses. RESULTS: From January 2007 to December 2016, study investigators performed 131 ECLS procedures (IHCA, n = 45, 34.4%; OHCA, n = 86, 65.6%). The mean age of patients was 43.2 years, and 71.8% were male. Baseline characteristics were comparable between both groups except mean no-flow duration (0.2 minutes vs 2.5 minutes; p < 0.001) and low-flow duration (46.9 minutes vs 85.3 minutes; p < 0.001), which were significantly shorter in the IHCA group. A total of 103 (82.4%) patients died during ECLS (IHCA, 79.1% vs OHCA, 84.1%; p = 0.479). The complication rate during ECLS was comparable between both groups. Twenty (16%) patients were successfully weaned from ECLS (IHCA, 18.6% vs OHCA, 14.6%; p = 0.565) after a mean support period of 6.7 days. Survival to hospital discharge with good neurologic outcome was not different between the two matched groups (odds ratioOHCA vs IHCA 1.3; 95% confidence interval, 0.023 to 74.902; p = 0.9). Presence of shockable rhythm was associated with a better outcome (odds ratioshockable vs nonshockable 6.674; 95% confidence interval, 1.078 to 41.336; p = 0.044). CONCLUSIONS: Patients in the IHCA and OHCA groups experienced the same survival with good neurologic outcome after ECLS support. A better selection of patients with IHCA is mandatory to avoid futile support.

Adding sufentanil to ropivacaine in continuous thoracic paravertebral block fails to improve analgesia after video-assisted thoracic surgery: A randomised controlled trial.

BACKGROUND: The benefit of adding opioid to a local anaesthetic for continuous thoracic paravertebral analgesia after video-assisted thoracic surgery (VATS) is unclear. OBJECTIVES: To analyse the analgesic efficacy of ropivacaine and sufentanil in combination compared with ropivacaine alone after VATS. DESIGN: A randomised, double-blinded, single-centre clinical trial. SETTING: A tertiary university hospital between March 2010 and April 2014. PATIENTS: Ninety patients were recruited, two were not included leaving 88 randomised into two groups. Eighteen patients were excluded from analysis and 70 completed the study. INTERVENTION: To receive thoracic paravertebral analgesia with either 2 mg ml ropivacaine and 0.25 µg ml sufentanil (ropivacaine + sufentanil group) or 2 mg ml ropivacaine alone (ropivacaine group) for 48 h postoperatively. Infusion rate was set at 0.15 ml kg h in both groups. MAIN OUTCOME MEASURES: The primary endpoint was the mean total amount of self-administered morphine by the patients in each group at 48 h postoperatively. RESULTS: The mean ± SD total amount of self-administered morphine was not significantly different between groups (53.1 ±â€Š27.2 mg in the ropivacaine + sufentanil group vs. 58.8 ±â€Š34.3 mg in the ropivacaine group; P = 0.72). No significant differences were found between the two groups in either pain scores at rest or during movement, in opioid-related adverse reactions, in patient satisfaction or length of hospital stay. CONCLUSION: Adding 0.25 µg ml sufentanil to 2 mg ml ropivacaine in continuous thoracic paravertebral analgesia for VATS did not reduce morphine consumption or pain scores when compared with ropivacaine alone. We cannot recommend its use for routine clinical practice. Further studies analysing different concentrations and infusion rates of sufentanil are needed before a lack of efficacy can be confirmed. TRIAL REGISTRATION: Clinical trial registrations: EudraCT: 2009-014832-38. ClinicalTrials.gov: NCT 01082744.

Intra-Thoracic Chemo-Hyperthermia for pleural recurrence of thymoma.

BACKGROUND: Pleural recurrences are a hallmark of thymomas, and represent a challenge for multidisciplinary management. The purpose of this study was to assess the feasibility and the results in terms of morbidity, mortality and survival rates, of Intra-Thoracic Chemo-Hyperthermia (ITCH) for the treatment of pleural recurrences of thymomas. METHODS: Retrospective analysis of 19 consecutives patients between 1997 and 2015 treated by surgical cytoreduction (pleurectomy) followed by ITCH with 25mg/m2 of mitomycin, and 50mg/m2 of Cisplatin. RESULTS: There were 8 men and 11 women with a median age of 44 years. ITCH was combined with pleurectomy alone in 4 (22%) patients, pleurectomy and wedge resections in 14 (74%) patients; 1 (5%) patient had a pleuropneumonectomy. There were no perioperative deaths, and 5 patients (26%) presented with postoperative complication, including 3 (16%) cases related to chemotherapy (one case of reversible grade 2 bone marrow aplasia, and 2 cases of reversible, acute kidney failure). The median length of stay in intensive care unit and hospital were 1day and 10days, respectively. After a median follow-up period of 39 months (range 10-127 months), median disease-free survival was 42 months. Five patients (26%) died during follow-up. CONCLUSIONS: Our data indicate that ITCH is a feasible option for selected patients with pleural recurrence of thymomas. ITCH clearly provides long local control, without major safety issues, and prolonged survival may be achieved in selected patients. This therapeutic option should be discussed at a multidisciplinary tumor board.

Extracorporeal life support for refractory out-of-hospital cardiac arrest: Should we still fight for? A single-centre, 5-year experience.

BACKGROUND: Cardiopulmonary resuscitation displays low survival rate after out-of-hospital cardiac arrest (OHCA). Extracorporeal life support (ECLS) could be suggested as a rescue therapeutic option in refractory OHCA. The aim of this report is to analyze our experience of ECLS implantation for refractory OHCA. METHODS: We performed a retrospective observational analysis of our prospectively collected database. Patients were divided into a shockable rhythm (SH-R) and a non-shockable rhythm (NSH-R) group according to cardiac rhythm at ECLS implantation. The primary endpoint was survival to hospital discharge with good neurological recovery. RESULTS: From January 2010 to December 2014 we used ECLS in 68 patients (SH-R, n=19, 27.9% vs. NSH-R, n=49, 72.1%) for refractory OHCA. The clinical profile before ECLS implantation was comparable between the groups. Eight (11.7%) patients were successfully weaned from ECLS (SH-R=31.5% vs. NSH-R=4.0%, p=0.01) after a mean period of support of 2.1 days (SH-R=4.1 days vs. NSH-R=1.4 days, p=0.01). Six (8.8%) patients survived to discharge (SH-R=31.5% vs. NSH-R=0%, p=0.00). In the SH-R group 50% of the survivors were discharged without neurological complications. CONCLUSIONS: ECLS for refractory OHCA should be limited in consideration of its poor, especially neurological, outcome. Non-shockable rhythms could be considered as a formal contraindication allowing a concentration of our efforts on the shockable rhythms, where the chances of success are substantial.

Adjunctive remifentanil infusion in deeply sedated and paralyzed ICU patients during fiberoptic bronchoscopy procedure: a prospective, randomized, controlled study.

BACKGROUND: Even with an adequate pain assessment, critically ill patients under sedation experience pain during procedures in the intensive care unit (ICU). We evaluated the effects of adjunctive administration of Remifentanil, a short-acting drug, in deeply sedated patient on variation of Bispectral Index (BIS) during a fiberoptic bronchoscopy. METHODS: A prospective, randomized, blinded, placebo-controlled study was conducted in 18-bed ICU. Patients needing a tracheal fibroscopy under deep sedation (midazolam (0.1 mg/kg per hour) fentanyl (4 µg/kg per hour)) and neuromuscular blocking (atracurium 0.5 mg/kg) were included in the study. A continuous monitoring of BIS, arterial pressure, and heart rate were realized before, during, and after the fiberoptic exam. An adjunctive continuous placebo or Remifentanil infusion was started just before the fiberoptic exam with a target effect-site concentration of 4 ng/ml using a Base Primea pump. RESULTS: Mean arterial pressure and heart rates were comparable between the placebo and Remifentanil groups at all times of the procedure. We did not observe differences in the variation of BIS values between the two groups during procedure. We described no change in BIS values relative to the placebo group in this population. CONCLUSIONS: In deeply sedated and paralyzed patients, receiving analgesic support based on a scale score an additional administration of short-acting analgesic drug, such as Remifentanil, seems not to be necessary for acute pain control. TRIAL REGISTRATION: NCT00162591.