Adjuvant Transthoracic Negative-Pressure Ventilation in Nonintubated Thoracoscopic Surgery.

BACKGROUND: To minimize the risks of barotrauma during nonintubated thoracoscopic-surgery under spontaneous ventilation, we investigated an adjuvant transthoracic negative-pressure ventilation (NPV) method in patients operated on due to severe emphysema or interstitial lung disease. METHODS: In this retrospective study, NPV was employed for temporary low oxygen saturation and to achieve end-operative lung re-expansion during nonintubated lung volume reduction surgery (LVRS) for severe emphysema (30 patients, LVRS group) and in the nonintubated wedge resection of undetermined interstitial lung disease (30 patients, wedge-group). The results were compared following 1:1 propensity score matching with equivalent control groups undergoing the same procedures under spontaneous ventilation, with adjuvant positive-pressure ventilation (PPV) performed on-demand through the laryngeal mask. The primary outcomes were changes (preoperative-postoperative value) in the arterial oxygen tension/fraction of the inspired oxygen ratio (ΔPO2/FiO2;) and ΔPaCO2, and lung expansion completeness on a 24 h postoperative chest radiograph (CXR-score, 2: full or 1: incomplete). RESULTS: Intergroup comparisons (NPV vs. PPV) showed no differences in demographic and pulmonary function. NPV could be accomplished in all instances with no conversion to general anesthesia with intubation. In the LVRS group, NPV improved ΔPO2/FiO2 (9.3 ± 16 vs. 25.3 ± 30.5, p = 0.027) and ΔPaCO2 (-2.2 ± 3.15 mmHg vs. 0.03 ± 0.18 mmHg, p = 0.008) with no difference in the CXR score, whereas in the wedge group, both ΔPO2/FiO2 (3.1 ± 8.2 vs. 9.9 ± 13.8, p = 0.035) and the CXR score (1.9 ± 0.3 vs. 1.6 ± 0.5, p = 0.04) were better in the NPV subgroup. There was no mortality and no intergroup difference in morbidity. CONCLUSIONS: In this retrospective study, NITS with adjuvant transthoracic NPV resulted in better 24 h oxygenation measures than PPV in both the LVRS and wedge groups, and in better lung expansion according to the CXR score in the wedge group.

Erector Spinae Plane Block Versus Serratus Plane Block in Breast Conserving Surgery: Α Randomized Controlled Trial.

BACKGROUND/AIM: Erector spinae plane block (ESP Block) was introduced in 2016 as a surgical post-operative analgesia procedure. The present prospective, randomized trial aimed to compare ESP Block with serratus plane block (SPB) plus pectoral nerve blocks (PECS I) during breast conserving surgery (BCS). PATIENTS AND METHODS: Between February 2019 and March 2021, 104 patients undergoing BCS were randomized to receive either ESP block (ESP group n=54) or SPB+PECS I (SPB group=49). Assessment of postoperative pain was recorded by the dynamic and static visual analog scale (VAS) and was compared between groups. RESULTS: Between-group two-way ANOVA did not reach a statistically significant difference in static and dynamic VAS (p=0.879; p=0.917, respectively). Despite ESP group requiring for higher value of patient-controlled analgesia (PCA) bolus, no statistically significant difference was found in PCA activation pattern between groups (p=0.109). ESP block was a faster technique when compared to SPB+PECS I (p=0.007) and no complications or opioid side-effects were recorded in all groups examined. CONCLUSION: ESP Block could represent a safe, faster alternative with a single injection to SPB+PECS I in BCS.

Incidence of pneumomediastinum in COVID-19: A single-center comparison between 1st and 2nd wave.

In this study, we compared the incidence of pneumomediastinum in coronavirus disease (COVID-19) patients during the ascending phases of the 1st and 2nd epidemic waves. Crude incidence was higher during the 2nd wave at a quasi-significant level (0.68/1000 vs. 2.05/1000 patient-days, p = 0.05). When restricting the analysis to patients who developed pneumomediastinum during noninvasive ventilation, the difference became clearly significant (0.17/1000 vs 1.36/1000 patient-days, p = 0.039). At logistic regression, predisposing factors (p = 0.031), and COVID-19 radiological severity (p = 0.019) were independently associated with pneumomediastinum. Mortality in patients with pneumomediastinum was 87.5%. However, pneumomediastinum seemed to be related to a generally worse disease presentation in hospitalized patients during the 2nd wave, rather than to a separate pattern of disease.

Staged unilateral lung volume reduction surgery: from mini-invasive to minimalist treatment strategies.

Lung volume reduction surgery (LVRS) entailing unilateral or bilateral non-anatomical resection of severely damaged emphysematous tissue carried out by thoracoscopic or open surgical approaches, under general anesthesia with single-lung ventilation, has resulted in significant and long-lasting clinical and functional benefit. Unfortunately, the morbidity rates reported by simultaneous bilateral resectional LVRS has led to raise criticism regarding its cost-effectiveness and has stimulated in recent years the development of less invasive bronchoscopic and surgical non-resectional methods of treatment that are preferentially performed in a staged unilateral fashion. We had previously proposed an innovative LVRS modality, which did not entail any resection of lung tissue and was electively carried out according to a staged unilateral strategy by a multiport thoracoscopic access, through thoracic epidural anesthesia in conscious, spontaneously ventilating patients (awake LVRS). The awake LVRS resulted in significant clinical benefit paralleling that achieved by the resectional method with lower morbidity rates and shorter hospital stay. Moreover, the awake LVRS proved also suitable to be employed in stringently selected patients to perform redo procedures following previous successful bilateral LVRS. More recently, in order to minimize the global surgery- and anesthesia-related traumas, we have modified our original non-resectional method by adopting a single thoracoscopic access as well as an anesthesia protocol entailing use of a simple intercostal block with target control sedation, to realize an ultra-minimally invasive or minimalist LVRS. Hence, a deeper investigation of the pros and cons of staged unilateral LVRS strategies as well as of the novel surgical non-resectional and redo LVRS is warranted in order to verify, the optimal strategies of treatment, which will prove to reduce the typical LVRS-related morbidity while assuring the most durable benefit in patients with advanced emphysema.

Uniportal non-intubated lung metastasectomy.

BACKGROUND: More than 15 years ago, we started a program of uniportal video-assisted thoracoscopies (VATS) lung metastasectomy in non-intubated local anesthesia. Hereby we present the short and long-term results of this combined surgical-anesthesiological technique. METHODS: Between 2005 and 2015, 71 patients (37 men and 34 women) with pulmonary oligometastases, at the first episode, underwent uniportal VATS metastasectomy under non-intubated anesthesia. RESULTS: Four patients (5.6%) required intubation for intolerance. Mean number of lesions resected per patient was 1.51. There was no mortality. The study group demonstrated a significant reduction of operative time from the beginning of the experience (P=0.001), good level of consciousness at Richmond scale and quality of recovery after both 24 and 48 hours. Median hospital stay was 3 days and major morbidity rate was 5.5%. Both disease-free survival and overall survival were similar to those achieved with intubated surgery. CONCLUSIONS: VATS lung metastasectomy in non-intubated local anesthesia was safely performed in selected patients with oligometastases with significant advantages in overall operative time, hospital stay and economical costs. Long-term results were similar.

Surgical pneumothorax under spontaneous ventilation-effect on oxygenation and ventilation.

Surgical pneumothorax allows obtaining comfortable surgical space for minimally invasive thoracic surgery, under spontaneous ventilation and thoracic epidural anesthesia, without need to provide general anesthesia and neuromuscular blockade. One lung ventilation (OLV) by iatrogenic lung collapse, associated with spontaneous breathing and lateral position required for the surgery, involves pathophysiological consequences for the patient, giving rise to hypoxia, hypercapnia, and hypoxic pulmonary vasoconstriction (HPV). Knowledge of these changes is critical to safely conduct this type of surgery. Surgical pneumothorax can be now considered a safe technique that allows the realization of minimally invasive thoracic surgery in awake patients with spontaneous breathing, avoiding the risks of general anesthesia and ensuring a more physiological surgical course.

Awake video-assisted pleural decortication for empyema thoracis.

OBJECTIVE: To evaluate feasibility, technical features and results of video-assisted pleural decortication for empyema thoracis performed in awake patients. METHODS: This retrospective analysis involved a cohort of 19 patients (median age: 58 years) undergoing awake video-assisted thoracoscopic pleural decortication under epidural anaesthesia (N=15) or paravertebral blocks (N=4) between March 2004 and September 2008. Baseline and perioperative data including degree of postoperative lung re-expansion at 48 h, hospital stay, morbidity rate and daily fluid loss were recorded. In addition, intra- and perioperative changes in main pathophysiological variables PaO(2)/FiO(2) ratio, PaCO(2), mean arterial pressure and heart rate were analysed. RESULTS: Origin of the empyema was parapneumonic (N=14), post-traumatic (N=3) and cancer related (N=2). All patients underwent previous conservative management. The duration of the symptoms averaged 35 days (quartile range (QR): 28-40). Co-morbidities included chronic obstructive pulmonary disease (COPD) (N=4), HIV infection (N=1), diabetes mellitus (N=2) and cirrhosis (N=1). Operation was performed videothoracospically in 15 patients whereas four patients with major pleural thickening underwent awake lateral thoracotomy. Operative time averaged 50 min (QR: 40-70). Perioperative data analysis showed no intra-operative deterioration in arterial oxygenation (median-Delta: 0 mm Hg, QR: -5/+9, P=0.6). Transient permissive hypercapnia (<55 mm Hg) developed in three patients with no need of conversion to general anaesthesia. Median pain level assessed by a visual analogue score (VAS) 1h postoperatively was 4 (QR: 2-5), and it was significantly reduced on postoperative day 1 (median 3, QR: 2-4, P=0.03). There was neither mortality nor major morbidity. Hospitalisation averaged 6 days (QR: 5-7). At postoperative chest X-ray, lung re-expansion was rated as complete in 16 patients, satisfactory in (>80%) two patients and unsatisfactory in a 86-year-old patient with pleural mesothelioma who has the chest drain still in place 5 months after surgery. No patient had recurrence of the empyema at subsequent follow-ups. CONCLUSIONS: In our study, awake video-assisted pleural decortication proved feasible and resulted in satisfactory lung re-expansion in 95% of the patients. We hypothesise that spontaneous ventilation facilitated both identification of the correct plane and dissection, thus resulting in lesser surgical injury on the underlying lung.

Continuous femoral nerve block provides superior analgesia compared with continuous intra-articular and wound infusion after anterior cruciate ligament reconstruction.

BACKGROUND AND OBJECTIVES: This prospective, randomized, clinical trial compared pain intensity and analgesic drug consumption after anterior cruciate ligament (ACL) reconstruction with patellar tendon under femoral-sciatic nerve block anesthesia in patients who received either a continuous femoral nerve block (CFNB) or continuous local anesthetic wound and intra-articular infusions. METHODS: Fifty patients were randomized to CFNB (n = 25) or an ON-Q device (I-Flow Corp, Lake Forest, Calif) (n = 25). All patients received sciatic nerve block (25 mL of ropivacaine 7.5 mg/mL and clonidine 30 microg). The first group received a CFNB (2 mg/mL of ropivacaine at 7 mL/hr), and the second group received a single-shot femoral nerve block (both using 25 mL of ropivacaine 7.5 mg/mL and clonidine 30 microg). At the end of the intervention, an ON-Q device was positioned on the ON-Q patients to continuously infuse the patellar tendon wound and intra-articular cavity with ropivacaine 2 mg/mL at 2 mL/hr for each catheter. Data regarding demographic, hemodynamic, pain scores, adverse effects, and need for supplemental analgesia were registered in a 36-hr follow-up period. RESULTS: The CFNB group reported lower visual analog scale values than the ON-Q group: at rest at 12 hrs (2.4 [SD, 2.2] vs 5.4 [SD, 3.1]; P < 0.001) and on movement at 12 (3.1 [SD, 2.5] vs 6.3 [SD, 2.9]; P < 0.001) and 24 hrs (2.7 [SD, 1.9] vs 4.6 [SD, 2.6]; P = 0.01) after surgery. The number of morphine and ketorolac boluses was lower in the CNFB group (morphine: 3.2 [SD, 2.2] vs 6.2 [SD, 2.5]; P < 0.001; ketorolac: 1.1 [SD, 1.0] vs 2.4 [SD, 0.9]; P < 0.001). CONCLUSION: Continuous femoral nerve block provides better analgesia than the continuous patellar tendon wound and intra-articular infusions after anterior cruciate ligament reconstruction with patellar tendon.

A prospective comparison of continuous wound infiltration with ropivacaine versus single-injection paravertebral block after modified radical mastectomy.

BACKGROUND: The efficacy of continuous wound infiltration with local anesthetic has not been compared with that of thoracic paravertebral block (PVB) after breast surgery. In this study, we evaluated the analgesic efficacy and morphine consumption of the two techniques after mastectomy. METHODS: Forty-eight patients undergoing modified radical mastectomy with axillary dissection were randomly assigned to either a preoperative PVB with 20 mL of ropivacaine 0.5% (group PVB) or a continuous ropivacaine 0.5% infusion (CRI) at a 2 mL/h rate for each of two multilumen catheters placed subcutaneously at the end of the procedure (group CRI). The catheters were left in place for 24 h postoperatively. A standardized general anesthetic was administered to all patients. Postoperative morphine consumption, pain scores and painful restricted movement of the shoulder for 24 h postoperatively as well as incidence of adverse events, including postoperative nausea and vomiting, were recorded. RESULTS: Morphine consumption was similar between groups (PVB: 42.6 +/- 11 vs CRI: 38.7 +/- 11 mg in 24 h, P = 0.225). Absolute pain scores were low in both groups. Four hours after surgery, group PVB showed a significant reduction in postoperative pain (PVB: 0 [0-10] vs CRI: 0 [0-30], P = 0.002) and reduced painful restricted movement (P = 0.004), whereas the CRI group had lower pain scores (PVB: 10 [0-30] vs CRI: 0 [0-20], P = 0.034) and painful restricted movement (P = 0.043) 16 and 24 h (PVB: 10 [0-30] vs CRI: 0 [0-30], P = 0.012) after surgery. Postoperative nausea and vomiting was significantly more frequent in the CRI group (P = 0.017). CONCLUSIONS: Continuous wound infiltration of local anesthetics is an effective alternative to paravertebral analgesia after mastectomy with axillary dissection.

Efficacy of continuous femoral nerve block with stimulating catheters versus nonstimulating catheters for anterior cruciate ligament reconstruction.

BACKGROUND AND OBJECTIVES: This prospective randomized controlled trial investigated the clinical efficacy of stimulating catheters for continuous femoral nerve block in patients who underwent anterior cruciate ligament reconstruction. METHODS: Seventy patients were randomized to either a stimulating catheter (SC, n = 35) or a nonstimulating catheter (NSC, n = 35) for femoral nerve block using 25 mL ropivacaine 7.5 mg/mL and clonidine 50 microg injected through the catheter. A single-injection sciatic block was also given to ensure surgical anesthesia. The time to loss of sensation to cold and pinprick of the femoral nerve was registered as the onset time. Data were registered intra- and postoperatively regarding pain scores, adverse effects, and need for supplemental anesthesia and analgesia other than a continuous postoperative infusion of ropivacaine 2 mg/mL through the continuous femoral nerve catheter set at 7 mL/h. RESULTS: Onset time was faster in the SC group (SC: 6.4 +/- 2.5, NSC: 8.3 +/- 2.9 min, P = .006). Visual analog scale pain scores were similar in both groups. The number of patient-controlled regional analgesia boluses (SC: 14.6 +/- 12.6, NSC: 23.2 +/- 13.6 mg ropivacaine 2 mg/mL, P = .008) as well as intravenous rescue ketorolac (SC: 34.3 +/- 35.7, NSC: 54 +/- 39.7 mg, P = .033) administered were higher in the NSC group. CONCLUSION: Although the use of a stimulating catheter was associated with faster onset time for the femoral nerve block and lower additional analgesics postoperatively, the clinical superiority (analgesia; lateral femoral cutaneous, and obturator nerve block) of stimulating catheters was not evident in this clinical setting.