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The aim of this study was to compare the efficacy of ultrasound-guided erector spinae plane block (ESPB), thoracic paravertebral block (TPVB), and ESPB and TPVB combination on acute pain after video-assisted thoracoscopic surgery (VATS).Seventy-five patients were evaluated (3 groups (ESPB, TPVB, or combined ESPB-TPVB (Comb-group, each 25 patients). All interventions were performed with the same volume of bupivacaine (20 mL). Primary outcome was VAS (Visual analog scale) during the first 24 hours. Secondary outcomes were postoperative morphine consumption and rescue analgesic requirements.VAS during rest and coughing of TPVB was significantly higher compared to other groups (in all measurements compared to Comb-group; and in all but 24 h measurement to ESPB) ESPB and Comb-group had similar VAS in all measurements. (e.g. Median VAS in ESPB, TPVB and Comb-group at 8th hour: 3-4-2 (p=0.014) during coughing and 2-3-1 in rest (p0.001), respectively). Morphine consumption was statistically significantly higher in TPVB than Comb-group (ESPB: 15.28 mg; TPVB: 19.30 mg; ESPB+TPVB: 10.00 mg) (p: 0.003). Rescue analgesic requirement was statistically significantly higher in the TPVB group than Comb-group (p: 0.009).ESPB alone and the combination of ESPB and TPVB provided superior primary outcomes compared to TPVB alone. Morphine and rescue analgesic consumptions were higher in TPVB than Comb-group. ESPB and Comb-group were statistically similar in terms of primary and secondary outcomes. This study is one of the first studies using the combination of ESBP and TPVB for pain after VATS, and shows the efficacy of this approach.

Continuous monitoring of clinical outcomes after thoracotomy is very important to improve medical services and to reduce complications. The use of regional analgesia techniques for thoracotomy offers several advantages in the perioperative period including effective pain control, reduced opioid consumption and associated side effects, enhanced recovery, and improved patient satisfaction. Postthoracotomy complications, such as chronic postthoracotomy pain syndrome, postthoracotomy ipsilateral shoulder pain, pulmonary complications, recurrence, and unplanned admission to the intensive care unit are frequent and may be associated with poor outcomes and mortality. The role of regional techniques to reduce the incidence of these complications is questionable. This narrative review aims to investigate the impact of regional analgesia on the long-term clinical outcomes after thoracotomy.

To find a reliable answer to the question in the title: Should fluid management in thoracic surgery be goal directed?'Moderate' fluid regimen is the current recommendation of fluid management in thoracic anesthesia, however, especially in more risky patients; 'Goal-Directed Therapy' (GDT) can be a more reliable approach than just 'moderate'. There are numerous studies examining its effects in general anesthesia; albeit mostly retrospective and very heterogenic. There are few studies of GDT in thoracic anesthesia with similar drawbacks.Although the evidence level is low, GDT is generally associated with fewer postoperative complications. It can be helpful in decision-making for volume-optimization, timing of fluid administration, and indication of vasoactive agents.

This review attempts to focus on protective ventilation approaches during one-lung ventilation (OLV) and will summarize recent findings. Recent studies have demonstrated the importance of low tidal volume (low TV) and reduced driving pressure during OLV. Along with low TV, correct use of positive end-expiratory pressure (PEEP) seems to have a vital role in terms of protecting the ventilated lung. PEEP decremental trial and the use of electrical impedance tomography are prominent techniques for individualizing the PEEP. The use of alveolar recruitment maneuvers (ARMs) is furthermore recommended. Nevertheless, there are several studies published considering negative effects of ARM. Although small tidal volumes are highly recommended during OLV, it is not possible for low TV to be beneficial unless an optimal PEEP is applied. Use of ARM is still under debate. Yet, it seems to be the only way for preventing injurious tidal recruitment, which is known to be harmful to the lungs.

Contains fulltext : 244115.pdf (Publisher’s version ) (Closed access) The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority, and there is an increasing need to fully define the optimal oncologic management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Healthcare providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer; an imminent spike due to mortality from acute coronavirus disease 2019 (COVID-19) infection, and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were deemed less urgent, delayed, or cancelled. The European Association of Cardiothoracic Anaesthesiology and Intensive Care Thoracic Anesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectious period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

Background: despite studies on the adverse effects of hyperoxia, its use is still recommended by the World Health Organization. The aim of this study was to test the possible harmful effects of hyperoxia on the lung, kidney, heart, and liver in a rat mechanical ventilation model. Methods: male Wistar rats were randomly assigned into two groups (n=6/group): Normoxic (FiO(2): 0.3) or hyperoxic (FiO(2): 1.0) ventilation for 4 h. The injury was evaluated in bronchoalveolar lavage (BAL), blood, lung, liver, kidney, and heart was evaluated in terms of cell surface integrity, extracellular matrix (sialic acid, syndecan-1), osmotic stress (free hemoglobin), and redox homeostasis-lipid peroxidaation (malondialdehyde). BAL and wet/dry weight ratio were also evaluated for cellular permeability. Results: four hours of hyperoxic ventilation did not lead to significant changes in (1) sialic acid, syndecan-1, (2) malondialdehyde levels and wet/dry weight ratio in liver, kidney, heart, and lung compared to normoxic ventilation. Conclusion: mechanical ventilation with hyperoxia seems to have almost similar effects compared to ventilation with normoxia. However, the long term effect of hyperoxia should be evaluated. / Amaç: hiperoksinin olumsuz etkileri üzerine yapılan çalışmalara rağmen, Dünya Sağlık Örgütü (WHO) hiperoksinin kullanımını önermektedir. Bu çalışmanın amacı sıçan mekanik ventilasyon modelinde hiperoksinin akciğer, böbrek, kalp ve karaciğer üzerindeki olası olumsuz etkilerini test etmektedir. Gereç ve yöntem: erkek Wistar sıçanlar dört saat boyunca normoksik (FiO2: 0.3) veya hiperoksik (FiO2: 1.0) ventile edilerek iki gruba (n=6/grup) ayrıldı. Hasar hücre yüzey bütünlüğü, ekstraselüler matriks (sialik asit, sindekan-1), ozmotik stres (serbest hemoglobin) ve redoks homeostazisi-lipit peroksidasyonu (malondialdehit) açısından bronkoalveolar lavaj, kan, akciğer, böbrek, kalp ve karaciğer örneklerinde değerlendirildi. Ayrıca bronkoalveolar lavaj ve ıslak/kuru ağırlık oranı ile hücre geçirgenliği değerlendirildi. Bulgular: dört saatlik hiperoksik ventilasyon sialik asit, sindekan-1, malondialdehit düzeylerinde ve organların ıslak kuru ağırlıklarında anlamlı bir değişikliğe neden olmadı. Tartışma: hiperoksik ventilasyonun normoksik ventilasyona benzer bir etki gösterdiği görülmektedir. Ancak, hiperoksinin uzun vadeli etkileri değerlendirilmelidir., NA

The objective of this study was to compare analgesic efficacy of erector spinae plane block (ESPB), thoracic paravertebral block (TPVB), and intercostal nerve block (ICNB) after video-assisted thoracoscopic surgery (VATS).Prospective, randomized, single-blind study.University hospital, single institution.Adult patients undergoing VATS.Ultrasonography-guided ESPB, ultrasonography-guided TPVB, or ICNB.Patients were enrolled into the following three groups according to analgesia technique as ESPB, TPVB, or ICNB, respectively, group erector spinae plane block (GESP) (n = 35), group thoracic paravertebral block (GTPV) (n = 35), and group intercostal nerve block (GICN) (n = 36). Multimodal analgesia was achieved with paracetamol, tenoxicam, and intravenous morphine (via patient-controlled analgesia) for all study groups. Pain scores were assessed by visual analog scale, and morphine consumption, rescue analgesic requirement, and side effects were recorded postoperatively. Dynamic visual analog scale at the first hour as primary outcome was determined five (two-seven), four (one-six) and (two-six) in GESP, GTPV, and GICN, respectively. Dynamic pain scores were significantly lower in GTPV compared with GESP and GICN at 24 hours (p0.017). Dynamic pain scores in GICN were significantly lower at 12 hours compared with GESP (p0.017). Morphine consumption for the first 24 hours was similar in GICN and GTPV, and it was significantly lower in GICN and GTPV in comparison to GESP (p0.017). Rescue analgesic requirement and side effects were similar among groups.All three blocks can obtain sufficient analgesia after VATS; however, TPVB appeared to be the preferable method compared with ESPB and ICNB, with a more successful analgesia and less morphine consumption.

Resumo Justificativa e objetivos A disfuncao cognitiva no pos‐operatorio e comum apos cirurgia cardiaca. A perfusao cerebral adequada e essencial e a espectroscopia no infravermelho proximo (NIRS) pode medir a oxigenacao cerebral. O objetivo deste estudo foi comparar a incidencia de disfuncao cognitiva no pos‐operatorio, precoce e tardio, em pacientes idosos tratados com monitoracao convencional ou espectroscopia no infravermelho proximo. Metodos Os pacientes submetidos a cirurgia coronariana, acima de 60 anos, foram incluidos e randomicamente alocados em dois grupos: grupo controle e grupo NIRS. O manejo dos pacientes no periodo perioperatorio foi feito com NIRS no grupo NH e com abordagem convencional no grupo controle A bateria de testes foi feita antes da cirurgia, na primeira semana e no terceiro mes de pos‐operatorio. A bateria incluiu o desenho do relogio, a memoria, a geracao de uma lista de palavras, a sequencia de digitos e subtestes que exigem habilidades visuoespaciais.Disfuncao cognitiva no pos‐operatorio foi definida como queda de um DP (desvio‐padrao) da fase basal em dois ou mais testes. O teste U de Mann Whitney foi usado para comparacao de medidas quantitativa e o teste exato do qui‐quadrado para comparar dados quantitativos. Resultados Vinte e um pacientes do grupo controle e 19 do grupo NIRS concluiram o estudo. Os dados demograficos e operacionais foram semelhantes. Na primeira semana, nove pacientes (45%) do GC e sete pacientes (41%) do grupo NIRS apresentaram disfuncao cognitiva no pos‐operatorio. No terceiro mes, 10 pacientes (50%) foram avaliados como disfuncao cognitiva no pos‐operatorio; a incidencia foi de quatro (24%) no grupo NIRS (p = 0,055). O grupo que apresentou disfuncao cognitiva no pos‐operatorio precoce e tardio teve uma permanencia significativamente maior na UTI (1,74 + 0,56 vs. 2,94 + 0,95; p Conclusao Neste estudo piloto, a monitoracao convencional e a espectroscopia no infravermelho proximo resultaram em taxas semelhantes de disfuncao cognitiva no pos‐operatorio precoce. A disfuncao cognitiva tardia tende a melhorar com espectroscopia no infravermelho proximo. Os declinios cognitivos precoces e tardios foram associados a internacoes prolongadas tanto em UTI quanto hospitalares.

Resumo Introducao A disfuncao cognitiva pos‐operatoria (DCPO) e um resultado adverso cirurgico que e mais comum apos cirurgias cardiacas abertas. O objetivo deste estudo foi investigar o papel dos niveis de glicose no sangue rigorosamente controlados durante a cirurgia coronariana no declinio cognitivo precoce e tardio. Metodos Foram randomizados em dois grupos 40 pacientes acima de 50 anos e submetidos a cirurgia coronariana eletiva. No grupo “controle rigoroso” (GI), a glicemia foi mantida entre 80‐120 mg.dL −1 ; enquanto no grupo “liberal” (GII), variou entre 80‐180 mg.dL −1 . A bateria de testes neuropsicologicos foi feita tres vezes: fase basal, antes da cirurgia e na primeira e 12a semana de acompanhamento no pos‐operatorio. DCPO foi definida como uma queda de um desvio padrao da fase basal em dois ou mais testes. Resultados Na primeira semana de pos‐operatorio, os testes neurocognitivos mostraram que 10 pacientes no GI e 11 pacientes no GII apresentaram DCPO. A incidencia de DCPO precoce foi semelhante entre os grupos. No entanto, a avaliacao tardia revelou que a disfuncao cognitiva persistiu em cinco pacientes no GII, enquanto nenhum paciente foi classificado como cognitivamente prejudicado no GI ( p = 0,047). Conclusao Sugerimos que o controle glicemico rigoroso no perioperatorio de cirurgia coronariana pode desempenhar um papel na prevencao da deterioracao cognitiva persistente.

To the Editor We were very interested to read the remarkable work in the January issue of Regional Anesthesia & Pain Medicine entitled ‘Influence of postoperative analgesia on systemic inflammatory response and postoperative cognitive dysfunction after femoral fractures surgery’.[1][1] The

BACKGROUND Cognitive dysfunction in the early postoperative course is common for the elderly population. Anesthetic management may affect postoperative cognitive decline. Effective analgesia, early recovery and modulation of the stress response are advantages of neuraxial blocks. This study aims to compare the effects of general anesthesia and the combination of general anesthesia with epidural analgesia for postoperative cognitive dysfunction (POCD). We hypothesized that neuraxial block combined with general anesthesia (GA) would have a favorable influence on POCD prevention. METHODS Patients above 60 years undergoing non-cardiac surgery were included in this randomized, prospective study and randomized into two groups. Patients in the first group (GI) were treated under GA, whereas in the second group (GII), epidural analgesia was combined with GA. Patients' cognitive function was assessed before and one week after surgery using a neuropsychological test battery. POCD was defined as a drop of one standard deviation from baseline on two or more tests. RESULTS A total of 116 patients were allocated for the final analysis. Demographic and operative data were similar between groups, except maximum pain scores, which were significantly higher in GI than GII (4.9±2.8 vs. 1.7±1.7; p

Contains fulltext : 225360.pdf (Publisher’s version ) (Closed access) The novel coronavirus has caused a pandemic around the world. Management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. The thoracic subspecialty committee of European Association of Cardiothoracic Anaesthesiology (EACTA) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. It should be emphasized that both the management of the infected patient with COVID-19 and the self-protection of the anesthesia team constitute a complicated challenge. The text focuses therefore on both important topics.

Thoracic anesthesia, a fascinating subspecialty, provides perioperative medicine for a spectrum of dynamically evolving surgical procedures ranging from classical thoracotomies to minimally invasive and ultra-minimally invasive video or robotically assisted procedures. Its core mission is to provide optimal surgical conditions by deflating the operative lung while providing adequate oxygenation and avoiding injury to the ventilated lung. Thoracic anesthesia also provides preoperative care to achieve best possible health status before surgery and improves postoperative recovery by providing means of pain therapy and enhanced recovery following some of the most painful procedures in patients who are at the highest risk for developing chronic pain. This chapter focuses on major current paradigms of general thoracic anesthesia representing the clinical views and preferences of a substantial core leadership of the EACTA thoracic subcommittee. As such, it is a uniquely European perspective not on the exact procedure specific details but, as the title demands, on the fundamentally basic principles of thoracic anesthesia. While covering the traditional topics of airway management, ventilation and acute pain in sufficient detail, it also expands into newer areas of interest as preoperative optimization through prehabilitation and introducing new methods to prevent chronic pain. While the discussed strategies currently represent our view as a group, we hope to formally test these concepts in the near future by subjecting these recommendations to a formal consensus statement (Thoracic Anaesthesia Consensus Agreement, TOSSCA) through a robust Delphi process involving the full membership of the EACTA Thoracic committee and the wider EACTA membership.

Two major challenges should be considered during one-lung ventilation (OLV): Hypoxemia and lung injury. The former is mainly because the increase in intrapulmonary shunt; the latter is mainly because volo-, baro, atelecto-, and biotraumas. The so-called “protective ventilation”, consisting of low tidal volume, PEEP and recruitment manoeuvres can help to deal with these challenges. Low FiO2, CPAP to the non-dependent lung are other recommendations, but they have limits in daily practice. There is no particular ventilatory mode to recommend. Inhalational anaesthetics can have a “slightly” negative effect on oxygenation, but have benefits regarding the inflammatory response.

The development of less invasive regional techniques and the evolution of thoracoscopic approaches have led to questioning the epidural pre-eminent role in thoracic surgery.

Thoracic surgery in patients with a previous lung resection is a very difficult challenge for thoracic surgeons and anesthesiologists.

Background Postoperative pulmonary complications (PPC) may result in longer duration of in-hospital stay and even mortality. Both thoracic surgery and intraoperative mechanical ventilation settings add considerably to the risk of PPC. It is unclear if one-lung ventilation (OLV) for thoracic surgery with a strategy of intraoperative high positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM) reduces PPC, compared to low PEEP without RM. Methods PROTHOR is an international, multicenter, randomized, controlled, assessor-blinded, two-arm trial initiated by investigators of the PROtective VEntilation NETwork. In total, 2378 patients will be randomly assigned to one of two different intraoperative mechanical ventilation strategies. Investigators screen patients aged 18 years or older, scheduled for open thoracic or video-assisted thoracoscopic surgery under general anesthesia requiring OLV, with a maximal body mass index of 35 kg/m2, and a planned duration of surgery of more than 60 min. Further, the expected duration of OLV shall be longer than two-lung ventilation, and lung separation is planned with a double lumen tube. Patients will be randomly assigned to PEEP of 10 cmH2O with lung RM, or PEEP of 5 cmH2O without RM. During two-lung ventilation tidal volume is set at 7 mL/kg predicted body weight and, during OLV, it will be decreased to 5 mL/kg. The occurrence of PPC will be recorded as a collapsed composite of single adverse pulmonary events and represents the primary endpoint. Discussion PROTHOR is the first randomized controlled trial in patients undergoing thoracic surgery with OLV that is adequately powered to compare the effects of intraoperative high PEEP with RM versus low PEEP without RM on PPC. The results of the PROTHOR trial will support anesthesiologists in their decision to set intraoperative PEEP during protective ventilation for OLV in thoracic surgery. Trial registration The trial was registered in clinicaltrials.gov (NCT02963025) on 15 November 2016. Electronic supplementary material The online version of this article (10.1186/s13063-019-3208-8) contains supplementary material, which is available to authorized users.

Trials 20(1), 213 (2019). doi:10.1186/s13063-019-3208-8

After lung recruitment, lateral decubitus and differential lung ventilation may enable the titration and application of optimum-selective positive end-expiratory pressure values for the dependent and nondependent lungs. We aimed at compare the effects of optimum-selective positive end-expiratory pressure with optimum global positive end-expiratory pressure on regional collapse and aeration distribution in an experimental model of acute respiratory distress syndrome.Prospective laboratory investigation.University animal research laboratory.Seven piglets.A one-hit injury acute respiratory distress syndrome model was established by repeated lung lavages. After replacing the tracheal tube by a double-lumen one, we initiated lateral decubitus and differential ventilation. After maximum-recruitment maneuver, decremental positive end-expiratory pressure titration was performed. The positive end-expiratory pressure corresponding to maximum dynamic compliance was defined globally (optimum global positive end-expiratory pressure) and for each individual lung (optimum-selective positive end-expiratory pressure). After new maximum-recruitment maneuver, two steps were performed in randomized order (15 min each): ventilation applying the optimum global positive end-expiratory pressure and the optimum-selective positive end-expiratory pressure. CT scans were acquired at end expiration and end inspiration.Aeration homogeneity was evaluated as a nondependent/dependent ratio (percent of total gas content in upper lung/percent of total gas content in lower lung) and tidal recruitment as the difference in the percent mass of nonaerated tissue between expiration and inspiration. At the end of the 15-minute optimum-selective positive end-expiratory pressure, compared with the optimum global positive end-expiratory pressure, resulted in 1) decrease in the percent mass of collapse in the lower lung at expiratory CT (19% ± 15% vs 4% ± 5%; p = 0.03); 2) decrease in the nondependent/dependent ratio between the optimum global positive end-expiratory pressure-expiratory-CT and optimum-selective positive end-expiratory pressure-expiratory-CT (3.7 ± 1.2 vs 0.8 ± 0.5; p = 0.01); 3) decrease in the nondependent/dependent ratio between the optimum global positive end-expiratory pressure-inspiratory-CT and optimum-selective positive end-expiratory pressure-inspiratory-CT (2.8 ± 1.1 vs 0.6 ± 0.3; p = 0.01); and 4) less tidal recruitment (p = 0.049).After maximum lung recruitment, lateral decubitus and differential lung ventilation enabled the titration of optimum-selective positive end-expiratory pressure values for the dependent and the nondependent lungs, made possible the application of an optimized regional open lung approach, promoted better aeration distribution, and minimized lung tissue inhomogeneities.

One-lung ventilation (OLV) has two major challenges: oxygenation and lung protection. The former is mainly because the ventilation of one lung is stopped while the perfusion continues; the latter is mainly because the whole ventilation is applied to only one lung. Recommendations for maintaining the oxygenation and methods of lung protection can contradict each other (such as high vs. low inspiratory oxygen fraction (FiO2), high vs. low tidal volume (TV), etc.). In light of the (very few) randomized clinical trials, this review focuses on a recent strategy for OLV, which includes a possible decrease in FiO2, lower TVs, positive end-expiratory pressure (PEEP) to the dependent lung, continuous positive airway pressure (CPAP) to the non-dependent lung and recruitment manoeuvres. Other applications such as anaesthetic choice and fluid management can affect the success of ventilatory strategy; new developments have changed the classical approach in this respect.

Amac: Direkt laringoskopi trakeal entubasyon egitiminde kullanilan geleneksel bir metoddur. Ancak bu alanda ustalasmak zordur. Videolaringoskopi havayolu yonetiminde deneyimsiz medikal personel egitimi icin yaygin olarak kabul gormus bir tekniktir. Bu calismada deneyimsiz kullanicilarin direkt ve indirekt laringoskoplardaki performanslarini karsilastirmayi amacladik.Gerec ve yontemler: Daha once trakeal entubasyon deneyimi bulunmayan 58 birinci sinif anestezi teknikerligi ogrencisi calismaya dahil edildi. Standart 3 no’lu Macintosh, Miller, McCoy, McGrath, Storz C-Mac laringoskoplari kullanildi. Katilimcilardan AirMan mankeni her aygitla beser kez entube etmeleri istendi. Katilimcilarin bilgisayar oyunlarina karsi yatkinliklari da sorgulandi. Tum ogrenciler besinci entubasyonlarini tamamladiginda altinci entubasyonlari icin basarili trakeal entubasyon suresi, girisim sayisi, basari orani, dental travma siddeti ve kullanilan optimizasyon manevralari kaydedildi.Bulgular: Basarili entubasyon suresi 5.34±2.19 sn ile C-Mac laringoskop icin en dusuktu. Optimizasyon manevra gereksinimi ve ek entubasyon girisimleri C-Mac ve McGrath laringoskoplar icin Macintosh, Miller and McCoy laringoskoplarla karsilastirildiginda anlamli olarak daha dusuktu (p < 0.001). Dental travma insidansi C-Mac laringoskop kullaniminda anlamli olarak daha dusuktu (p < 0.001). Entubasyon kolayligi uzerine Gorsel analog skala skorlari C-Mac laringoskopla anlamli olarak daha dusuktu. Bilgisayar oyunlarina yatkinlikla iliskili bir avantaj dokumente edilemedi.Sonuc: Sonuc olarak normal havayolu senaryosunda C-Mac’in trakeal entubasyon icin daha yuksek genel basari orani ve daha dusuk dental travma insidansi sagladigi ortaya konuldu.

Background: The effect of intravenously administered dexmedetomidine on oxygenation during one-lung ventilation has not been studied. The hypothesis of this prospective, randomized study was that dexmedetomidine would be associated with an improvement in oxygenation during one-lung ventilation. The secondary outcome was the change in the intrapulmonary shunt. Materials and Methods: Thirty patients undergoing one-lung ventilation were included. Patients in Group D (n = 15) received a bolus dose of 1 μg·kg-1 dexmedetomidine at 10 min after induction of anaesthesia followed by an infusion of 0.4 μg·kg-1·hr-1 that was stopped at the end of the surgery, and those in the control group(Group C, n = 15) were given saline at the same dosage. Vital signs, PaO2, and pulmonary shunting (Qs/Qt) were compared. Results: During one-lung ventilation, the PaO2 in Group D increased significantly and Qs/Qt significantly decreased compared to Group C (PaO2, 203.7 ± 42.3 mmHg vs. 173 ± 37.6 mmHg [P = 0.04] and Qs/Qt 19.8% ± 4.5% vs. 31% ± 2.4% [P < 0.0001], Group D and Group C, respectively). Conclusion: Intravenous administration of dexmedetomidine achieved an improvement in oxygenation during one-lung ventilation. This was associated with a decrease in pulmonary shunt. Use of intraoperative dexmedetomidine during thoracic surgery can be suggested.

World Health Organization and the United States Center for Disease Control have recently recommended the use of 0.8 FIO2 in all adult surgical patients undergoing general anaesthesia, to prevent surgical site infections. This recommendation has arisen several discussions: As a matter of fact, there are numerous studies with different results about the effect of FIO2 on surgical site infection. Moreover, the clinical effects of FIO2 are not limited to infection control.

Introduction Video assisted thoracoscopic surgeries (VATS) as well as thoracotomies require multimodal analgesia. Erector spinae plane block (ESPB) is newly introduced and showed adequate analgesia after VATS (1). In this report, we aimed to investigate the analgesic efficacy of the ESPB in thoracoscopic surgeries. Methods Written informed consent was obtained from all patients (for use of images and information) in this report. Patients (ASA I to III) above 18 years undergoing VATS were enrolled. Prior to anesthesia induction, we performed unilateral, single-injection ESPB at the level of T5 with USG guidance (figure 1). We used 20mL of 0.5% bupivakain. Multimodal analgesia comprised morphine via patient controlled analgesia, NSAID and paracetamol. Postoperative pain was questioned at 1st, 4th, 12th, 24th, 36th, and 48th hours (at rest and cough) using visual analog scale (VAS). Morphine consumption, additional analgesic (tramadol 0.5 mg/kg) requirement were enrolled as well as complications, mobilization and feeding times. Results This case series consisted of 3 female and 10 male patients with a mean age of 57±7. Four of them underwent lobectomy and resting 9 segmentectomy. VAS values (at rest and cough) are summarized in table 1. Mean morphine consumption for 12th and 24th hours were respectively 27.7±5.5mg and 48.2±13.6mg. Eleven of study patients needed once additional analgesic at 5±2.4 hours. Mobilization time was postoperatively at 4.7±0.98 hours and feeding at 5.11±0.92 hours. There was no complication among patients. Discussion ESPB is a simple and safe block with USG and systemic complications are rare. We think that ESPB is a suitable and reliable option at rest; meanwhile multimodal analgesia is still essential to ensure adequate analgesia for dynamic pain control after VATS.

Objective Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for multimodal postoperative pain management. The purpose of this study was to evaluate the postoperative pain relief and opioid-sparing effects of dexketoprofen and lornoxicam after major orthopedic surgery. Methods After obtaining ethical committee approval and informed consent, 120 patients undergoing elective hip or knee replacement under general anesthesia were randomized to receive two intravenous injections of 50 mg dexketoprofen (GD), 8 mg lornoxicam (GL) or saline as placebo (GP) intravenously. Postoperatively, patient-controlled analgesia (PCA) morphine was started as a 0.01 mg.kg-1 bolus dose, with lockout time of 10 minutes without continuous infusion. Pain assessment was made using the Visual Analogue Scale (VAS) at rest or during movement at postoperative 1, 2, 4, 6, 8, 12, and 24 hours. Results The three groups were similar in terms of age, gender, American Society of Anesthesiologists (ASA) class, number of patients who underwent hip or knee surgery, weight, height, and operation duration. Patients in GD and GL demonstrated significantly reduced pain scores at rest and active motion compared to GP, with lower scores in the dexketoprofen group. Patients in GD and GL used significantly less morphine in the postoperative period compared to GP. The total morphine consumption of patients in GD was lower than in GL. Conclusion Intravenous application of 50 mg dexketoprofen twice a day and 8 mg lornoxicam twice a day improved analgesia and decreased morphine consumption following major orthopedic surgery. When the two active drugs were compared, it was found that dexketoprofen was superior to lornoxicam in terms of analgesic efficacy and opioid consumption.

Background The use of neuromuscular blocking agents is still controversial in myasthenic patients but rocuronium could be useful after the introduction of sugammadex as a selective antagonist. The aim of the study was to evaluate the use of rocuronium-sugammadex in myasthenic patients undergoing thoracoscopic thymectomy. Methods After ethical approval, 10 myasthenic patients undergoing videothoracoscopic-assisted thymectomy were enrolled in the study. Neuromuscular block was achieved with 0.3 mg/kg rocuronium and additional doses were given according to train-of-four (TOF) monitoring or movement of the diaphragm. Sugammadex 2 mg/kg was given after surgery. Recovery time (time to obtain a TOF value > 0.9) was recorded for all subjects. Result All patients were extubated in the operating room after administration of sugammadex. Mean rocuronium dose was 48 mg and the average operation time was 62 min. Recovery time after sugammadex administration was 111 s (min 35; max 240). Conclusions A rapid recovery of neuromuscular function was found in myasthenic patients receiving rocuronium when sugammadex was used for reversal. This combination could be a rational alternative for myasthenic patients for whom neuromuscular blockade is mandatory during surgery.

Fluid management during thoracic anesthesia remains as a challenge for the anesthesiologists. The "safe zone" between volume overload (risk of pulmonary edema) and hypovolemia (potential risk of renal failure) is hard to determine and narrow. Relationship between perioperative fluid administration and postoperative lung injury has been clearly demonstrated but lung injury can even occur after the most restrictive management. Multiple hit hypothesis and endothelial glycocalyx in addition to revised Starling equation can help us understand this dilemma. Although a "liberal" fluid strategy is out of question for thoracic surgery, evidence on "restrictive" and "goal-directed" fluid strategies are missing. New monitors with dynamic parameters can help to evaluate if the patient will respond to a fluid challenge. However, "volume responsiveness" should not be equated with volume deficiency, especially in a patient with thoracic epidural catheter. Fluid type (crystalloids or colloids) is also another unclear point, although balanced solutions should be preferred for crystalloids. Minimal discontinuation of oral hydration, early feeding and mobilization should be encouraged. This review summarizes current evidence on the topic and highlights unanswered questions.

Pain after thoracotomy is intense, and uncontrolled pain can have negative consequences such as impaired respiratory function, delayed recovery, and transition to chronic pain. The aim is to achieve efficient analgesia without further compromising respiratory system or increasing unwanted complication risks with a multimodal regimen. For this reason, thoracic epidural analgesia and recently paravertebral blocks have gained popularity. Proper preparation followed by comprehensive teamwork and meticulous follow-up can ensure patient comfort and safety.

Incidence of the requirement of prolonged mechanical ventilation after thoracic surgery appears to be decreasing. However, the importance of some severe and specific challenges remains the same. As an example, combination of prolonged air leakage and respiratory insufficiency can be considered as a double-edged sword. Besides the classical approach of “protective” ventilation, which should also be examined again and again, methods like “high-frequency jet ventilation” and “independent lung ventilation” should be considered in selected cases. Not at least, a physician dealing with the postthoracotomy patient should be familiar with the management of chest tubes in different cases.

World Health Organization and the United States Center for Disease Control have recently recommended the use of 0.8 FIO2 in all adult surgical patients undergoing general anaesthesia, to prevent surgical site infections. This recommendation has arisen several discussions: As a matter of fact, there are numerous studies with different results about the effect of FIO2 on surgical site infection. Moreover, the clinical effects of FIO2 are not limited to infection control. We asked some prominent authors about their comments regarding the recent recommendations.

OBJECTIVES In arthroscopic rotator cuff surgery for postoperative analgesia opioids, nonsteroid analgesics, and local anesthetics can be used. This study aimed to compare the effectiveness, additional analgesic requirements, patients satisfaction, and complications of single-shot interscalene and supraclavicular blocks. METHODS After obtaining the ethics committee's approval and informed consent, 50 ASA I-II patients were randomized to either the interscalene (GISB) or supraclavicular (GSCB) group. Preoperatively, patients received an ultrasonography-guided block using 30 ml of 0.5% bupivacaine. In the postoperative period, morphine patient-controlled analgesia was administered as a 0.3-mg/h basal dose and 1-mg bolus dose, with a 20-min lockout time. Postoperative visual analog scale (VAS; 0-10 cm) scores of the patients were evaluated at 4, 8, 12, and 24 h postoperatively; additional analgesic requirements, adverse effects, and complications were recorded. Patient satisfaction (PS) scores were evaluated after 24 h. RESULTS VAS scores at 4 h were lower in the GSCB group than in the GISB group, and the VAS scores at 8, 12, and 24 h were lower in the GISB group than in the GSCB group, with no statistical significance. Additional analgesic requirements was 28% in the GISB group and 68% in the GSCB group (p < 0.05). Total morphine consumption was lower in the GISB group than in the GSCB group (18.95±9.2 mg vs. 30.6 ± 9.6 mg; p < 0.001). PS scores were higher in the GISB group than in the GSCB group (7.0±1.0 vs. 6.1±0.9; p < 0.01). Adverse effects and complication rates were similar in both the groups. In GISB group, seven patients (28%) had nausea/vomiting, whereas in the GSCB group, 12 patients (48%) had nausea/vomiting. This difference was statistically insignificant. CONCLUSION Supraclavicular block can be considered as an alternative to interscalene block for arthroscopic shoulder surgery.

Myasthenia gravis (MG), an autoimmune disease of neuromuscular junction, is associated with an interaction with the muscle relaxants (MR). Thymectomy is often the method of choice for its treatment; anesthetic and also postoperative management require meticulous preoperative evaluation, careful monitoring, and adequate dose titration. The frequency of video-assisted thoracoscopic extended thymectomy (VATET) is also increasing, thus making the use of MR obligatory. Introduction of sugammadex into modern practice has provided a safe choice to the avoidance of prolonged action of MR also in patients with MG. Still, postoperative management of MG can be challenging, including the risks of prolonged mechanical ventilation, both cholinergic and myasthenic crisis, and drug interactions. This chapter aims to give information about some approaches to obtain a safe postoperative period in patients with MG. The general approach to MG and also other operations of myasthenic patients are not included within the range of this chapter.

OBJECTIVES Despite several risks, infraclavicular approaches to the brachial plexus gained popularity. The present study compared success rates, block onset times, block performance times, and frequency of adverse effects of vertical infraclavicular (VIB) and coracoid blocks (CB) in patients undergoing forearm surgery. METHODS After ethical committee approval and informed consent 40 patients undergoing forearm surgery were included. The brachial plexus was located using a nerve stimulator and an insulated pencil point needle. Thirty ml bupivacaine 0.5% was used for the block. The blocks were assessed every minute for the first 5 min, then every 5 min for 15 min and then every 15 min and at the end of the operation. RESULTS Block onset times of both groups were similar. Higher rates of sensory block were found in group CB at the 5th, 10th, and 15th minutes of assessment. Also higher rates of motor block were found in group CB at the 5th, 10th, 15th and 30th minutes of assessment. Time to perform block was shorter in group VIB. One patient in CB group required general anaesthesia. Except two vascular punctures in group CB no other side-effects were observed. CONCLUSION Coracapid block provided higher rates of sensorial and motor blocks in a similar onset time without serious complications. CB can be accepted as a safe and reliable alternative to VIB for forearm surgery.

Introduction: Postoperative cognitive dysfunction (POCD) is an adverse outcome of surgery that is more common after open heart procedures. The aim of this study is to investigate the role of tightly controlled blood glucose levels during coronary artery surgery on early and late cognitive decline. Methods: 40 patients older than 50 years undergoing elective coronary surgery were randomized into two groups. In the “Tight Control” group (GI), the glycemia was maintained between 80 and 120 mg dL−1 while in the “Liberal” group (GII), it ranged between 80–180 mg dL−1. A neuropsychological test battery was performed three times: baseline before surgery and follow-up first and 12th weeks, postoperatively. POCD was defined as a drop of one standard deviation from baseline on two or more tests. Results: At the postoperative first week, neurocognitive tests showed that 10 patients in the GI and 11 patients in GII had POCD. The incidence of early POCD was similar between groups. However the late assessment revealed that cognitive dysfunction persisted in five patients in the GII whereas none was rated as cognitively impaired in GI (p = 0.047). Conclusion: We suggest that tight perioperative glycemic control in coronary surgery may play a role in preventing persistent cognitive impairment. Resumo: Introdução: A disfunção cognitiva pós-operatória (DCPO) é um resultado adverso cirúrgico que é mais comum após cirurgias cardíacas abertas. O objetivo deste estudo foi investigar o papel dos níveis de glicose no sangue rigorosamente controlados durante a cirurgia coronariana no declínio cognitivo precoce e tardio. Métodos: Quarenta pacientes com idades acima de 50 anos e submetidos à cirurgia coronariana eletiva foram randomizados em dois grupos. No grupo “controle rigoroso” (GI), a glicemia foi mantida entre 80-120 mg.dL−1; enquanto no grupo “liberal” (GII), variou entre 80-180 mg.dL−1. A bateria de testes neuropsicológicos foi realizada três vezes: fase basal, antes da cirurgia e na primeira e décima segunda semana de acompanhamento no pós-operatório. DCPO foi definida como uma queda de um desvio padrão da fase basal em dois ou mais testes. Resultados: Na primeira semana de pós-operatório, os testes neurocognitivos mostraram que 10 pacientes no GI e 11 pacientes no GII apresentaram DCPO. A incidência de DCPO precoce foi semelhante entre os grupos. No entanto, a avaliação tardia revelou que a disfunção cognitiva persistiu em cinco pacientes no GII, enquanto nenhum paciente foi classificado como cognitivamente prejudicado no GI (p = 0,047). Conclusão: Sugerimos que o controle glicêmico rigoroso no perioperatório de cirurgia coronariana pode desempenhar um papel na prevenção da deterioração cognitiva persistente. Keywords: Glucose control, Cognitive dysfunction, Coronary artery bypass surgery, Palavras-chave: Controle glicêmico, Disfunção cognitiva, Cirurgia de revascularização do miocárdio

Background One-lung ventilation (OLV) results in alveolar proinflammatory effects, whereas their extent may depend on administration of anesthetic drugs. The current study evaluates the effects of different volatile anesthetics compared with an intravenous anesthetic and the relationship between pulmonary and systemic inflammation in patients undergoing open thoracic surgery. Methods Sixty-three patients scheduled for elective open thoracic surgery were randomized to receive anesthesia with 4 mg · kg⁻¹ · h⁻¹ propofol (n = 21), 1 minimum alveolar concentration desflurane (n = 21), or 1 minimum alveolar concentration sevoflurane (n = 21). Analgesia was provided by remifentanil (0.25 μg · kg⁻¹ · min⁻¹). After intubation, all patients received pressure-controlled mechanical ventilation with a tidal volume of approximately 7 ml · kg ideal body weight, a peak airway pressure lower than 30 cm H₂O, a respiratory rate adjusted to a Paco2 of 40 mmHg, and a fraction of inspired oxygen lower than 0.8 during OLV. Fiberoptic bronchoalveolar lavage of the ventilated lung was performed immediately after intubation and after surgery. The expression of inflammatory cytokines was determined in the lavage fluids and serum samples by multiplexed bead-based immunoassays. Results Proinflammatory cytokines increased in the ventilated lung after OLV. Mediator release was more enhanced during propofol anesthesia compared with desflurane or sevoflurane administration. For tumor necrosis factor-α, the values were as follows: propofol, 5.7 (8.6); desflurane, 1.6 (0.6); and sevoflurane, 1.6 (0.7). For interleukin-8, the values were as follows: propofol, 924 (1680); desflurane, 390 (813); and sevoflurane, 412 (410). (Values are given as median [interquartile range] pg · ml⁻¹). Interleukin-1β was similarly reduced during volatile anesthesia. The postoperative serum interleukin-6 concentration was increased in all patients, whereas the systemic proinflammatory response was negligible. Conclusions OLV increases the alveolar concentrations of proinflammatory mediators in the ventilated lung. Both desflurane and sevoflurane suppress the local alveolar, but not the systemic, inflammatory responses to OLV and thoracic surgery.