Clinical studies of anesthesia for thoracic surgery including provision and maintenance of safe one-lung ventilation and postthoracotomy analgesia.
Anesthesia management of the morbidly obese patient.
The appropriate dose of succinylcholine (SCH) in morbidly obese patients is unknown. We studied 45 morbidly obese (body mass index >40 kg/m2) adults scheduled for gastric bypass surgery. The response to ulnar nerve stimulation of the adductor pollicis muscle at the wrist was recorded using the TOF-Watch SX acceleromyograph. In a randomized double-blind fashion, patients were assigned to one of three study groups. In Group I, patients received SCH 1 mg/kg ideal body weight, in Group II 1 mg/kg lean body weight, and in Group III 1 mg/kg total body weight. After SCH administration, endotracheal intubating conditions were scored. The recovery from neuromuscular block was recorded for 20 min. There was no difference in the onset time of maximum neuromuscular blockade among groups, but maximum block was significantly less in Group I. The recovery intervals were significantly shorter in Groups I and II. In one third of the patients in Group I, intubating conditions were rated poor, whereas no patient in Group III had poor intubating conditions. Our study demonstrates that for complete neuromuscular paralysis and predictable laryngoscopy conditions, SCH 1 mg/kg total body weight is recommended.
View details for DOI 10.1213/01.ane.0000194876.00551.0e
View details for Web of Science ID 000234912900022
View details for PubMedID 16428539
The specialty of thoracic surgery has evolved along with the modem practice of anesthesia. This close relationship began in the 1930s and continues today. Thoracic surgery has grown from a field limited almost exclusively to simple chest wall procedures to the present situation in which complex procedures, such as lung volume reduction or lung transplantation, now can be performed on the most severely compromised patient. The great advances in thoracic surgery have followed discoveries and technical innovations in many medical fields. One of the most important reasons for the rapid escalation in the number and complexity of thoracic surgical procedures now being performed has been the evolution of anesthesia for thoracic surgery. There has been so much progress in this area that numerous books and journals are devoted entirely to this subject. The author has been privileged to work with several surgeons who specialized in noncardiac thoracic surgery. As a colleague of 25 years, the noted pulmonary surgeon James B.D. Mark wrote, "Any operation is a team effort... (but) nowhere is this team effort more important than in thoracic surgery, where near-choreography of moves by all participants is essential. Exchange of information, status and plans are mandatory". This team approach between the thoracic surgeon and the anesthesiologist reflects the history of the two specialties. With new advances in technology, such as continuous blood gas monitoring and the pharmacologic management of pulmonary circulation to maximize oxygenation during one-lung ventilation, in the future even more complex procedures may be able to be performed safely on even higher risk patients.
View details for PubMedID 15707342
The effect of patient position on the view obtained during laryngoscopy was investigated.60 morbidly obese patients undergoing elective bariatric were studied. Patients were randomly assigned into one of two groups. In Group 1, a conventional "sniff" position was obtained by placing a firm 7-cm cushion underneath the patient's head, thus raising the occiput a standard distance from the operating-table while the patient remained supine. In Group 2, a "ramped" position was achieved by arranging blankets underneath the patient's upper body and head until horizontal alignment was achieved between the external auditory meatus and the sternal notch. Following induction of general anesthesia, tracheal intubation was performed using a Video MacIntosh laryngoscope. The laryngoscopy and intubation sequences were recorded onto videotape. Three independent investigators, unaware as to which position the patient had been in at the time of tracheal intubation, then viewed the videotape and assigned a numerical grade to the best laryngeal view obtained.The "ramped" position improved the laryngeal view when compared to a standard "sniff" position, and this difference was statistically significant (P=0.037).The "ramped" position is superior to the standard "sniff" position for direct laryngoscopy in morbidly obese patients.
View details for Web of Science ID 000224972600005
View details for PubMedID 15527629
View details for DOI 10.1016/S1053-0770(03)00046-6
View details for Web of Science ID 000183865000002
View details for PubMedID 12827573
The tracheas of obese patients may be more difficult to intubate than those of normal-weight patients. We studied 100 morbidly obese patients (body mass index >40 kg/m(2)) to identify which factors complicate direct laryngoscopy and tracheal intubation. Preoperative measurements (height, weight, neck circumference, width of mouth opening, sternomental distance, and thyromental distance) and Mallampati score were recorded. The view during direct laryngoscopy was graded, and the number of attempts at tracheal intubation was recorded. Neither absolute obesity nor body mass index was associated with intubation difficulties. Large neck circumference and high Mallampati score were the only predictors of potential intubation problems. Because in all but one patient the trachea was intubated successfully by direct laryngoscopy, the neck circumference that requires an intervention such as fiberoptic bronchoscopy to establish an airway remains unknown. We conclude that obesity alone is not predictive of tracheal intubation difficulties.In 100 morbidly obese patients, neither obesity nor body mass index predicted problems with tracheal intubation. However, a high Mallampati score (greater-than-or-equal to 3) and large neck circumference may increase the potential for difficult laryngoscopy and intubation.
View details for Web of Science ID 000174031800047
View details for PubMedID 11867407
View details for Web of Science ID A1996UC48200032
View details for PubMedID 8615510
Data on the normal depth of insertion of double-lumen tubes have not been published. We studied 101 adult patients undergoing thoracic operations whose tracheas were intubated with a left double-lumen tube. A fiberoptic bronchoscope was introduced into the tracheal lumen, and the tube position was adjusted until the cephalad surface of the bronchial cuff was immediately below the carinal bifurcation. The average depth of insertion for both male and female patients 170 cm tall was 29 cm, and for each 10-cm increase or decrease in height, average placement depth was increased or decreased 1 cm. The correlation between depth of insertion and height was highly significant (P less than 0.0001) for both male and female patients. As depth of DLT insertion at any given height was normally distributed, a technique to confirm correct double-lumen tube position always should be used after initial placement.
View details for Web of Science ID A1991GL86500010
View details for PubMedID 1952136
View details for DOI 10.1097/AIA.0b013e3182960847
View details for PubMedID 23797647
Perineural catheter insertion with ultrasound guidance alone has been described, but it remains unknown whether this new technique results in the same procedural time and success rate for obese and nonobese patients. We therefore tested the hypothesis that obese patients require more time for perineural catheter insertion compared to nonobese patients despite using ultrasound.Data from 5 previously published randomized clinical trials comparing ultrasound- and stimulation-guided perineural catheter insertion techniques were reviewed, and patients who received ultrasound-guided catheters were divided into 2 groups: obese (body mass index ?30 kg/m(2)) and nonobese (body mass index <30 kg/m(2)). A standardized ultrasound-guided nonstimulating catheter technique was used with mepivacaine, 1.5% (40 mL), as the initial bolus via the placement needle for the primary surgical nerve block. The primary outcome was the procedural time for perineural catheter insertion. Secondary outcomes included block efficacy, procedure-related pain, fluid leakage, vascular puncture, and catheter dislodgment.A sample of 120 patients was identified: 51 obese and 69 nonobese. All obese patients had successful catheter placement compared to 68 of 69 (98%) nonobese patients (P = .388). The time for perineural catheter insertion [median (10th-90th percentiles)] was 7 (4-12) minutes for obese patients versus 7 (4-15) minutes for nonobese patients (P = .732). There were no statistically significant differences in other secondary outcomes.On the basis of this retrospective analysis, perineural catheter insertion is not prolonged in obese patients compared to nonobese patients when an ultrasound-guided technique is used. However, these results are only suggestive and require confirmation through prospective study.
View details for Web of Science ID 000295551300006
View details for PubMedID 21968486
View details for DOI 10.1097/EJA.0b013e3283474b53
View details for Web of Science ID 000292496100011
View details for PubMedID 21670689
The unique anesthetic risks associated with the morbidly obese (MO) population have been documented. Pharmacologic management of these patients may be altered because of the physiologic and anthropometric changes associated with obesity. Unfortunately, studies examining the effects of extreme obesity on the pharmacology of anesthetics have been sparse. Although propofol is the induction drug most frequently used in these patients, the appropriate induction dosing scalar for propofol remains controversial in MO subjects. Therefore, we compared different weight-based scalars for dosing propofol for anesthetic induction in MO subjects.Sixty MO subjects (body mass index ?40 kg/m(2)) were randomized to receive a propofol infusion (100 mg · kg(-1) · h(-1)) for induction of anesthesia based on total body weight (TBW) or lean body weight (LBW). Thirty control subjects (body mass index ?25 kg/m(2)) received a propofol infusion (100 mg · kg(-1) · h(-1)) based on TBW. Syringe drop was used as the marker for loss of consciousness (LOC), at which point the propofol infusion was stopped. The propofol dose required for syringe drop and time to LOC were recorded.Total propofol dose (mg/kg) required for syringe drop and time to LOC were similar between control subjects and MO subjects given propofol based on LBW. MO subjects receiving a propofol infusion based on TBW had a significantly larger propofol dose and significantly shorter time to LOC. There was a strong relationship between LBW and total propofol dose received in all 3 groups.LBW is a more appropriate weight-based scalar for propofol infusion for induction of general anesthesia in MO subjects.
View details for DOI 10.1213/ANE.0b013e3181f6d9c0
View details for Web of Science ID 000291971900011
View details for PubMedID 20861415
Obesity is associated with a number of anaesthetic-related risks. Regional anaesthesia offers many potential advantages for the obese surgical patient. Advantages include a reduction in systemic opioid requirements and their associated side effects, and possible avoidance of general anaesthesia in select circumstances, with a lower rate of complications. Historically, performing regional anaesthesia procedures in the obese has presented challenges due to difficulty in identifying surface landmarks and availability of appropriate equipment. Ultrasound guidance may aid the regional anaesthesia practitioner with direct visualisation of underlying anatomic structures and real-time needle direction. Further research is needed to determine optimal regional anaesthesia techniques, local anaesthetic dosage and perioperative outcomes in obese patients.
View details for PubMedID 21516914
Obese patients often may demonstrate an acquired prolonged QTc interval due to alteration in cardiac physiology, electrolyte disturbances, and/or medication use. Intraoperatively, bariatric surgery may further contribute additional cardiac stressors to obese patients with long QT syndrome (LQTS). We present a case report of an obese woman with LQTS who underwent laparoscopic Roux-en-Y gastric bypass surgery and sustained an intraoperative cardiac arrest. We discuss identification, prevention, and treatment strategies for LQTS in the bariatric surgery patient.
View details for DOI 10.1007/s11695-010-0137-8
View details for Web of Science ID 000286423600020
View details for PubMedID 20383601
Morbid obesity and bariatric surgery are both risk factors for the development of postoperative rhabdomyolysis (RML). RML results from injury to skeletal muscle, and a serum creatine phosphokinase (CK) level >1,000 IU/L is considered diagnostic of RML. The aim of this study was to determine if intraoperative intravenous fluid (IVF) volume affects postoperative CK levels following laparoscopic bariatric operations.Prospective, single blinded, and randomized trial was conducted.Patients scheduled to undergo laparoscopic sleeve gastrectomy, adjustable gastric band, or Roux-en-Y gastric bypass operations were randomized into two groups. Subjects in Group A received 15 ml/kg total body weight (TBW) of IV crystalloid solution during surgery, while subjects in Group B received 40 ml/kg TBW. Preoperative and postoperative CK and creatinine levels and intra- and postoperative urine output were monitored and recorded.Forty-seven patients were assigned to Group A and 53 patients to Group B. Group B patients had significantly higher urine output in the operating room, in the post-anesthesia care unit (PACU), and on postoperative days 0 and 1. Group B patients also had significantly lower serum creatinine level in the PACU and a trend towards lower creatinine levels on postoperative days 0, 1, and 2. There were no statistical differences in CK levels at any time between the two groups. Four patients in Group A and three patients in Group B developed postoperative RML.Conservative (15 ml/kg) versus liberal (40 ml/kg) intraoperative IVF administration did not change the incidence of RML in patients undergoing laparoscopic bariatric operations. Since the occurrence of RML in this patient population is relatively high, postoperative CK levels should be routinely obtained in patients at special risk.
View details for DOI 10.1007/s11695-010-0092-4
View details for Web of Science ID 000278289500004
View details for PubMedID 20198451
View details for DOI 10.1007/s11695-009-9992-6
View details for Web of Science ID 000273470100022
View details for PubMedID 19813064
Selective collapse of a lung and one-lung ventilation (OLV) is now performed for most thoracic surgical procedures. Modern double-lumen endobronchial tubes and bronchial blockers have made lung separation safe and relatively easy to achieve. However, OLV in the patient with a 'difficult airway' can present a challenge to the anaesthesiologist. This review considers the different techniques used to achieve lung separation and their application to the patient with a difficult airway.
View details for DOI 10.1093/bja/aep262
View details for PubMedID 20007992
Worldwide, the number of overweight and obese patients has increased dramatically. As a result, anesthesiologists routinely encounter obese patients daily in their clinical practice. The use of regional anesthesia is becoming increasingly popular for these patients. When appropriate, a regional anesthetic offers advantages and should be considered in the anesthetic management plan of obese patients. The following is a review of regional anesthesia in obesity, with special consideration of the unique challenges presented to the anesthesiologist by the obese patient.Recent studies report difficulty in achieving peripheral and neuraxial blockade in obese patients. For example, there is an increased incidence of failed blocks in obese patients compared with similar, normal weight patients. Despite difficulties, regional anesthesia can be used successfully in obese patients, even in the ambulatory surgery setting.Successful peripheral and neuraxial blockade in obese patients requires an anesthesiologist experienced in regional techniques, and one with the knowledge of the physiologic and pharmacologic differences that are unique to the obese patient.
View details for DOI 10.1097/ACO.0b013e32832eb7bd
View details for Web of Science ID 000270051500024
View details for PubMedID 19550304
View details for DOI 10.1007/s11695-008-9795-1
View details for Web of Science ID 000264848100027
View details for PubMedID 19089518
View details for PubMedID 19961116
View details for PubMedID 19961110
Unrecognized tension pneumothorax can have catastrophic consequences. We report a case of a patient who developed a contralateral tension pneumothorax during thoracotomy without the classic signs of marked hypoxemia and hemodynamic instability. A tension pneumothorax should be considered in any patient who develops high peak inspiratory pressures during one-lung ventilation with an open chest, even in the absence of the classic signs of hypoxemia and hypotension.
View details for DOI 10.1213/01.ane.0000287685.02860.47
View details for Web of Science ID 000251824300009
View details for PubMedID 18165551
Today, thoracic surgeons routinely perform complex operations on even the most complicated patient. However, just 75 years ago the ability to operate within the chest was strictly limited to only the simplest and quickest procedures. The dramatic advances in the specialty of thoracic surgery have closely paralleled the introduction of new anesthetic practices, equipment and drugs. This review will identify major events in the history of anesthesia for thoracic surgery.
View details for Web of Science ID 000250234700006
View details for PubMedID 17380101
The potential advantages of regional anesthesia include minimal airway intervention, less cardiopulmonary depression, excellent postoperative analgesia, less postoperative nausea and vomiting, and shorter recovery room and hospital stays. These concerns are particularly important for the obese surgical patient. This review discusses the application of regional anesthetic techniques in obesity. Further clinical studies are needed to fill the knowledge gap about regional anesthesia and outcome in obese and morbidly obese patients.
View details for Web of Science ID 000249112000002
View details for PubMedID 18074486
A patient with a prior left pneumonectomy required surgical drainage of a right upper lobe aspergilloma. A left double-lumen endobronchial tube was placed in the right bronchus intermedius, isolating the right upper lobe while allowing ventilation of the right middle and lower lobes.
View details for DOI 10.1213/01.ane.0000270106.22502.e2
View details for Web of Science ID 000248343400008
View details for PubMedID 17646485
This review considers the anesthetic management of obese patients undergoing thoracic surgery. Extremely or morbidly obese patients differ from patients of normal weight in several ways. Obese patients have altered anatomy and physiology, and usually have associated comorbid medical conditions that may complicate their operative course and increase their risks for postoperative complications.During anesthetic induction and laryngoscopy for tracheal intubation the morbidly obese patient should be in the reverse Trendelenburg position with the head and neck elevated above the table. Placement of a double-lumen tube should be no more difficult in an obese patient than in a normal-weight patient. There are no clear advantages for any of the commonly available inhalational anesthetic agents and each can be used for general anesthesia.With proper attention to their special needs, the morbidly obese patient can safely undergo thoracic surgery and one-lung ventilation.
View details for PubMedID 17211160
The prevalence of obesity is increasing worldwide. For severely obese patients, bariatric surgery is the only effective option for sustained weight loss and associated health improvement. As a consequence, the number of bariatric surgical procedures being performed is growing exponentially. Systematic knowledge regarding the effect of obesity on the pharmacokinetics and pharmacodynamics of anesthetic agents is generally lacking, and data for morbidly obese (body mass index [BMI] 40-49 kg/m2)) and super-obese patients (BMI > 50 kg/m2) are almost completely non-existent. Most drug-dosing guidelines are based on results from relatively small studies in moderately obese patients. Future systematic pharmacological research is needed for improved and more rational peri-operative care of morbidly obese patients.
View details for PubMedID 16831123
Laparoscopic Roux-en-Y gastric bypass (RYGBP) is a commonly performed operation for morbid obesity. A significant number of patients experience postoperative nausea and vomiting (PONV) following this procedure. The aim of this study was to determine the effect, if any, of intra-operative fluid replacement on PONV.Patients who underwent laparoscopic (RYGBP) for morbid obesity during a 12-month period were included in this retrospective analysis. Demographic data including age, gender, and body mass index (BMI) were collected. Perioperative data also included total volume of intra-operative fluids administered, rate of administration, urine output, length of surgery, and incidence of PONV as determined by nursing or anesthesia records in the postanesthesia care unit (PACU). Data were analyzed by t-test.The table below depicts demographic and perioperative data, comparing patients who experienced PONV (n=125) in the PACU with those who did not (n=55). Values are mean +/- standard deviation.PONV is a common complication after laparoscopic RYGB. Patient who did not experience PONV received a larger volume of intravenous fluid at a faster rate than similar patients who complained of PONV.
View details for Web of Science ID 000239131000007
View details for PubMedID 16839481
View details for Web of Science ID 000238156200009
View details for PubMedID 16756733
Preoperative assessment of blood volume (BV) is important for patients undergoing surgery. The mean value for indexed blood volume ((In)BV) in normal weight adults is 70 mL/kg. Since (In)BV decreases in a non-linear manner with increasing weight, this value cannot be used for obese and morbidly obese patients. We present an equation that allows estimation of (In)BV over the entire range of body weights.
View details for Web of Science ID 000238156200017
View details for PubMedID 16756741
Recent national efforts have focused on improving patient safety in surgical procedures including examining adverse events. An adverse event in laparoscopic Roux-en-Y gastric bypass (LRYGBP) which has not received much scrutiny involves orogastric tube complications during gastric pouch formation.Retrospective review was conducted of all LRYGBPs (n=727) performed by 5 surgeons over 5 years at 2 institutions. Cases with intraoperative orogastric tube (OGT) related complications (n=9) were identified.9 patients (1.2%) had preventable orogastric tube-related complications. Mean patient demographics were as follows: age 47 years, female 56%, pre-op BMI 52 kg/m(2), co-morbidities 3.5 and mortality 0%. 7 of 9 patients' cases were complicated by stapling of an orogastric tube during gastric pouch formation. The remaining 2 patients had complications involving suturing of the Levacuator tube during gastrojejunostomy formation. All complications required gastric pouch or anastomotic revision. 2 patients required conversion to an open procedure, 2 required re-operation for anastomotic leak, and 1 had respiratory failure and prolonged hospital stay.Orogastric tube complications can occur during laparoscopic RYGBP, but are seldom reported and can be associated with significant morbidity. Treatment options are dependent upon the situation. More importantly, prevention strategies must include constant communication with the anesthesiologist and removal or manipulation of an OGT prior to stapling or suturing, use of large bore OGTs for increased visual or tactile recognition, retraction of the OGT proximal to the anastomosis during gastrojejunal construction and employing alternatives to esophageal temperature probes (i.e. Foley temperature probes).
View details for Web of Science ID 000236566000166
View details for PubMedID 16608608
View details for DOI 10.1053/j.jvca.2005.01.036
View details for Web of Science ID 000237072000017
View details for PubMedID 16616665
View details for Web of Science ID 000235766400035
View details for PubMedID 16508416
View details for DOI 10.1053/j.jvca.2005.03.035
View details for Web of Science ID 000235490300034
View details for PubMedID 16458237
View details for DOI 10.1053/j.jvca.2005.07.016
View details for Web of Science ID 000233054400023
View details for PubMedID 16202909
A simple formula for estimating ideal body weight (IBW) in kilograms for both men and women is presented. The equation IBW = 22 x H2, where H is equal to patient height in meters, yields weight values midway within the range of weights obtained using published IBW formulae.
View details for Web of Science ID 000231046800299
View details for PubMedID 16105412
To determine which patient parameters best predict left bronchial width (LBW) when selecting the correct size double-lumen tube (DLT). If LBW is known, a DLT that will fit that bronchus can be chosen.Prospective study.University medical center.Three hundred twenty-one consecutive patients scheduled for thoracic surgery and for whom there was a chest radiograph and for whom tracheal width (TW) and LBW could be measured.Tracheal width and LBW were directly measured from the chest radiograph. Patient demographic data were recorded and then analyzed to see which factor(s) best predicted LBW. Parameters often used for DLT selection (age, sex, height, and weight) as well as TW were compared by univariate and multivariate statistical analysis to see which factor(s) most accurately predicted LBW.There were weak but significant correlations between age and height and LBW in men, and height and LBW in women. Multivariate statistical analysis showed that, for both men and women, TW was the best predictor of LBW. Sex, height, and weight did not improve predictability over TW alone. The equation that best predicts LBW for both sexes is: LBWmm = (0.50)(TWmm) + 3.7 mm. This model explains 46% of the variance in LBW. As structures measured from a chest radiograph are magnified by 10%, the formula to predict LBW, which normalizes for this magnification factor, is: LBWmm = (0.45)(TWmm(CXR)) + 3.3 mm.Direct airway measurement is the most accurate way to select an appropriate DLT. However, when direct measurement of LBW cannot be performed, estimating LBW from TW is a better predictor of LBW than either sex, height, or weight.
View details for DOI 10.1016/j.jclinane.2004.07.008
View details for Web of Science ID 000230236200006
View details for PubMedID 15950850
View details for Web of Science ID 000229492900012
View details for PubMedID 17080563
Thorough and timely anesthesia preoperative evaluation is essential for good patient outcomes. Perioperative care is becoming more complex and comprehensive, while older and sicker patients are being considered for major thoracic surgery. In addition to pulmonary and wound care, prevention of cardiac complications with beta-blocker therapy, multimodal pain control, tighter glycemic control, nutritional support, and prevention of thromboembolism are important perioperative goals. Early identification of significant medical and nonmedical issues allows for complete evaluation and planning and decreases the likelihood of delays, cancellations, and complications. Good communication and preparation benefit everyone. The implementation of an anesthesia preoperative assessment program or clinic can help achieve these important goals.
View details for PubMedID 15999528
Nitrous oxide (N2O) is frequently used to supplement more potent anesthetic agents. One side-effect of N2O is its ability to expand an air-containing space. We investigated if N2O adversely affected operating conditions by distending normal bowel during laparoscopic bariatric procedures.50 morbidly obese patients were divided into 2 study groups. Group 1 patients were ventilated with a halogenated anesthetic/oxygen/air mixture, while Group 2 received a halogenated anesthetic/oxygen/N2O mixture. At 30, 60, and 90 min intervals during the operation, the surgeon was asked if N2O was being used.The surgeons responded correctly only 42% (30 min), 50% (60 min), and 48% (90 min) of the time. In Group 2 (N2O) patients, they incorrectly answered that N2O was not being used 88% (30 min), 68% (60 min), and 68% (90 min); and in Group 1 (air) patients, they incorrectly answered that N2O was being used 28% (30 min), 32% (60 min), and 36% (90 min) of the time.We found that using N2O did not cause noticeable bowel distention during laparoscopic bariatric procedures of relatively short duration.
View details for Web of Science ID 000228911000006
View details for PubMedID 15946427
The debate continues as to whether a fiberoptic bronchoscope must be used to position a double-lumen tube. This review supports the argument that although bronchoscopy is extremely helpful, it is not always needed for the routine placement of left double-lumen tubes.Several recent clinical reports have demonstrated that an experienced anesthesiologist can safely and consistently position double-lumen tubes without bronchoscopic assistance. In order to do so several important factors must be considered. These include the appropriate choice of tube (left or right), size of tube, and endpoint for the depth of insertion.Although bronchoscopy is useful, no double-lumen tube positioning method is fail-safe. The choice of which approach to use, 'blind' versus fiberoptic bronchoscope-assisted, is influenced by many factors. Operator experience with any method increases the likelihood of success. A fiberoptic bronchoscope is not always needed for left double-lumen tube placement.
View details for PubMedID 17021523
View details for DOI 10.1053/S1053-0770(03)00212-X
View details for Web of Science ID 000186144400016
View details for PubMedID 14579222
View details for DOI 10.1213/01.ANE.0000063165.15467.1B
View details for Web of Science ID 000183148900060
View details for PubMedID 12761028
To familiarize anesthesiologists with recent advances in endoscopic pulmonary stenting. These interventions have replaced surgical procedures for the relief of central airway obstructions.A pulmonary stent can provide immediate relief of symptoms and improvement in pulmonary function for both intrinsic and extrinsic airway lesions. The current indications for the use of both silicone-rubber stents and expandable metal stents are reviewed. Considerations for the anesthetic management of patients undergoing pulmonary stent placement are also discussed.Tracheo-bronchial stenting procedures are being employed with increasing frequency. The practicing anesthesiologist must be familiar with the management of patients undergoing airway stenting procedures.
View details for PubMedID 17021444
Each of the different positions employed during surgery can compromise cardiopulmonary function in the morbidly obese patient. An understanding of the physiologic changes that can occur is essential for the successful management of these patients.
View details for Web of Science ID 000180505600007
View details for PubMedID 12568178
To determine if there is a relationship between tracheal width (TW) and left bronchial width (LBW).Three-dimensional chest computed tomography (CT) scans were used to reconstruct major airways for measurement of TW and LBW.Stanford University Medical Center, Stanford, California.Thirty-one adult patients undergoing chest CT scans.Cursors were used to directly measure internal diameter from coronal images of the trachea at midclavicular level and the left main bronchus at a level 1 cm below the carina.TW and LBW, but not the LBW-to-TW ratio, were significantly larger in men than in women. The LBW-to-TW ratio was consistent for men (0.75 +/- 0.09) and women (0.77 +/- 0.10).LBW is proportional to TW. If LBW cannot be measured directly but TW can, the ratio of LBW to TW can be used to predict LBW. An appropriate-sized left double-lumen tube can then be selected for the patient.
View details for Web of Science ID 000168082600014
View details for PubMedID 11312482
Modern techniques to isolate the lungs, coupled with accurate continuous non-invasive monitoring, have made single-lung ventilation safe and easy to perform. Most patients maintain an adequate arterial oxygen tension during single-lung ventilation. In order to maximize oxygenation, efforts are directed towards optimizing perfusion and ventilation to the ventilated lung or increasing the oxygen content of blood returning from the collapsed lung.
View details for PubMedID 17016387
Continuing advances in anesthesiology enable surgeons to perform more and more complex operations. Nowhere is this relation more important than for the patient undergoing thoracic surgery. Specialized anesthetic techniques including safe lung separation, the maintenance of oxygenation during selective one-lung ventilation, and effective postoperative analgesia allow procedures such as lung volume reduction surgery and lung transplantation to be performed routinely. This paper reviews modern clinical practices in the field of thoracic anesthesia.
View details for Web of Science ID 000168131500011
View details for PubMedID 11338017
Video-assisted thoracoscopic surgery is finding an ever-increasing role in the diagnosis and treatment of a wide range of thoracic disorders that previously required sternotomy or open thoracotomy. The potential advantages of video-assisted thoracoscopic surgery include less postoperative pain, fewer operative complications, shortened hospital stay and reduced costs. The following review examines the surgical and anesthetic considerations of video-assisted thoracoscopic surgery, with an emphasis on recently published articles.
View details for PubMedID 17016278
View details for Web of Science ID 000083982400019
View details for PubMedID 10589621
View details for Web of Science ID 000080974400017
View details for PubMedID 10392687
View details for Web of Science ID 000080974400013
View details for PubMedID 10392683
The routine practice of monitoring oxygenation, ventilation, circulation, and temperature during surgery is now the standard of care. However, with the possible exception of pulse oximetry and capnography, extensive physiologic monitoring has not been shown to reduce the incidence of adverse anesthetic-related events. Monitors are useful adjuncts, but they alone cannot replace careful observation by a vigilant anesthesiologist.
View details for Web of Science ID 000080356600013
View details for PubMedID 10331341
View details for Web of Science ID 000073194700015
View details for PubMedID 9583553
View details for Web of Science ID A1996UQ74400029
View details for PubMedID 8669693
A prospective analysis of placement of left-sided plastic double-lumen tubes in 100 patients is presented. Intubation of the left bronchus was successfully accomplished using only auscultation and clinical signs ("blind" placement) in 91 patients. Double-lumen tubes were positioned in less than five minutes in 84 patients. The most common problem encountered (30%) was initial intubation of the right main bronchus. Seven of these patients required bronchoscopic assistance to guide the tube into the left bronchus. There were four minor intraoperative complications due to DLT malposition that were recognized and corrected by withdrawing the tube slightly back in the bronchus. The plastic double-lumen tubes functioned properly during the procedure in all 100 patients.
View details for Web of Science ID A1995RX49400009
View details for PubMedID 8787258
To evaluate postthoractomy analgesia in patients receiving lumbar epidural hydromorphone versus intrapleural bupivacaine.A randomized, prospective, double-blind study.A university-affiliated medical center.Twenty patients undergoing lateral thoracotomy for either pulmonary wedge resection, lobectomy, or pneumonectomy.Nine patients received epidural hydromorphone, and 11 patients received intrapleural bupivacaine in the postoperative period.Severity of pain was assessed using a visual analog pain scale (VAPS) (0 to 100 mm) at 1, 3, and 5 hours. Patients receiving epidural hydromorphone had a statistically significant improvement in VAPS scores. Patients who received intrapleural bupivacaine did not achieve a significant reduction in pain scores. Nine of 11 patients in the intrapleural bupivacaine group had "failed" postoperative analgesia as defined by a VAPS greater than 30. Only 3 of 9 patients in the continuous epidural hydromorphone group had "failed" analgesia.Epidural hydromorphone is superior to intrapleural bupivacaine in achieving satisfactory pain outcomes during the first 5 hours after thoracotomy.
View details for Web of Science ID A1995TB74600009
View details for PubMedID 8547554
Patients with non-Hodgkins lymphoma undergoing autologous bone marrow harvest were studied in a prospective, randomized fashion. All patients received a general anesthetic consisting of intravenous thiopental, fentanyl, and vecuronium and were ventilated with oxygen and isoflurane. Group I (19) patients also were ventilated with nitrous oxide (70%) whereas patients in Group II (19) did not receive nitrous oxide. Bone marrow samples were obtained at the beginning and end of the harvest. Viability of bone marrow mononuclear cells was assessed with a colony-forming unit-granulocyte macrophage (CFU-GM) assay, CFU-GM growth is a marker for myeloid progenitor cells and is dependent on intact deoxyribonucleic acid synthesis. Rate of neutrophil engraftment after autologous bone marrow transplantation was also studied. Both groups of patients were statistically similar in age, weight, anesthetic duration, CFU-GM counts at both sample draws, and the time for successful engraftment. There appears to be no difference in bone marrow viability as assayed by both CFU-GM colony growth and engraftment in human bone marrow exposed to a general anesthetic with nitrous oxide.
View details for Web of Science ID A1995QP46200021
View details for PubMedID 7893033
Arterial tonometry has been introduced for continuous noninvasive measurement of blood pressure. The accuracy of this method depends on the performance of two components: a piezoelectric crystal array and an oscillometric cuff. This study evaluates overall performance of arterial tonometry in terms of the performance of these two components by comparing it with simultaneous recording of blood pressure from an intraarterial catheter.Seventeen adult patients were studied during general anesthesia. Blood pressure was measured with an intraarterial catheter and with an arterial tonometry system. Analog pressure waveforms were sampled at 100 Hz. Blood pressure measurements obtained by oscillometry were recorded by computer. Comparisons of mean blood pressure on a beat-by-beat basis were made with and without correction for the calibration error introduced by oscillometry.The difference between pairs of blood pressure determined by arterial tonometry and intraarterial measurement was 1.3 +/- 9.4 mmHg (mean +/- SD, bias +/- precision) with 88,158 pairs of measurements. The difference between blood pressure determined by oscillometry and intraarterial measurement was 2.4 +/- 7.5 mmHg (mean +/- SD) with 401 comparisons. After correcting for calibration error, the difference between the tonometry measurements and intraarterial measurements was -1.0 +/- 5.6 mmHg. Continuous episodes of discrepancy from intraarterial measurements in excess of 10 mmHg and lasting 5-60 s occurred 4.6 +/- 0.8 times per hour with tonometry and 12.6 +/- 1.4 times per hour with oscillometry.Discrepancies in blood pressure readings by arterial tonometry versus intraarterial measurement result from both the piezoelectric crystal array and the oscillometry used for calibration. Accuracy for individual measurement is inferior to oscillometry alone. The ability to detect significant changes of blood pressure more rapidly than with oscillometry alone is limited by the accuracy of the piezoelectric crystal component but is enhanced by the reduced interval between measurements.
View details for Web of Science ID A1994PG11900007
View details for PubMedID 8092502
View details for PubMedID 8268441
A method for detecting air leak when using a double-lumen endobronchial tube is described. The ventilatory circuit is directly attached to the lumen of the ventilated lung. A balloon is fitted snugly over the open lumen of the tube to the nonventilated lung. If lung separation is incomplete, the balloon will inflate with each ventilation.
View details for Web of Science ID A1993LH44100048
View details for PubMedID 8512424
Because evidence from uncontrolled, unblinded studies suggested fewer side effects from epidural hydromorphone than from epidural morphine, we employed a randomized, blinded study design to compare the side effects of lumbar epidural morphine and hydromorphone in 55 adult, non-obstetric patients undergoing major surgical procedures. A bolus dose of epidural study drug was given at least 1 h prior to the conclusion of surgery, followed by a continuous infusion of the same drug for two postoperative days. Infusions were titrated to patient comfort. Visual analog scale (VAS) pain scores, VAS sedation scores, and subjective ratings of nausea and pruritus were assessed twice daily. The two treatments provided equivalent analgesia. Sedation scores and prevalence of nausea did not differ significantly between groups. Prevalence of pruritus, however, differed significantly on postoperative day 1, with moderate to severe pruritus reported by 44.4% of patients in the morphine group versus 11.5% in the hydromorphone group (P < .01). On post-operative day 2, reports of pruritus by patients receiving morphine remained higher than those among the hydromorphone-treated subjects, although this difference was no longer statistically significant (32% vs. 16.7%, P = .18). We conclude that lumbar epidural morphine and hydromorphone afford comparable analgesia, but the occurrence of moderate to severe pruritus on the first postoperative day is reduced by the use of hydromorphone.
View details for Web of Science ID A1992KC86500008
View details for PubMedID 1281625
To evaluate the clinical use of a cardiorespiratory rate monitor in patients receiving epidural opioids following major surgery.For 6 hours during the night following surgery, patients were continuously monitored with a cardiorespiratory rate monitor and a pulse oximeter, as well as by an in-room observer.Postoperative surgical ward at a university hospital.Eight ASA physical status I and II patients ages 30 to 76 years.Any bradypneic, hypoxemic, bradycardic, or tachycardic event was confirmed by the observer and recorded.The cardiorespiratory rate monitor accurately identified true bradypneic episodes in five of the eight patients. There were no false-positive alarms. The respiratory rate monitor and the pulse oximeter identified one episode of hypoxemia. There were no episodes of bradycardia or tachycardia.The cardiorespiratory rate monitor is useful in patients at risk for bradypnea following surgery.
View details for Web of Science ID A1992JP81600006
View details for PubMedID 1384579
The pressure/volume characteristics of the bronchial cuff of a polyvinylchloride (PVC) double-lumen endobronchial tube (DLT) was compared with the inflatable cuff of a bronchial blocker. At the volumes needed to seal a series of rigid model bronchi the PVC DLT bronchial cuff consistently generated significantly lower pressures than the bronchial blocker cuff.
View details for PubMedID 1568005
View details for Web of Science ID A1992HP46100011
View details for PubMedID 1503292
Sixteen consenting patients scheduled for elective thoracotomy were enrolled into a randomized trial of epidural morphine and hydromorphone. Each patient had a lumbar epidural catheter placed preoperatively for the purpose of post-thoracotomy analgesia. Shortly before the end of the operative procedure each patient received 5 mg of morphine and 0.75 mg of hydromorphone via the epidural catheter. Blood was sampled at regular intervals following the opiate administration and patients were randomized to 1 of 7 cervical CSF sampling times. Blood and CSF samples were assayed for morphine and hydromorphone concentration to determine blood and CSF pharmacokinetic profiles. A maximum blood morphine concentration of 60 +/- 25 ng/ml (mean +/- S.D.) was obtained at 11 +/- 6 min (mean +/- S.D.). The blood hydromorphone peak of 14 +/- 13 ng/ml (mean +/- S.D.) occurred 8 +/- 6 min (mean +/- S.D.). The mean peak CSF opioid concentrations of 1581 ng/ml for morphine and 309 ng/ml for hydromorphone occurred 60 min after epidural administration. The blood and CSF pharmacokinetic profiles for morphine and hydromorphone are presented. These profiles are similar for the two drugs after lumbar epidural administration.
View details for Web of Science ID A1991FJ99300003
View details for PubMedID 1713663
View details for PubMedID 1907867
Forty-four patients were treated with a continuous infusion of lumbar epidural hydromorphone (0.05%) after thoracic operations. Postoperatively, visual analog pain scores were obtained. On postoperative day 1 and 2, more than 90% of the patients experienced either no pain (visual analog pain scale = 0) or mild pain (visual analog pain score = 1 to 3) at rest. The incidence of side effects (hypoventilation, pruritus, and nausea) was less than reported with other epidurally administered opioids. Continuous infusion of lumbar epidural hydromorphone produced safe, predictable analgesia after thoracotomy.
View details for Web of Science ID A1990EL24100006
View details for PubMedID 1700682
View details for PubMedID 1720030
Pressure damage to respiratory mucosa from overinflation of bronchial cuffs has been implicated as a cause of bronchial rupture, a rare but devastating complication of double-lumen endobronchial tubes (DLTs). We compared the pressure/volume characteristics of the bronchial cuffs of three different polyvinylchloride (PVC) DLTs and an equivalent sized red-rubber Robertshaw DLT. At the volume needed to seal effectively our bronchial model, two of the three PVC tube cuffs tested generated significantly less pressure than did that of the cuffs of the third PVC and the red-rubber Robertshaw tubes.
View details for Web of Science ID A1989AX41300010
View details for PubMedID 2802196
View details for PubMedID 2520924
Severe intraoperative hypoxaemia occurred in a previously healthy 19-yr-old accident victim. Although rare, major lung collapse secondary to mucous plugging should be considered in the differential diagnosis of intraoperative hypoxaemia, particularly following major trauma.
View details for Web of Science ID A1989T064000021
View details for PubMedID 2923772
Sixty healthy surgical patients were monitored during surgery with a pulse oximeter. At the completion of the operation, nitrous oxide and oxygen were discontinued abruptly in 50 of these patients. During air breathing, a small drop in arterial hemoglobin oxygen saturation (SaO2), to about 4% below preoperative values, was observed in all patients. In 10 patients, only oxygen was given before removal of the mask. There was no sudden drop in SaO2 in these patients, but by 5 minutes after discontinuation there was no difference between the two groups of patients--SaO2 was reduced 2 to 3% below preoperative values in both groups. For patients without cardiopulmonary disease, the phenomenon of "diffusion hypoxia" is a mild and transient event. Clinically significant hypoxemia (SaO2 less than 90%) after removal of nitrous oxide/oxygen at the completion of the anesthetic occurred in 3 patients (6%) and was associated with airway obstruction in each case.
View details for Web of Science ID A1988Q419800003
View details for PubMedID 3193147
View details for Web of Science ID A1988M768100023
View details for PubMedID 3354877
View details for PubMedID 2979124
View details for PubMedID 2980375
Two matched groups of patients with Hodgkin's disease undergoing a staging laparotomy received thiopentone, pancuronium bromide or suxamethonium 1.0 mg kg-1 (group 2) to facilitate tracheal intubation. There were no differences in the sites or degree of postoperative myalgia between the groups. It is concluded that efforts to reduce the frequency of suxamethonium muscle pains in patients having major abdominal operations are not justified.
View details for Web of Science ID A1980JE97400012
View details for PubMedID 7362724
View details for Web of Science ID A1979GP62000027
View details for PubMedID 434522
View details for Web of Science ID A1979HL46100017
View details for PubMedID 475029
View details for Web of Science ID A1978GD35900024
View details for PubMedID 34414