Journal of cardiothoracic and vascular anesthesia最新文献

This is the first part of a series of articles prepared for a comprehensive, international, and professional society-approved consensus project to advise on thoracic anesthesia. It represents the views and structured opinions of experts delegated to the General Management: Monitoring Task Force of the Thoracic Subcommittee of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC). This review highlights international leaders' main concepts and expert opinions on how monitoring is the core task of anesthesiologists involved in the care of thoracic patients, providing recommendations for assessing principal organ systems and using different devices in routine and specialized scenarios. The consensus statement addresses the following main clinical topics and questions: (1) What constitutes standard basic and advanced monitoring? (2) What are the overall goals and means of monitoring the respiratory system? (3) How shall we monitor the circulation in thoracic anesthesia? (4) What are the main aspects of monitoring neuromuscular blockade? (5) What are the best practices for monitoring the depth of anesthesia and neurologic function? (6) What are the research priorities for thoracic anesthesia monitoring? (7) The authors briefly discuss how these recommendations relate to the concepts of good clinical practice and enhanced recovery. This document was developed and formally evaluated by senior clinicians representing the core membership of the EACTAIC Thoracic Subspecialty Committee from Europe, the United States, Africa, and the Middle East. Although a high-level evidence base is generally limited and significant controversies remain, all recommendations of the Task Force achieved an agreed (>60%), strong (>80%), or sometimes full (>95%) consensus. This consensus should serve as a consolidation of diverse practices of thoracic anesthesia and a starting point toward obtaining more robust evidence to further enhance our clinical practice in the future.

This article is the third in a series of articles prepared as part of a comprehensive, international and professional society-approved consensus project to advise on thoracic anesthesia. It represents the views and structured opinions of experts delegated to the Airway Management Task Force of the Thoracic Subcommittee of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC). This review highlights the main concepts and expert opinion of international leaders on the task of lung isolation and separation, as well as the current recommendations on the benefits and disadvantages of different devices in both routine and difficult airway scenarios. The consensus statement addresses the following main clinical topics and questions: (1) What are the overall goals and means of lung isolation and separation? (2) What are the best practices for using double-lumen tubes? (3) What is the role of alternative devices, specifically bronchial blockers? (4) What are the best practices for managing a difficult airway? (5) What are the recommendations for special cases? (6) What are the research priorities for thoracic anesthesia regarding airway management? The authors conclude with a brief reference to how these recommendations relate to the concepts of good clinical practice and enhanced recovery. The document was developed and formally evaluated by senior clinicians representing the core membership of the EACTAIC Thoracic Subcommittee from Europe, the United States, Africa, and the Middle East. Although the high-level evidence base is generally limited and significant controversies remain, all recommendations of the Task Force achieved an agreed (>60%), strong (>80%), or sometimes full (>95%) consensus. This consensus should serve as a consolidation of diverse practices of thoracic anesthesia and a starting point toward obtaining stronger evidence to further enhance our clinical practice in the future.

Objective: Circadian rhythms influence cardiovascular physiology and surgical stress responses, raising the possibility that the timing of cardiac surgery may affect outcomes. Previous studies have reported conflicting results regarding whether morning (AM) versus afternoon (AF) surgery influences perioperative morbidity and mortality. The present study aimed to systematically evaluate whether the timing of cardiac surgery, specifically AM versus AF procedures, influences short-term outcomes.

Design: A meta-analysis of observational cohort studies.

Settings: Cardiovascular centers.

Participants: Patients who underwent elective cardiac surgery.

Interventions: The AM or the AF group.

Measurements: The primary outcome was hospitalized mortality. Secondary outcomes included major morbidities (new-onset atrial fibrillation, myocardial infarction, stroke, renal and infectious complications, reexploration, mechanical circulatory support) and postoperative recovery profiles (mechanical ventilation duration, length of stay [LOS] in the intensive care unit and hospital).

Main results: Fourteen observational studies involving 135,672 patients (81,391 in the AM group and 54,281 in the AF group) were included. Pooled analysis showed no significant difference in hospitalized mortality between the two groups (1.25% [998/79,550] v 1.17% [615/52,442], OR = 1.09, 95% CI = 0.99 to 1.21; p = 0.08]. The incidences of myocardial infarction, stroke, renal and infectious complications, reexploration, and mechanical circulatory support use were also comparable. However, AM surgery was associated with a modestly higher incidence of new-onset atrial fibrillation (26.05% [2,319/8,907] v 25.50% [1,000/3,921], OR = 1.11, 95% CI = 1.01 to 1.21; p = 0.03). No significant differences were observed in mechanical ventilation duration [MD = -0.20 hours, 95% CI = -0.40 to 0.00; p = 0.05], intensive care unit LOS [MD = -0.35 hours, 95% CI = -6.14 to 5.43; p = 0.90], or hospital LOS [MD = -0.10 days, 95% CI = -0.39 to 0.19; p = 0.49].

Conclusions: These findings suggest that circadian influences on elective cardiac surgical outcomes are limited. Future multicenter prospective studies are warranted to further define the role of surgery timing in high-risk populations.

Objectives: To compare injectate spread between superficial parasternal intercostal plane (SPIP) and deep parasternal intercostal plane (DPIP) blocks, and to evaluate anatomical factors relevant to procedural safety. We hypothesized that DPIP blocks provide greater cranio-caudal distribution than SPIP blocks.

Design: An anatomical cadaveric study.

Setting: Secondary-level academic anatomy facility in northern Italy, within a body donation program.

Participants: Five fresh-frozen human cadavers (10 hemithoraces).

Interventions: Ultrasound-guided SPIP and DPIP blocks were performed bilaterally at the third intercostal level using a 22-gauge, 50 mm needle. Each injection delivered 20 mL of diluted black tissue-marking dye (1:5 ratio with saline).

Measurements and main results: Gross dissection assessed the cranio-caudal spread of dye by the number of intercostal spaces. Histology measured the distance between the internal thoracic artery and the fourth rib. DPIP blocks spread across more intercostal spaces than SPIP blocks (median 4, IQR 4-5 vs median 2, IQR 2-2; p < 0.001). Histological analysis showed the internal thoracic artery was a median 1.9 mm (IQR 1.7-2.2) from the fourth rib, separated only by soft tissue.

Conclusions: DPIP blocks produce a wider craniocaudal spread than SPIP blocks, which may enhance clinical efficacy. However, their close proximity to the internal thoracic artery and pleura underscores safety considerations.

Objective: The optimal tidal volume for patients undergoing thoracic surgery with one-lung ventilation (OLV) remains unclear. This study aimed to evaluate whether driving pressure-guided tidal volume titration could reduce lung injury in these patients.

Design: Prospective, single-center, randomized controlled trial.

Setting: Single-center academic hospital in China.

Participants: A total of 96 patients undergoing thoracic surgery with OLV.

Interventions: Patients were randomly assigned to either the driving pressure-guided tidal volume group (n = 46) or the control group (n = 50). In the control group, tidal volume was set at 8 mL/kg of predicted body weight (PBW) during OLV. In the driving pressure-guided group, tidal volume was adjusted to maintain a driving pressure between 8 and 10 cm H₂O, with modifications within 4 to 8 mL/kg PBW during OLV.

Measurements and main results: The primary outcome was the concentration of interleukin 6 (IL-6) in the dependent lung following OLV. The tidal volume in the driving pressure-guided group was 4.65 [4.23-5.65] mL/kg at 15 minutes and 4.58 [4.27-5.41] mL/kg at 45 minutes of OLV. The concentration of IL-6 in the dependent lung after OLV was significantly lower in the driving pressure group (5.31 [3.62]) compared to the control group (7.37 [5.21]) (mean difference: -0.46 [-0.86 to -0.05] cm H₂O; p = 0.025). There were no significant differences between groups in the incidence of postoperative pulmonary complications or in the oxygenation index 45 minutes after the start of OLV.

Conclusions: Driving pressure-guided tidal volume titration significantly reduces IL-6 levels in bronchoalveolar lavage fluid from the dependent lung following OLV in patients undergoing thoracic surgery, compared to conventional ventilation using 8 mL/kg PBW.