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INTRODUCTION - Double aortic arch is a rare congenital malformation of the aortic arch that most frequently presents in childhood. Early surgical intervention typically yields excellent outcomes.
OBJECTIVES - To describe aortotracheal fistula as a rare, yet serious complication of vascular ring and subsequent aortic aneurysm in an adult patient.
METHODS - Clinical history, as well as radiographic and endoscopic imaging were obtained to describe the development, diagnosis, and clinical course of this patient's aortotracheal fistula. Additionally, follow up data was obtained to document the healing of this fistula after surgical repair.
RESULTS - We describe a case of a 46-year-old male with DiGeorge Syndrome and a double aortic arch, repaired in childhood, which developed into an aortotracheal fistula after tracheostomy placement as an adult.
CONCLUSIONS - This case demonstrates that dangerous complications of a double aortic arch can persist into adulthood, even after surgical repair in infancy. Each patient's unique anatomy must be considered when thinking about airway management and prevention of complications of this rare congenital anomaly.
BACKGROUND - Routine manometry is recommended to prevent complications during therapeutic thoracentesis, but has not definitively been shown to prevent pneumothorax or reexpansion pulmonary edema. As chest discomfort correlates with negative pleural pressures, we aimed to determine whether the use of manometry could anticipate the development of chest discomfort during therapeutic thoracentesis.
METHODS - A retrospective chart review of 214 consecutive adults who underwent outpatient therapeutic thoracentesis at our institution between January 1, 2011 and June 30, 2013 was performed. We compared preprocedural to postprocedural discomfort (using a linear analog scale from 0 to 10) in patients undergoing thoracentesis with or without manometry. We used a multivariate model to adjust for possible confounders. Changes of dyspnea scores were also analyzed.
RESULTS - Manometry was performed in 82/214 patients (38%). On univariate and multivariate analyses, neither the change in chest discomfort nor dyspnea scores was significantly different in the manometry versus the control group (P=0.12 and 0.24, respectively). Similar results were also found in the subgroup of large-volume thoracentesis (P=0.32 for discomfort, P=1.0 for dyspnea).
CONCLUSIONS - In our retrospective study, the use of manometry did not appear to anticipate the development of chest discomfort during therapeutic thoracentesis. Prospective studies are needed to confirm these findings.
PURPOSE OF REVIEW - Chronic pain after surgery is a major public health problem and a major concern for perioperative physicians. Thoracic surgery presents a unique challenge, as thoracotomy is among the highest risk surgeries to develop persistent postsurgical pain. The purpose of this review is to discuss the relevance of research in pain epigenetics to patients with persistent pain after thoracic surgery.
RECENT FINDINGS - Recent advances have linked chronic pain states to genetic and epigenetic changes. Progress in our understanding of chronic pain has highlighted the importance of immune modulation of pain. It is possible that epigenetic changes driving chronic pain occur in the perioperative setting via histone modification and DNA methylation.
SUMMARY - The transition from acute to chronic pain after thoracic surgery may be mediated by epigenetics. Here, we discuss epigenetic modifications that have been discovered in animal models of chronic pain that may predispose patients to persistent neuropathic pain after thoracic surgery.
BACKGROUND - We evaluated focused training in lung hilar dissection with a reanimated porcine lung model in the boot camp setting.
METHODS - A total of 64 first-year cardiothoracic surgical residents participated in four consecutive hours devoted to training in open hilar dissection as part of the Thoracic Surgical Directors Association boot camps. Each resident participated in two open hilar dissections. Component tasks were assessed on a 5-point rating scale for the first and second dissections.
RESULTS - Immediate assessment performed after completion of the session showed improvements in all graded components. The mean total score on a 50-point scale improved significantly between the first and second repetition (36.03 ± 7.03 to 41.16 ± 6.95; p = 0.001).
CONCLUSIONS - Focused massed (single-session) practice in the boot camp setting improved the ability of residents to perform hilar dissection on simulators using reanimated porcine lung models. Given these early successes in massed simulation-based surgical education, there is good reason to expect that deliberate and distributed practice on similar simulators would improve resident education in cardiothoracic surgery.
Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
BACKGROUND - Acute kidney injury (AKI) is common after cardiac surgery, and expeditious recognition with specific biomarkers may help improve outcome.
OBJECTIVE - Because the economic impact of a biomarker-based diagnostic strategy is unknown, we assessed the cost-effectiveness of using urinary neutrophil gelatinase-associated lipocalin (NGAL) for the diagnosis of AKI after cardiac surgery compared with current diagnostic methods.
METHODS - A decision analysis model was developed using the societal perspective to evaluate the cost-effectiveness of NGAL. Cost per quality-adjusted life-year (QALY) was determined for NGAL and standard strategies. The base case was a 67-year-old male patient undergoing coronary artery bypass graft surgery in the United Kingdom. Multiple sensitivity analyses were performed to determine how cost-effectiveness would vary with changes in the underlying clinical and economic variables.
RESULTS - The base case yielded expected costs of £4244 and 11.86 QALYs for the NGAL strategy compared with £4672 and 11.79 QALYs for the standard therapy. The cost-effectiveness ratio for the NGAL strategy was £358/QALY compared with £396/QALY for the standard regimen. Cost-effectiveness increased as the treatment effect-defined as the ability to prevent progression of established AKI (kidney injury or failure)-for the therapy triggered by an elevated NGAL level rose. Sensitivity analysis demonstrated that the model was most responsive to the probability of developing AKI and least sensitive to the test cost for NGAL. Probabilistic sensitivity analysis supported the NGAL strategy as the most cost-effective option. Because this study was a decision analysis model incorporating a nonspecific treatment for AKI (as opposed to an observational study or controlled trial), model structural assumptions may therefore have underestimated mortality and the likelihood of developing AKI, although these were tested in multiple sensitivity analyses. Indirect costs were also not explicitly factored.
CONCLUSION - The use of urinary NGAL after cardiac surgery appears to be cost-effective in the early diagnosis of AKI.
Copyright © 2011 Elsevier HS Journals, Inc. All rights reserved.
PURPOSE - We hypothesized that patients who received ketamine during thoracic surgery would benefit from suppression of the inflammatory cascade, represented by lower interleukin (IL)-6 and C-reactive protein (CRP) plasma levels.
METHODS - This study was a randomized, double blind, placebo controlled clinical trial of ketamine in patients undergoing thoracic surgery. The setting was a single university teaching hospital. Forty patients who presented to the preoperative clinic prior to thoracic surgery (20 control, 20 treatment) were randomized to receive either a 0.5 mg/kg ketamine bolus or an equivalent volume of normal saline intravenously prior to chest wall incision. Plasma samples taken prior to induction of anesthesia and at 24 h following surgery were assayed for IL-6 and CRP levels. Verbal pain scores were reported at 4 and 24 h following surgery and at discharge.
RESULTS - IL-6 plasma levels did not differ significantly at 24 h for patients receiving ketamine (245 ± 287 pg/ml, mean ± SD) compared to patients who received placebo (269 ± 210 pg/ml), p = 0.39. Additionally, CRP levels at 24 h were not significantly different (8.8 ± 4.5 mg/dl for ketamine, 9.3 ± 5.6 mg/dl for placebo patients), p = 0.37. Finally, verbal pain scores were not significantly different between patient groups at 4 or 24 h, or at discharge.
CONCLUSIONS - These findings suggest that the routine use of a single dose of ketamine prior to chest wall incision is not effective at reducing pain or inflammation in thoracic surgery patients at 24 h postoperatively.
PURPOSE OF REVIEW - The purpose of this review is to examine the evidence for and the clinical use of continuous positive airway pressure (CPAP) and positive end-expiratory pressure (PEEP) for the management of one-lung ventilation during thoracic surgery. CPAP and PEEP use are important as we are increasingly challenged with patients with less respiratory reserve and greater comorbidity leading to the need for greater clinical management and more interventions during one-lung ventilation for thoracic surgery to prevent perioperative complications.
RECENT FINDINGS - The focus of this article is on the most recent literature with selected classic articles. First, the supportive literature and rationale for application of PEEP, CPAP or both during thoracic surgery are reviewed, relative to the threats of hypoxemia, hyperoxia and mechanical lung injury. The second part of the article focuses on the clinical use of PEEP and CPAP. Algorithms for the application of CPAP and PEEP to patients both at risk and not at risk of acute lung injury are presented.
SUMMARY - CPAP and PEEP are useful not only to treat hypoxia and atelectasis as the consequence of one-lung ventilation, perhaps more importantly, also as part of a protective lung-ventilation strategy to ameliorate mechanical stress and prevent acute lung injury.