Abstract Background Pneumoperitoneum and extreme positioning during robotic surgery impose substantial mechanical load on the respiratory system. Whether bedside electrical impedance tomography (EIT) is beneficial for individualized positive end-expiratory pressure (PEEP) titration under routinely high-PEEP ventilation remains uncertain. We assessed the feasibility and benefits of EIT-guided PEEP titration during clinical routine and explored whether pre-EIT respiratory parameters or anthropometric variables can predict EIT-guided best PEEP and EIT endpoints: lung collapse reduction, overdistention reduction, and regional ventilation delay reduction in routine perioperative care. Materials and methods Prospective observational study in 177 patients undergoing elective robotic procedures spanning steep Trendelenburg (e.g., prostate/rectal) and non-Trendelenburg (e.g., adrenalectomy) positions with a laparoscopic pressure of 20 cmH2O. After establishing pneumoperitoneum and final positioning, EIT (OD–CL crossing-point method) was used to titrate PEEP. Primary endpoints were EIT-guided best PEEP and change in PEEP. Secondary endpoints were change in dynamic compliance (Cdyn), driving pressure (DP), and mechanical power (MP) normalized to Cdyn (MPadj), as well as EIT-derived endpoints: lung collapse reduction, overdistention reduction, and regional ventilation delay reduction. Associations between pre-EIT variables and outcomes were tested by correlations and ROC analysis. Results For the primary endpoints, EIT-guided PEEP increased pre-EIT PEEP from 12.0 ± 2.0 to 14.8 ± 2.1 cmH2O and, hence, by 2.8 ± 2.3 cmH2O. Of the secondary endpoints, Cdyn improved in 82% of the patients after EIT-guided PEEP titration. DP lowered in 31% of the patients, with post-EIT DP of ≤ 15 cmH2O. Despite mechanical gains, MPadj increased on average from 0.42 to 0.43 J·cmH2​O·min−1ml−1. Concerning the EIT-derived endpoints, lung collapse reduction was 88%, overdistention reduction was 12%, and regional ventilation delay reduction was 30%. Proportions in secondary endpoints did not differ across surgical subgroups. Baseline anthropometrics showed poor predictive value for EIT-guided best PEEP (strongest correlation with MPadj: r = 0.33, R2 = 0.109) and change in PEEP (strongest correlation with the difference between laparoscopic pressure and PEEP (lap. pressure-PEEP), r = 0.38; R2 = 0.144). Pre-EIT Cdyn best signalled lung collapse reduction with an ROC-derived cutoff < 45.75 ml/H2O (accuracy 0.82, sensitivity 0.84, specificity 0.68). Discussion EIT-guided PEEP titration improved ventilation parameters in a heterogeneous robotic cohort with high abdominal pressure subject to high-PEEP, maintaining lung-protective ventilation. Pre-EIT respiratory data and anthropometric variables were insufficient for the reliable prediction of EIT-guided best PEEP. Our study demonstrates that EIT can be implemented in clinical routine and allows for individualization of respiratory treatment during robotic surgery, subject to high-PEEP ventilation. Clinical trial number Not applicable.

Spontaneous ventilation video-assisted thoracoscopic surgery (SV-VATS) has been propagated for nearly two decades without a prospective in-depth analysis of anaesthetic management and anaesthetic processing times. This would be important as anaesthetic management of SV-VATS imposes fundamental changes to standards in thoracic anaesthesia and may increase anaesthetic risks. Therefore, this study aimed to provide such in-depth analysis and compare the results to data from matched intubated VATS (I-VATS) patients. 3D-reconstruction of bronchial airways helped to estimate the risk reduction by avoiding double-lumen tube (DLT) intubation according to common selection methods in SV-VATS patients. SV-VATS patients receiving anatomical (N = 22) and non-anatomical (N = 16) lung cancer resections were prospectively enrolled. A retrospective I-VATS control cohort (N = 76) allowed for a 2:1 propensity score matching. DLT sizes necessary for SV-VATS patients according to common selection methods were evaluated by 3D-reconstruction of the left main bronchus and the ≥ 1 mm criterion. SV-VATS patients required substantially less propofol dosage (P < 0.001) with an increase in variability of drug dosing (P < 0.001) and higher BIS values (P < 0.001) as compared to I-VATS patients. SV-VATS lead to higher variability in respiratory parameters (P < 0.001) with less driving pressure (P < 0.001) and similar mean tidal volumes, oxygenation, and hemodynamic parameters compared to I-VATS. Spontaneous ventilation was achieved by allowing for permissive hypercapnia and respiratory acidosis. Anaesthetic processing time was reduced by 7 min (P < 0.001). 5–10

Abstract Background Appropriate selection of double-lumen tube sizes for one-lung ventilation is crucial to prevent airway damage. Current selection methods rely on demographic factors or 2D radiography. Prediction of left bronchial diameter is indispensable for choosing the adequate tube size. This prospective observational study investigates if current selection methods sufficiently predict individuals’ left bronchial diameters for DLT selection compared to the 3D reconstruction. Methods 100 patients necessitating thoracic surgery with one-lung ventilation and left-sided double-lumen tubes, ≥ 18 years of age, and a set of chest X-rays and 2D thorax CT scans for 3D reconstruction of the left main bronchus were included between 07/2021 and 06/2023. The cross-validated prediction error and the width of the 95%-prediction intervals of the 3D left main bronchial diameter utilizing linear prediction models were based on current selection methods. Results The mean bronchial diameter in 3D reconstruction was 13.6 ± 2.1 mm. The ranges of the 95%-prediction intervals for the bronchial diameter were 6.4 mm for demographic variables, 8.3 mm for the tracheal diameter from the X-ray, and 5.9 mm for bronchial diameter from the 2D-CT scans. Current methods violated the suggested ‘≥1 mm’ safety criterion in up to 7% (men) and 42% (women). Particularly, 2D radiography overestimated women’s left bronchial diameter. Current methods even allowed the selection of double-lumen tubes with bronchial tube sections greater than the bronchial diameter in women. Conclusions Neither demographic nor 2D-radiographic methods sufficiently account for the variability of the bronchial diameter. Wide 95%-prediction intervals for the bronchial diameter hamper accurate individual double-lumen tube selection. This increases women’s risk of bronchial damage, particularly if they have other predisposing factors. These patients may benefit from 3D reconstruction of the left main bronchus. Trial registration Not applicable.

BACKGROUND:Severe QT interval prolongation requires monitoring QTc intervals during anaesthesia with recommended therapeutic interventions at a threshold of 500 ms. The need for 12-lead ECG and lack of standardisation limit such monitoring. We determined whether automated continuous intraoperative QTc monitoring with 5-lead ECG measures QTc intervals comparable to 12-lead ECG and whether the interpretation of QTc intervals depends on the correction formulae and the patient's sex. We compared intraoperative QTc times to QTc times from resting ECGs of a population from the same region, to substantiate the hypothesis that patients under general anaesthesia may need specific treatment thresholds. METHODS:In this prospective observational study, intraoperative QT/QTc intervals were automatically recorded using 12 and 5-lead ECG in 100 patients (44% males). QTc values were analysed for sex and formula-specific aspects after correction for heart rate according to Bazett, Fridericia, Hodges, Framingham, Charbit and QTcRAS, and compared to a regional community-based cohort. The level of significance was set to α = 0.05. RESULTS:QT interval duration was not significantly different between 12-lead and 5-lead ECG (difference - 0.09 ms ± 8.5 ms, p = 0.793). The QTc interval duration significantly differed between the correction formulae (p < 0.001) and between sexes (p < 0.001). Mean intraoperative QTc duration was higher than in resting ECGs from a large community-based population with the same regional background (438 vs. 417 ms). The incidence of prolonged values >500 ms significantly depended on the correction formula (p < 0.001) and was up to tenfold higher in women versus men. CONCLUSION:Intraoperative QTc interval measurement using a 5-lead ECG is valid. Correction formulae and gender influence the intraoperative QTc interval duration and the incidence of pathologically prolonged values according to current limits. The consideration and definition of sex-specific normal limits for QTc times under general anaesthesia, therefore, warrant further investigation.

The pulmonary vascular permeability index (PVPI) is a quotient of the extravascular lung water (EVLW) and the pulmonary blood volume (PBV). In acute respiratory distress syndrome (ARDS), the alveolar-capillary membrane integrity is disrupted. The result is a disproportionate increase of EVLW compared to the PBV and, hence, an increase in PVPI. Thus, PVPI has repetitively been discussed to extend the definition of ARDS. Besides sex, the influence of other anthropometric variables on PVPI has not been studied so far. However, since it is known that EVLW depends on body height and sex, we hypothesize that PVPI depends on anthropometric variables as well. This prospective single-center observational study included 1533 TPTD measurements of 251 non-critically ill patients (50.6% men) undergoing elective neuro-, thoracic, or abdominal surgery at the Munich Clinic Bogenhausen of the Technical University of Munich. Multivariate regressions were used to measure the influence of sex, age, and body height on PVPI. In all patients, PVPI was significantly higher in women (P < 0.001), with 34.4% having a PVPI > 2 compared to 15.9% of men. Mean PVPI significantly decreased with height (P < 0.001) and age (P < 0.001). Multivariate regressions allowed the calculation of mean reference surfaces. The 95th percentile surface for PVPI was > 3 for small and young women and well above 2 for all but tall and elderly men. In patients who underwent (lung reduction) thoracic surgery, the PVPI before and after surgery did not differ significantly (P = 0.531), and post-surgical PVPI did not correlate with the amount of lung resected (P = 0.536). Hence, we conclude that PVPI may be independent of the extent of lung volume reduction. However, PVPI is heavily dependent on sex, age, and body height. Anthropometric variables thus have a significant impact on the likelihood of misclassified abnormal PVPI. This warrants further studies since an increased PVPI, e.g. in the context of an ARDS, may be overlooked if anthropometric variables are not considered. We suggest reference surfaces based on the 95th-percentile corrected for sex, age, and height as a novel approach to normalize PVPI.

Introduction: Robotic-assisted surgery is increasingly performed in various surgical disciplines demonstrating improved oncological and functional outcomes compared to conventional surgery. Objective: Unclear is how robotic- assisted surgery affects perioperative anemia and the need for blood products. Methods: In this case-control study, 15,009 matched patient pairs undergoing urological, visceral, or thoracic surgery were included. Pairwise comparisons between robotic-assisted surgery, laparoscopic surgery, and open surgery were performed with propensity score matching. Results: Robotic-assisted surgery compared to open surgery was associated with a risk reduction of allogeneic red blood cell transfusion by RR: 0.32 (95% CI: 0.27-0.37) and a limited reduction of perioperative hemoglobin (perioperative hemoglobin difference of 0.40 g/dL, 95% CI: 0.31-0.49). Robotic-assisted surgery was associated with a shorter length of hospital stay by 4.29 days (95% CI: 3.74-4.84). Compared to laparoscopic surgery, robotic- assisted surgery had no significant effect on red blood cell transfusions (RR: 0.94, 95% CI: 0.75-1.18), perioperative hemoglobin (0.27 g/dL, 95% CI: 0.16-0.38), or length of hospital stay 0.53 days (95% CI: - 0.14 - 1.19). Conclusions: Robotic-assisted and laparoscopic procedures are associated with reduced blood transfusions compared to open surgery and, thus the advancement of minimally invasive procedures constitutes an important measure to improve patient outcomes.

Anemia affects humans throughout life, and is linked to higher morbidity and mortality. Unclear is whether hemoglobin values are equivalent between women and men. This study evaluates the association of preoperative hemoglobin levels with in-hospital mortality and estimates thresholds for survival equity between men and women. All adult patients undergoing surgery between 2010 and 2019 from 14 German hospitals were included in the study. Thresholds for survival equity were determined with generalized additive models. In total, 842,130 patients with a median in-hospital follow-up time of 7 days were analyzed. During follow-up 20,370 deaths occurred. Preoperative hemoglobin stratified in-hospital mortality (log-rank test p < 0.001) and was associated with mortality independently of demographic risk, surgical risk and health status. For each 1 g/dL reduction in preoperative hemoglobin, the odds of mortality increased by a factor of 1.22 (95% CI 1.21–1.23, p < 0.001). A preoperative hemoglobin threshold of 10.5 g/dL reflected equivalent risk for both male and female patients. Hemoglobin levels below 10.5 g/dL had higher risk of mortality for women than for men. The findings from this study aid evidence-based thresholds, inform anemia management and promote equitable care, thus enhancing patient outcomes.

BACKGROUND:Patient Blood Management (PBM) is a patient-centred, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood whilst promoting patient safety and empowerment. The effectiveness and safety of PBM over a longer period have not yet been investigated. METHODS:We performed a prospectively designed, multicentre follow-up study with non-inferiority design. Data were retrospectively extracted case-based from electronic hospital information systems. All in-hospital patients (≥18 yr) undergoing surgery and discharged between January 1, 2010 and December 31, 2019 were included in the analysis. The PBM programme focused on three domains: preoperative optimisation of haemoglobin concentrations, blood-sparing techniques, and guideline adherence/standardisation of allogeneic blood product transfusions. The outcomes were utilisation of blood products, composite endpoint of in-hospital mortality and postoperative complications (myocardial infarction/ischaemic stroke/acute renal failure with renal replacement therapy/sepsis/pneumonia), anaemia rate at admission and discharge, and hospital length of stay. RESULTS:A total of 1 201 817 (pre-PBM: n=441 082 vs PBM: n=760 735) patients from 14 (five university/nine non-university) hospitals were analysed. Implementation of PBM resulted in a substantial reduction of red blood cell utilisation. The mean number of red blood cell units transfused per 1000 patients was 547 in the PBM cohort vs 635 in the pre-PBM cohort (relative reduction of 13.9%). The red blood cell transfusion rate was significantly lower (P<0.001) with odds ratio 0.86 (0.85-0.87). The composite endpoint was 5.8% in the PBM vs 5.6% in the pre-PBM cohort. The non-inferiority aim (safety of PBM) was achieved (P<0.001). CONCLUSIONS:Analysis of >1 million surgical patients showed that the non-inferiority condition (safety of Patient Blood Management) was fulfilled, and PBM was superior with respect to red blood cell transfusion. CLINICAL TRIAL REGISTRATION:NCT02147795.

BACKGROUND:Critical Care Providers (CCPs) experience situations that challenge their ethics and professional standards and may entail moral distress (MD). AIM:To analyze MD perceived by CCPs in intensive care units (ICUs) or emergency departments (EDs) and further clarify whether CCPs who rely on spiritual resources differ in their perception of MD from those who do not utilize these resources. METHODS:A cross-sectional anonymous survey was administered using a modified version of the German language version of the Moral Distress Scale (MDS) with 2 × 12 items to assess the frequency and the respective perceived burden of specific situations by applying a 5-point Likert scale. Explorative factor analysis was performed and the sub-constructs of the respective items regarding MD frequency and burden were identified. Job burden and professional satisfaction were measured using visual analogue scales (VAS) and a four-point Likert scale, respectively. The 15-item SpREUK questionnaire was applied to measure spiritual attitudes and behaviours and to differentiate between religious and spiritual persons. Data from 385 German-speaking CCPs were included (55% physicians, 45% nurses). RESULTS:Conflict situations are similar for physicians and nurses although they are perceived as more burdensome by nurses. Among physicians, the MDS factor Looking away/Resignation scores highest for assistant physician residents, whereas distress caused by looking away is more often perceived by specialist physicians without a managerial position. Work satisfaction is inversely associated with MD and emotional exhaustion is positively associated with it. Participants' spirituality is marginally associated with MD. The best predictors of both MD frequency and burden are emotional exhaustion with further influences of work satisfaction, being a nurse, and being a non-believer on the frequency of MD perception. Being a nurse, participants' experience in ICU/ED, and being of the male gender are further predictors of MD burden. CONCLUSIONS:MD is experienced differently by different groups of CCPs depending on their place in the hierarchy of responsibility. As MD perception is best predicted by emotional exhaustion, these situations should be avoided. Although some CCPs may rely on spiritual resources, all need individual and team support to cope with MD.

Purpose Anaemia is common in patients presenting with aneurysmal subarachnoid (aSAH) and intracerebral haemorrhage (ICH). In surgical patients, anaemia was identified as an idenpendent risk factor for postoperative mortality, prolonged hospital length of stay (LOS) and increased risk of red blood cell (RBC) transfusion. This multicentre cohort observation study describes the incidence and effects of preoperative anaemia in this critical patient collective for a 10-year period. Methods This multicentre observational study included adult in-hospital surgical patients diagnosed with aSAH or ICH of 21 German hospitals (discharged from 1 January 2010 to 30 September 2020). Descriptive, univariate and multivariate analyses were performed to investigate the incidence and association of preoperative anaemia with RBC transfusion, in-hospital mortality and postoperative complications in patients with aSAH and ICH. Results A total of n = 9081 patients were analysed (aSAH n = 5008; ICH n = 4073). Preoperative anaemia was present at 28.3% in aSAH and 40.9% in ICH. RBC transfusion rates were 29.9% in aSAH and 29.3% in ICH. Multivariate analysis revealed that preoperative anaemia is associated with a higher risk for RBC transfusion ( OR = 3.25 in aSAH, OR = 4.16 in ICH, p < 0.001), for in-hospital mortality ( OR = 1.48 in aSAH, OR = 1.53 in ICH, p < 0.001) and for several postoperative complications. Conclusions Preoperative anaemia is associated with increased RBC transfusion rates, in-hospital mortality and postoperative complications in patients with aSAH and ICH. Trial registration ClinicalTrials.gov , NCT02147795, https://clinicaltrials.gov/ct2/show/NCT02147795

Abstract Background Blood transfusions are common medical procedures and every age group requires detailed insights and treatment bundles. The aim of this study was to examine the association of anaemia, co-morbidities, complications, in-hospital mortality, and transfusion according to age groups to identify patient groups who are particularly at risk when undergoing surgery. Methods Data from 21 Hospitals of the Patient Blood Management Network Registry were analysed. Patients were divided into age subgroups. The incidence of preoperative anaemia, co-morbidities, surgical disciplines, hospital length of stay, complications, in-hospital mortality rate, and transfusions were analysed by descriptive and multivariate regression analysis. Results A total of 1 117 919 patients aged 18–108 years were included. With increasing age, the number of co-morbidities and incidence of preoperative anaemia increased. Complications, hospital length of stay, and in-hospital mortality increased with age and were higher in patients with preoperative anaemia. The mean number of transfused red blood cells (RBCs) peaked, whereas the transfusion rate increased continuously. Multivariate regression analysis showed that increasing age, co-morbidities, and preoperative anaemia were independent risk factors for complications, longer hospital length of stay, in-hospital mortality, and the need for RBC transfusion. Conclusion Increasing age, co-morbidities, and preoperative anaemia are independent risk factors for complications, longer hospital length of stay, in-hospital mortality, and the need for RBC transfusion. Anaemia diagnosis and treatment should be established in all patients.

Trotz zahlreicher Untersuchungen der zerebralen regionalen Sauerstoffsättigung (rSO2) mittels Nah-Infrarot-Spektroskopie (NIRS) an orthopädischen Patienten in Beach-chair-Position ist weiterhin unklar, ob patientenspezifische Faktoren wie kardiovaskuläre Begleiterkrankungen signifikant häufiger zum Auftreten pathologischer rSO2-Werte (zerebrale Desaturierungsereignisse, CDE) führen. Ziel der vorliegenden Studie war es, neben einer Identifikation möglicher patientenspezifischer Risikofaktoren zum ersten Mal auch eine Gewichtung dieser durchzuführen. Insgesamt wurden 397 Patienten untersucht. Als CDE wurde eine Abnahme der rSO2 > 20 % oder ein Wert < 50 % definiert. Patienten ohne und mit CDE wurden hinsichtlich ihrer unterschiedlichen American Society of Anesthesiologists (ASA)- und Revised Cardiac Risk Index (RCRI)- Klassifikation sowie arteriellen Hypertonie und ihres Alters unterschieden. Zweifaktorielle Varianzanalysen (ANOVA) wurden durchgeführt. Patienten mit CDE (n = 238) waren signifikant häufiger als ASA > 2 (p = 0,01) und RCRI > 1 (p = 0,01) klassifiziert, litten häufiger unter einem arteriellen Hypertonus (p = 0,01) und waren älter (Median [Jahre]: 60 vs. 55; p = 0,01) als Patienten ohne CDE (n = 159) in Beach-chair-Position. Eine arterielle Hypertonie war jeweils nach Entfernen des Effekts des Alters (p = 0,03) und der RCRI-Klassifikation (p = 0,04) weiterhin signifikant. Höheres Alter, ASA > 2, RCRI > 1 und v. a. ein arterieller Hypertonus konnten als Risikofaktoren bestimmt werden, die es bereits präoperativ ermöglichen, Patienten zu identifizieren, die gegenüber dem intraoperativen Auftreten von CDE in Beach-chair-Position besonders gefährdet sind.

Editor—Lung cancer surgery is associated with a high rate of postoperative pulmonary complications including pneumonia, acute lung injury, and adult respiratory distress syndrome (ARDS).1Alam N. Park B.J. Wilton A. et al.Incidence and risk factors for lung injury after lung cancer resection.Ann Thorac Surg. 2007; 84: 1085-1091Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar,2Kometani T. Okamoto T. Yoshida S. Yoshino I. Acute respiratory distress syndrome after pulmonary resection.Gen Thorac Cardiovasc Surg. 2013; 61: 504-512Crossref PubMed Scopus (14) Google Scholar It requires lung-protective ventilation strategies,3Marret E. Cinotti R. Berard L. et al.Protective ventilation during anaesthesia reduces major postoperative complications after lung cancer surgery: a double-blind randomised controlled trial.Eur J Anaesthesiol. 2018; 35: 727-735Crossref PubMed Scopus (37) Google Scholar,4Park M. Ahn H.J. Kim J.A. et al.Driving pressure during thoracic surgery: a randomized clinical trial.Anesthesiology. 2019; 130: 385-393Crossref PubMed Scopus (49) Google Scholar which include spontaneous ventilation video-assisted thoracoscopic surgery under general anaesthesia (SV-VATS).5Moon Y. AlGhamdi Z.M. Jeon J. Hwang W. Kim Y. Sung S.W. Non-intubated thoracoscopic surgery: initial experience at a single center.J Thorac Dis. 2018; 10: 3490-3498Crossref PubMed Scopus (8) Google Scholar,6He J. Liu J. Zhu C. et al.Expert consensus on tubeless video-assisted thoracoscopic surgery (Guangzhou).J Thorac Dis. 2019; 11: 4101-4108Crossref PubMed Scopus (10) Google Scholar During SV-VATS, patients in the lateral decubitus position breathe spontaneously with iatrogenic incomplete or subtotal lung collapse, and respiratory settings that allow for stable surgical access. Although advocated as protective for the lungs,5Moon Y. AlGhamdi Z.M. Jeon J. Hwang W. Kim Y. Sung S.W. Non-intubated thoracoscopic surgery: initial experience at a single center.J Thorac Dis. 2018; 10: 3490-3498Crossref PubMed Scopus (8) Google Scholar,6He J. Liu J. Zhu C. et al.Expert consensus on tubeless video-assisted thoracoscopic surgery (Guangzhou).J Thorac Dis. 2019; 11: 4101-4108Crossref PubMed Scopus (10) Google Scholar data on mechanical ventilator settings and resulting arterial blood gases during SV-VATS have not been reported. Such data constitute a prerequisite for evaluating the respiratory consequences of non-intubated spontaneous breathing patients during lung cancer surgery. Such data would also be necessary for the design of a prospective randomised trial comparing SV-VATS with standard management of thoracic surgical patients. Here we provide such data from anatomical lung resections including pneumonectomy in lung cancer patients. During a 19 month period, 20 patients scheduled for video-assisted thoracoscopic surgery (VATS) for anatomical resection of lung cancer including left lower lobectomy (n=7), middle lobectomy (n=5), right lower lobectomy (n=5), lingula resection (n=1), lower bilobectomy (n=1), and pneumonectomy (n=1) were offered non-intubated pressure support ventilation (SV-VATS). All patients gave informed written consent in agreement with the ethical committee of the Bayerische Landesärztekammer (2020-1041) and Bavarian hospital law (BayKrG §27). Surgical and anaesthetic management followed expert consensus6He J. Liu J. Zhu C. et al.Expert consensus on tubeless video-assisted thoracoscopic surgery (Guangzhou).J Thorac Dis. 2019; 11: 4101-4108Crossref PubMed Scopus (10) Google Scholar and included EEG monitored target-controlled infusion of propofol and remifentanil, laryngeal mask airway, intrathoracic vagal blockade, and pressure support ventilation (Zeus and Perseus ventilator; Dräger, Lübeck, Germany). Settings of pressure support ventilation were chosen to guarantee lung protective tidal volumes with a maximum of 6–8 ml kg−1 (predicted body weight), adequate oxygenation, and sufficient space for surgical access. Patients had 16 and 18 gauge peripheral venous access and an arterial blood pressure catheter. Treatment was provided in all patients by physicians with more than 20 yr of clinical experience in lung cancer surgery (JB) and thoracic anaesthesia (PF) including VATS. Data are presented as median [range]. Patient characteristics, preoperative lung function tests, settings of pressure-support ventilation, and results of intraoperative arterial blood gas analyses are presented in Table 1. Blood gases were in the normal range after the operation (PaO2: 12.6 [8.40–26.5] kPa; PaCO2: 5.60 [4.37–6.13] kPa; BE: –3.15 [–6.2 to –0.5]; pH 7.35 [7.30–7.40]). Intraoperative cardiorespiratory complications were not observed. The median length of postoperative hospital stay was 4 (3–11) days.Table 1Patient characteristics, preoperative lung function testing, intraoperative ventilator settings, and results of intraoperative arterial blood gas analysis (n=20). DLCO, diffusing capacity of the lungs for carbon monoxide; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; TLC, total lung capacity; TV, tidal volume.Preoperative dataMedianRangeIntraoperative dataMedianRangeAge (yr)7053–82Respiratory rate116.9–19Height (cm)164154–185TV (ml kg PBW–1)4.62.9–7.3Weight (kg)68.548–84PEEP (cm H2O)3.11.3–5.2BMI (kg m−2)24.219.8–31.2ΔPsupp (cm H2O)2.40.5–9.8Male (%)25Pmean PEEP (cm H2O)1.10.2–2.3FVC (%)90.968.8–132PaO2/FiO2 (Horowitz index)261144–406FEV1 (%)91.761.6–132AaDO2 (kPa)25.77.77–59.1FEV1/FVC0.790.64–0.97EtCO2 (kPa)6.435.01–8.37TLC (%)10175.8–144PaCO2 (kPa)7.646.52–9.88DLCO SB (%)91.060.7–111Base excess–5.13–8.5 to -1.25PaO2 (kPa)10.28.73–12.4pH7.237.14–7.28PaCO2 (kPa)4.683.33–5.29Duration of surgery (min)10560–195 Open table in a new tab Postoperative pulmonary complications are common after lung cancer surgery.1Alam N. Park B.J. Wilton A. et al.Incidence and risk factors for lung injury after lung cancer resection.Ann Thorac Surg. 2007; 84: 1085-1091Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 2Kometani T. Okamoto T. Yoshida S. Yoshino I. Acute respiratory distress syndrome after pulmonary resection.Gen Thorac Cardiovasc Surg. 2013; 61: 504-512Crossref PubMed Scopus (14) Google Scholar, 3Marret E. Cinotti R. Berard L. et al.Protective ventilation during anaesthesia reduces major postoperative complications after lung cancer surgery: a double-blind randomised controlled trial.Eur J Anaesthesiol. 2018; 35: 727-735Crossref PubMed Scopus (37) Google Scholar, 4Park M. Ahn H.J. Kim J.A. et al.Driving pressure during thoracic surgery: a randomized clinical trial.Anesthesiology. 2019; 130: 385-393Crossref PubMed Scopus (49) Google Scholar Lung-protective ventilation during single-lung ventilation using a double lumen tube is not always possible and adherence to lung protective ventilation strategies is incomplete.3Marret E. Cinotti R. Berard L. et al.Protective ventilation during anaesthesia reduces major postoperative complications after lung cancer surgery: a double-blind randomised controlled trial.Eur J Anaesthesiol. 2018; 35: 727-735Crossref PubMed Scopus (37) Google Scholar,4Park M. Ahn H.J. Kim J.A. et al.Driving pressure during thoracic surgery: a randomized clinical trial.Anesthesiology. 2019; 130: 385-393Crossref PubMed Scopus (49) Google Scholar SV-VATS has been advocated to reduce pulmonary complications after lung cancer surgery,5Moon Y. AlGhamdi Z.M. Jeon J. Hwang W. Kim Y. Sung S.W. Non-intubated thoracoscopic surgery: initial experience at a single center.J Thorac Dis. 2018; 10: 3490-3498Crossref PubMed Scopus (8) Google Scholar,6He J. Liu J. Zhu C. et al.Expert consensus on tubeless video-assisted thoracoscopic surgery (Guangzhou).J Thorac Dis. 2019; 11: 4101-4108Crossref PubMed Scopus (10) Google Scholar and to allow for faster postoperative recovery.5Moon Y. AlGhamdi Z.M. Jeon J. Hwang W. Kim Y. Sung S.W. Non-intubated thoracoscopic surgery: initial experience at a single center.J Thorac Dis. 2018; 10: 3490-3498Crossref PubMed Scopus (8) Google Scholar,6He J. Liu J. Zhu C. et al.Expert consensus on tubeless video-assisted thoracoscopic surgery (Guangzhou).J Thorac Dis. 2019; 11: 4101-4108Crossref PubMed Scopus (10) Google Scholar Despite expert consensus on perioperative ventilation concepts,6He J. Liu J. Zhu C. et al.Expert consensus on tubeless video-assisted thoracoscopic surgery (Guangzhou).J Thorac Dis. 2019; 11: 4101-4108Crossref PubMed Scopus (10) Google Scholar intraoperative ventilator settings and resulting blood gases during SV-VATS have not been reported. Our case series provides such data for the first time for major lung cancer surgery. The data demonstrate that spontaneous breathing during anatomical resection for lung cancer surgery is feasible even during pneumonectomy with adequate oxygenation in all patients. The data also demonstrate the presence of hypercarbia and respiratory acidosis in all patients. Both were reversible immediately after the end of surgery when iatrogenic pneumothorax was reversed and delivery of anaesthetic agents had ended. Permissive hypercarbia constitutes an established aspect of lung protective ventilatory strategies in critically ill patients.7Hickling K.G. Walsh J. Henderson S. Jackson R. Low mortality rate in adult respiratory distress syndrome using low-volume, pressure-limited ventilation with permissive hypercapnia: a prospective study.Crit Care Med. 1994; 22: 1568-1578Crossref PubMed Scopus (584) Google Scholar Hypercarbia and respiratory acidosis with values similar to those observed in our case series have been shown to be beneficial during one-lung positive pressure ventilation with a double lumen tube.8Gao W. Liu D.D. Li D. Cui G.X. Effect of therapeutic hypercapnia on inflammatory responses to one-lung ventilation in lobectomy patients.Anesthesiology. 2015; 122: 1235-1252Crossref PubMed Scopus (34) Google Scholar Our case series demonstrates that SV-VATS allows lung protective tidal volumes, lung protective intrapulmonary pressures, and lung-protective intrapulmonary pressure gradients during anatomical resection for lung cancer surgery even during pneumonectomy lasting >3 h with moderate respiratory acidosis. These data constitute a prerequisite for the design of a prospective randomised trial comparing the outcome of SV-VATS to that of standard management of thoracic surgical patients. The authors declare that they have no conflicts of interest.

INTRODUCTION:Approximately one in three patients has untreated preoperative anaemia, which in turn is associated with an increased need for transfusion of allogenic red blood cell concentrates (RBC) and complications in the context of a surgical intervention. Here, the prevalence of preoperative and postoperative anaemia as well as their effects on transfusion rate, hospital length of stay and hospital mortality in primary hip and knee arthroplasty has been analysed. METHODS:From January 2012 to September 2018, 378,069 adult inpatients from 13 German hospitals were analysed on the basis of an anonymized registry. Of these, n = 10,017 patients had a hip and knee joint primary arthroplasty. The primary endpoint was the incidence of preoperative anaemia, which was analysed by the first available preoperative haemoglobin value according to the WHO definition. Secondary endpoints included in-hospital length of stay, number of patients with red blood cell concentrate transfusion, incidence of hospital-acquired anaemia, number of deceased patients, and postoperative complications. RESULTS:The preoperative anaemia rate was 14.8% for elective knee joint arthroplasty, 22.9% for elective hip joint arthroplasty and 45.0% for duo-prosthesis implantation. Preoperative anaemia led to a significantly higher transfusion rate (knee: 8.3 vs. 1.8%; hip: 34.5 vs. 8.1%; duo-prosthesis: 42.3 vs. 17.4%), an increased red blood cell concentrate consumption (knee: 256 ± 107 vs. 29 ± 5 RBC/1000 patients; hip: 929 ± 60 vs. 190 ± 16 RBC/1000 patients; duo-prosthesis: 1411 ± 98 vs. 453 ± 42 RBC/1000 patients). Pre-operative anaemia was associated with prolonged hospital stay (12.0 [10.0; 17.0] d vs. 11.0 [9.0; 13.0] d; p < 0.001) and increased mortality (5.5% [4.6 - 6.5%] vs. 0.9% [0.7 - 1.2%]; Fisher p < 0.001) compared to non-anaemic patients. In patients aged 80 years and older, the incidence of preoperative anaemia and thus the transfusion rate was almost twice as high as in patients under 80 years of age. SUMMARY:Preoperative anaemia is common in knee and hip primary arthroplasty and was associated with a relevant increase in red blood cell concentrate consumption. In the context of patient blood management, a relevant potential arises, especially in elective orthopaedic surgery, to better prepare elective patients, to avoid unnecessary transfusions and thus to conserve the valuable resource blood.

SummaryPeri‐operative monitoring of brain oxygen saturation with near infrared spectroscopy (NIRS) has been used to identify episodes where the brain oxygen supply is low. We describe a 46‐year‐old patient with Brugada and Sick Sinus Syndrome suffering from sinus arrest during an elective rotator cuff operation in the deck chair position, with a concomitant fall in brain oxygen saturation. This case illustrates that peri‐operative NIRS monitoring can help identify the haemodynamic relevance of cardiac events in patients at risk and can support therapeutic decision‐making.

BACKGROUND: Intoxication with local anesthetics may induce cardiac arrhythmias by interaction with ion channels. Ropivacaine has been introduced into clinical anesthesia as a safer alternative to bupivacaine, which is associated with a relatively high risk of cardiac arrhythmias. Diverging safety profiles may result from differences in the mode of interaction with cardiac Na+ channels. We conducted this study to test this hypothesis and to provide experimental basis for the ongoing discussion regarding the cardiotoxic profiles of these local anesthetics.METHODS: The influence of bupivacaine and ropivacaine on the electrophysiological properties of Na+ channels was investigated in human embryonic kidney-293 cells stably transfected with SCN5A channels cloned from the human heart using the patch-clamp technique in the outside-out configuration.RESULTS: Open-channel block of SCN5A channels was concentration dependent, with bupivacaine being approximately 4.5-fold more potent than ropivacaine (IC50 = 69.5 +/- 8.2 mu M vs IC50 = 322.2 +/- 29.9 mu M). Both drugs influenced the voltage dependency of channel activation and steady-state inactivation by shifting the membrane potential of half-maximal activation/inactivation toward somewhat more negative membrane potentials. In their inactivated state, SCN5A channels were slightly more sensitive toward bupivacaine than toward ropivacaine (IC50 = 2.18 +/- 0.16 mu M vs IC50 = 2.73 +/- 0.27 mu M). Blockade of inactivated channels developed in a concentration-dependent manner, with comparable time constants for both drugs, whereas recovery from block was approximately 2-fold faster for ropivacaine than for bupivacaine.CONCLUSIONS: Human cardiac Na+ channels show state-dependent inhibition by ropivacaine, and the mode of interaction is comparable to that of bupivacaine. Therefore, modest differences in cardiotoxicity between these local anesthetic drugs are compatible with subtle differences in their interaction with human cardiac Na+ channels.

The long QT syndrome is caused by a change in cardiac repolarization due to functional ion channel defects. A differentiation is made between a congenital (cLQTS) and an acquired (aLQTS) form of the disease. The disease results in the name-giving prolongation of the QT interval in the electrocardiogram and represents a predisposition for cardiac arrhythmia and sudden cardiac death. This article summarizes the current knowledge on the history, pathophysiology, clinical symptoms and therapy of cLQTS and aLQTS. This knowledge of pathophysiological features of the symptoms allows the underlying anesthesiological approach for individualized perioperative concepts for patients suffering from LQTS to be derived.

Superficial cervical plexus neuropathy after interscalene brachial plexus block affects about 8% of patients postoperatively. One of the nerves involved in superficial cervical plexus neuropathy is the great auricular nerve. We report success in identification of the great auricular nerve with ultrasound and transcutaneous nerve stimulation in a clinical setting in the majority of cases (95% lower confidence limit 63%). Identification of the nerve is significantly more difficult in female and in obese patients. Further studies will allow determination of whether this information will help to reduce the incidence of superficial cervical plexus neuropathy. (Anesth Analg 2012;114:1128-30)

BACKGROUND:The effects of the local anesthetic bupivacaine on cardiac action potentials (APs) are mainly attributed to inhibition of cardiac Na(+) channels. The relevance of its ability to also induce high-affinity blockade of human ether-à-gogo-related gene (hERG) channels is unclear. We investigated whether this interaction may functionally become more significant in cellular and computational models of long (L)QT syndromes. METHODS:Left ventricular cardiomyocytes were isolated from adult guinea pig hearts, and bupivacaine-induced effects on APs were investigated using the patch-clamp technique. LQT-like states were pharmacologically induced by either blocking I(Ks) (LQT1-like, 10 μmol/L chromanol 293B), or I(Kr) (LQT2-like, 10 μmol/L E4031). Computational analysis of bupivacaine's effects was based on the Luo-Rudy dynamic model. RESULTS:Bupivacaine induced dose-dependent AP shortening in control myocytes. However, in the presence of 1 to 30 μmol/L bupivacaine, a high variability in AP duration with AP prolongations of up to 40% was observed. This destabilizing effect on AP duration was significantly increased in LQT1-like but not in LQT2-like myocytes. Similarly, the incidence of AP prolongations in the presence of 3 μmol/L bupivacaine was significantly increased from 6% in control myocytes to 24% in LQT1-like but not in LQT2-like myocytes. Computational modeling supported the concept that this bupivacaine-induced AP instability and the AP prolongations in the control and LQT1-like myocytes were caused by inhibition of hERG channels. CONCLUSIONS:This study provides evidence that bupivacaine induces inhibition of hERG channels, which is functionally silent under normal conditions but will become more relevant in LQT1-like states in which repolarization relies to a larger degree on hERG channels. Interactions with ion channels other than cardiac Na(+) channels may, therefore, determine the net cardiac effects of bupivacaine when the normal balance of ionic currents is altered.