In most centers, extracorporeal membrane oxygenation (ECMO) is the preferred means to provide cardiopulmonary support during lung transplantation. However, there is controversy about whether intraoperative venoarterial (VA) ECMO should be used routinely or selectively. A randomized controlled trial is the best way to address this controversy. In this publication, we describe a feasibility study to assess the practicality of a protocol comparing routine versus selective VA-ECMO during lung transplantation. This prospective, single-center, randomized controlled trial screened all patients undergoing lung transplantation. Exclusion criteria include retransplantation, multiorgan transplantation, and cases where ECMO is mandatory. We determined that the trial would be feasible if we could recruit 19 participants over 6 months with less than 10% protocol violations. Based on the completed feasibility study, we conclude that the protocol is feasible and safe, giving us the impetus to pursue a multicenter trial with little risk of failure due to low recruitment.

This article reviews research highlights in the field of thoracic anesthesia. The highlights of this year included new developments in the preoperative assessment and prehabilitation of patients requiring thoracic surgery, updates on the use of devices for one-lung ventilation (OLV) in adults and children, updates on the anesthetic and postoperative management of these patients, including protective OLV ventilation, the use of opioid-sparing techniques and regional anesthesia, and outcomes using enhanced recovery after surgery, as well as the use of expanding indications for extracorporeal membrane oxygenation, specialized anesthetic techniques for airway surgery, and nonintubated video-assisted thoracic surgery.

OBJECTIVE:Severe postoperative pain has been shown to affect many patients following minimally invasive cardiac surgeries (MICS). Multimodal pain management with regional anesthesia, particularly by delivery of local anesthetics using a paravertebral catheter (PVC), has been shown to reduce pain in operations involving thoracotomy incisions. However, few studies have reported high-quality safety and efficacy outcomes of PVCs following MICS.METHODS:Patients who underwent MICS at Vancouver General Hospital between 2016 and 2019 (N = 123) were reviewed for perioperative opioid-narcotic use. Primary outcomes were postoperative opioid use and hospital length of stay (LOS). Statistical analyses were performed using univariate and multivariable regression models to determine independent risk factors.RESULTS:A total of 54 patients received routine systemic analgesia (control), 53 patients received a paravertebral catheter (PVC), and 16 patients received another mode of regional analgesia (non-PVC). The mean hospital LOS was significantly different in patients in the PVC group at 5.8 ± 2.0 days versus 8.3 ± 7.1 days in the control and 6.6 ± 2.3 days in the non-PVC group (P = 0.033). The percentage of patients who did not require postoperative oxycodone was significantly higher in the PVC group (48.1%), compared with the control (24.5%) and non-PVC (37.5%; P = 0.043) groups.CONCLUSIONS:The administration of regional anesthesia using PVCs was associated with reduced need for opioids and a shorter LOS. The reduction in postoperative opioids may reduce the risk of potential opioid dependency in this population. Future studies should involve randomized controlled trials with systematic evaluation of pain scores to verify current study results.

In this chapter the authors will provide a comprehensive overview of the perioperative care for patients undergoing lung resection surgery. We will combine relevant and recent evidence with the authors institutional practice from a quaternary care academic center in Vancouver, Canada.

THIS SPECIAL ARTICLE is the fifth in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors would like to thank the editor-in-chief, Dr. Kaplan; the associate editor-in-chief, Dr. Augoustides; and the editorial board for the opportunity to expand this series, the research highlights of the year that specifically pertain to the specialty of thoracic anesthesia. The highlights of this year include new developments in the preoperative assessment and prehabilitation of thoracic surgery patients, updates on the use of devices for one-lung ventilation (OLV) in adults and children, updates on the anesthetic management of these patients, including protective ventilation, regional anesthesia, and outcomes when enhanced recovery after thoracic surgery protocols are followed, as well as the use of expanding indications for extracorporeal membrane oxygenation (ECMO) and nonintubated video-assisted thoracic surgery (NIVATS).

The authors regret that the name of the 6th author, Dr Bottiger, was misspelled in the published article. The correct spelling is given above. The authors would like to apologize for any inconvenience caused. The Year in Thoracic Anesthesia: Selected Highlights from 2019Journal of Cardiothoracic and Vascular AnesthesiaVol. 34Issue 7PreviewTHIS special article is the 4th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan; the associate editor-in-chief, Dr. Augoustides; and the editorial board for the opportunity to expand this series, the research highlights of the year that specifically pertain to the specialty of thoracic anesthesia. The major themes selected for 2019 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. Full-Text PDF

Selected highlights in thoracic anesthesia in 2020 include updates in the preoperative assessment and prehabilitation of patients undergoing thoracic surgery; updates in one-lung ventilation (OLV) pertaining to the devices used for OLV; the use of dexmedetomidine for lung protection during OLV and protective ventilation, recommendations for the care of thoracic surgical patients with coronavirus disease 2019; a review of recent meta-analyses comparing truncal blocks with paravertebral and thoracic epidural blocks; and a review of outcomes after initiating the enhanced recovery after surgery guidelines for lung and esophageal surgery.

DEEP VENOUS THROMBOSIS (DVT) and pulmonary embolism (PE) are relatively common postoperative complications in the surgical patient population. Estimates of the incidence of DVT and/or PE in the lung transplant population vary significantly. A recent Nationwide Inpatient Sample inquiry estimated that venous thromboembolism (VTE) is diagnosed in 6.3% of lung transplant recipients during their index admission for transplantation, with DVT alone diagnosed in 5.4%, or concurrent with PE in 1.1%. 1 Aboagye J.K. Hayanga J.W.A. Lau B.D. et al. Venous thromboembolism in patients hospitalized for lung transplantation. Ann Thorac Surg. 2018; 105: 1071-1076 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar However, this statistic is based primarily on reported diagnosis codes and may not capture all cases of interest. In addition, single-center reports suggest that there is likely a significant difference in the risk profile of transplant recipients between different institutions. According to one single-institution report, over one-third of double-lung transplant (DLT) recipients had upper- or lower-extremity DVT and at least 15% had evidence of PE, 2 Evans C.F. Iacono A.T.A.T. Sanchez P.G. et al. Venous thromboembolic complications of lung transplantation: A contemporary single-institution review. Ann Thorac Surg. 2015; 100: 2033-2040 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar while the overall incidence of VTE in a different institution was as high as 43.8%. 3 Ribeiro Neto M.L. Budev M. Culver D.A. et al. Venous thromboembolism after adult lung transplantation. Transplantation. 2018; 102: 681-687 Crossref PubMed Scopus (7) Google Scholar In all available reports, the diagnosis most commonly is made in the postoperative period. Existing literature, however, largely lacks data on the frequency of such a diagnosis in the preoperative period or at the time of transplantation. Given the progressive nature of end-stage lung disease, increasing oxygen requirements, and signs accompanying right heart failure are likely in this patient population. This makes the diagnosis of acute VTE particularly challenging. The literature suggests that both DVT and PE are associated with increased morbidity and mortality in lung transplant recipients 1 Aboagye J.K. Hayanga J.W.A. Lau B.D. et al. Venous thromboembolism in patients hospitalized for lung transplantation. Ann Thorac Surg. 2018; 105: 1071-1076 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar , 2 Evans C.F. Iacono A.T.A.T. Sanchez P.G. et al. Venous thromboembolic complications of lung transplantation: A contemporary single-institution review. Ann Thorac Surg. 2015; 100: 2033-2040 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar , 3 Ribeiro Neto M.L. Budev M. Culver D.A. et al. Venous thromboembolism after adult lung transplantation. Transplantation. 2018; 102: 681-687 Crossref PubMed Scopus (7) Google Scholar , 4 Krivokuca I. van de Graaf E.A. van Kessel D.A. et al. Pulmonary embolism and pulmonary infarction after lung transplantation. Clin Appl Thromb. 2011; 17: 421-424 Crossref PubMed Scopus (7) Google Scholar , 5 Kristensen A.W. Mortensen J. Berg R.M.G. Pulmonary thromboembolism as a complication of lung transplantation. Clin Transplant. 2017; 31: e12922 Crossref Scopus (4) Google Scholar , 6 Burns K.E.A. Iacono A.T. Pulmonary embolism on postmortem examination: An under-recognized complication in lung-transplant recipients?. Transplantation. 2004; 77: 692-698 Crossref PubMed Scopus (37) Google Scholar and may have an underappreciated role in early postoperative mortality. 6 Burns K.E.A. Iacono A.T. Pulmonary embolism on postmortem examination: An under-recognized complication in lung-transplant recipients?. Transplantation. 2004; 77: 692-698 Crossref PubMed Scopus (37) Google Scholar Here, the authors present a case of a common femoral vein DVT and PE in a DLT recipient diagnosed intraoperatively shortly following the induction of anesthesia, leading to the decision to cancel the surgery.

Purpose of review Despite marked improvements in perioperative outcomes, esophagectomy continues to be a high-risk operation associated with significant morbidity and mortality. Progress has been achieved through evidence-based changes in preoperative optimization, intraoperative ventilation strategies, fluid therapy, and analgesia, as well as expedited postoperative recovery pathways. This review will summarize the recent literature on the anesthetic management of patients undergoing esophageal resection. Recent findings The current focus in publications on the perioperative management of esophagectomy patients can be summarized under the umbrella term of enhanced recovery pathways, focusing on ventilation, fluid therapy, analgesia and minimally invasive surgical approaches. Lung protective ventilation reduces pulmonary complications in cases requiring one-lung ventilation. Excess fluid administration contributes to morbidity while restrictive approaches have not resulted in an increased risk of acute kidney injury. Goal-directed fluid therapy remains intuitive yet unproven. Thoracic epidural analgesia reduces the systemic inflammatory response, pulmonary complications, and enhances postoperative pain control, yet if causing perioperative hypotension may be associated with anastomotic leaks. Enhanced recovery pathways have facilitated low morbidity and mortality rates in a high-risk population but are heterogeneous and limited by a weak evidence base. Minimally invasive surgical approaches are increasingly popular and appear to have at least equivalent outcomes to open procedures. Summary The morbidity and mortality after esophagectomy remains high despite significant improvements over the last decades. Enhanced recovery pathways appear promising in achieving further marginal gains but at present are lacking large scale, prospective, multicenter evidence.

Anesthesia for lung transplantation remains one of the highest risk surgeries in the domain of the cardiothoracic anesthesiologist. End-stage lung disease, pulmonary hypertension, and right heart dysfunction as well as other comorbid disease factors predispose the patient to cardiovascular, respiratory and metabolic dysfunction during general anesthesia. Perhaps the highest risk phase of surgery in the patient with severe pulmonary hypertension is during the induction of anesthesia when the removal of intrinsic sympathetic tone and onset of positive pressure ventilation can decompensate a severely compromised cardiovascular system. Severe hypotension, cardiac arrest, and death have been reported previously. Here we present 2 high-risk patients for lung transplantation, their anesthetic induction course, and outcomes. We offer suggestions for the safe management of anesthetic induction to mitigate against hemodynamic and respiratory complications.

FENESTRATED SECUNDUM atrial septal defects (ASD) represent a minority of all secundum ASD and vary significantly in their morphology. 1 Silvestry F.E. Cohen M.S. Armsby L.B. et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: From the American Society of Echocardiography and Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr. 2015; 28: 910-958 Abstract Full Text Full Text PDF PubMed Scopus (267) Google Scholar Larger fenestrated ASD can be imaged easily with 2-dimensional transesophageal echocardiography (2D-TEE) and color-flow Doppler; however, smaller interatrial perforations may not be appreciated. 3D-TEE provides additional information on cardiac structure in real time, which impacts therapeutic decision making in the operating room (OR) and catheterization laboratories. 2 Lang R.M. Badano L.P. Tsang W. et al. EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. J Am Soc Echocardiogr. 2012; 25: 3-46 Abstract Full Text Full Text PDF PubMed Scopus (518) Google Scholar The authors present a case in which 3D-TEE proved superior to 2D-TEE in demonstration of actual fenestrations in the atrial septum. Real-time 3D-TEE imaging also demonstrated the transit of bubbles across the defect during an agitated saline bubble study.

Background: Acute kidney injury (AKI) is defined as oliguria or rise in serum creatinine but oliguria alone as a diagnostic criterion may over-diagnose AKI. Objectives: Given the association between fluid overload and AKI, we aimed to determine if positive fluid balance can complement the known parameters in assessing outcomes of AKI. Design: Prospective observational study. Setting: Teaching hospital in Vancouver, Canada. Patients: 111 consecutive patients undergoing elective cardiac surgery from January to April 2012. Measurements: Outcomes of cardiac surgery intensive care unit (CSICU) and hospital length of stay (LOS) in relation to fluid balance, urine output and serum creatinine. Methods: All fluid input and output was recorded for 72 hours post-operatively. Positive fluid balance was defined as >6.5 cc/kg. Daily serum creatinine and hourly urine output were recorded and patients were defined as having AKI according to the AKIN criteria. Results: Of the patients who were oliguric, those with fluid overload trended towards longer LOS than those without fluid overload [CSICU LOS: 62 and 39 hours (unadjusted p-value 0.02, adjusted p-value 0.58); hospital LOS: 13 and 9 days (unadjusted p-value: 0.05, adjusted p-value: 0.16)]. Patients with oliguria who were fluid overloaded had similar LOS to patients with overt AKI (change in serum creatinine ≥ 26.5 μmol/L), [CSICU LOS: 62 and 69 hours (adjusted p value: 0.32) and hospital LOS: 13 and 14 days (adjusted p value: 0.19)]. Patients with oliguria regardless of fluid balance had longer CSICU LOS (adjusted p value: 0.001) and patients who were fluid overloaded in the absence of AKI had longer hospital LOS (adjusted p value: 0.02). Limitations: Single centre, small sample, LOS as outcome. Conclusions: Oliguria and positive fluid balance is associated with a trend towards longer LOS as compared to oliguria alone. Fluid balance may therefore be a useful marker of AKI, in addition to urine output and serum creatinine.

BACKGROUND:There is under-recognition of comorbid conditions associated with chronic kidney disease (CKD) in children and adolescents after successful renal transplantation.STUDY DESIGN:Retrospective cross-sectional.SETTING & PARTICIPANTS:Children and adolescents aged 1 to 20 years with kidney disease in a transplant (n = 45) and native-kidney-disease cohort (n = 102) matched for CKD stages. CKD stages were assigned using glomerular filtration rate measured by means of nuclear medicine studies. A single pediatric nephrology group cared for all patients.PREDICTOR:History of kidney transplantation.OUTCOMES:Complications of CKD (anemia, hypertension, acidosis, and bone mineral metabolism).RESULTS:The transplant (38% CKD stages 1 to 2, 62% CKD stages 3 to 5) and native-kidney (55% CKD stages 1 to 2, 45% CKD stages 3 to 5) cohorts were similar in demographic and baseline profiles; 68% of transplant recipients had 2 or more complications compared with 29% of native-kidney patients. After adjusting for baseline variables, the odds of having anemia was greater in transplant recipients (odds ratio, 9.7; 95% confidence interval, 3.9 to 24.6) at all CKD stages. The odds of having hypertension was particularly greater (odds ratio, 12.9; 95% confidence interval, 3.4 to 49.4) in transplant recipients with stages 1 to 2 CKD. No significant differences in bone mineral metabolism or acidosis were seen between groups.LIMITATIONS:Retrospective cross-sectional design limits availability of data; lack of consistent protocols introduces treatment bias among physicians.CONCLUSIONS:Children with CKD after transplantation appear to have greater odds of having anemia and hypertension than those with CKD in native kidneys. We suggest that increased awareness and attention to these 2 modifiable risk factors for CKD and cardiovascular disease may improve outcomes after transplantation.