The Anesthesiologist's Perspective Regarding Non-intubated Thoracic Surgery: A Scoping Review

Non-intubated thoracic surgery (NITS) is a growing practice, alongside minimally invasive thoracic surgery. To date, only a consensus of experts provided opinions on NITS leaving a number of questions unresolved. We then conducted a scoping review to clarify the state of the art regarding NITS. The systematic review of all randomized and non-randomized clinical trials dealing with NITS, based on Pubmed, EMBASE, and Scopus, retrieved 665 articles. After the exclusion of ineligible studies, 53 were assessed examining: study type, Country of origin, surgical procedure, age, body mass index, American Society of Anesthesiologist's physical status, airway management device, conversion to orotracheal intubation and pulmonary complications rates and length of hospital stay. It emerged that NITS is a procedure performed predominantly in Asia, and certain European Countries. In China, NITS is more frequently performed for parenchymal resection surgery, whereas in Europe, it is mainly employed for pleural pathologies. The most commonly used device for airway management is the laryngeal mask. The conversion rate to orotracheal intubation is a~3%. The results of the scoping review seem to suggest that NITS procedures are becoming increasingly popular, but its role needs to be better defined. Further randomized clinical trials are needed to better define the role of the clinical variables possibly impacting on the technique effectiveness. SYSTEMATIC REVIEW REGISTRATION: https://osf.io/mfvp3/, identifier: 10.17605/OSF.IO/MFVP3

Impact of intubated vs. non-intubated anesthesia on postoperative diaphragmatic function: Results from a prospective observational study

Background: An altered diaphragmatic function was associated with the development of postoperative pulmonary complications following thoracic surgery. Methods: To evaluate the impact of different anesthetic techniques on postoperative diaphragmatic dysfunction, patients undergoing video-assisted thoracoscopic surgery (VATS) lung biopsy for interstitial lung disease were enrolled in a monocentric observational prospective study. Patients received intubated or non-intubated anesthesia according to risk assessment and preferences following multidisciplinary discussion. Ultrasound measured diaphragmatic excursion (DIA) and Thickening Fraction (TF) were recorded together with arterial blood gases and pulmonary function tests (PFT) immediately before and 12 h after surgery. Pain control and postoperative nausea and vomiting (PONV) were also evaluated. Results: From February 2019 to September 2020, 41 consecutive patients were enrolled. Five were lost due to difficulties in collecting postoperative data. Of the remaining 36 patients, 25 underwent surgery with a non-intubated anesthesia approach whereas 11 underwent intubated general anesthesia. The two groups had similar baseline characteristics. On the operated side, DIA and TF showed a lower residual postoperative function in the intubated group compared to the non-intubated group (54 vs. 82% of DIA and 36 vs. 97% of TF; p = 0.001 for both). The same was observed on the non-operated side (58 vs. 82% and 62 vs. 94%; p = 0.005 and p = 0.045, respectively, for DIA and TF). No differences were observed between groups in terms of pain control, PONV, gas exchange and PFT. Conclusion: This study suggests that maintenance of spontaneous breathing during VATS lung biopsy is associated with better diaphragmatic residual function after surgery

Blood clot stabilization after different mechanical and chemical root treatments: a morphological evaluation using scanning electron microscopy

none8noPurpose: This in vitro study was conducted to evaluate the effects of different debridement techniques and conditioning procedures on root surface morphology and blood clot stabilization. Methods: Two debridement techniques (curette [CU] vs. high-speed ultrasound [US]) and 2 conditioning procedures (ethylenediaminetetraacetic acid [EDTA] and phosphoric acid [PA]) were used for the study. Seven experimental groups were tested on root surfaces: 1) no treatment (C); 2) CU; 3) US; 4) CU+EDTA; 5) US+EDTA; 6) CU+PA; and 7) US+PA. Three specimens per group were observed under scanning electron microscopy (SEM) for surface characterization. Additional root slices received a blood drop, and clot formation was graded according to the blood element adhesion index by a single operator. Data were statistically analyzed, using a threshold of P<0.05 for statistical significance. Results: The C group displayed the most irregular surface among the tested groups with the complete absence of blood traces. The highest frequency of blood component adhesion was shown in the CU+EDTA group (P<0.05), while no differences were detected between the CU, US+EDTA, and CU+PA groups (P<0.05), which performed better than the US and US+PA groups (P<0.05). Conclusions: In this SEM analysis, EDTA and conventional manual scaling were the most efficient procedures for enhancing smear layer removal, collagen fiber exposure, and clot stabilization on the root surface. This technique is imperative in periodontal healing and regenerative procedures.openMartina Stefanini , Edoardo Ceraolo , Claudia Mazzitelli , Tatjana Maravic , Matteo Sangiorgi , Giovanni Zucchelli , Lorenzo Breschi , Annalisa MazzoniMartina Stefanini , Edoardo Ceraolo , Claudia Mazzitelli , Tatjana Maravic , Matteo Sangiorgi , Giovanni Zucchelli , Lorenzo Breschi , Annalisa Mazzon

Awake or intubated surgery in diagnosis of interstitial lung diseases? A prospective study

BACKGROUND: Risks associated with video-assisted surgical lung biopsy (VASLB) for interstitial lung disease (ILD) with endotracheal intubation and mechanical ventilation are not nil. Awake video-assisted surgical lung biopsy (Awake-VASLB) has been proposed as a method to obtain a precise diagnosis in several different thoracic diseases. OBJECTIVES: To compare clinical outcomes of Awake-VASLB and Intubated-VASLB in patients with suspected ILDs. METHODS: From June 2016 to February 2020, all patients submitted to elective VASLB for suspected ILD were included. Differences in outcomes between Awake-VASLB and Intubated-VASLB were assessed through univariable, multivariable-adjusted, and a propensity score-matched analysis. RESULTS: Awake-VASLB was performed in 66 out of 100 patients, while 34 underwent Intubated-VASLB. The Awake-VASLB resulted in a lower post-operative morbidity (OR 0.025; 95% CI 0.001–0.35; p=0.006), less unexpected intensive care unit admission, less need for rescue therapy for pain, a reduced surgical and anaesthesiologic time, a reduced chest drain duration, and a lower post-operative length of stay. CONCLUSION: Awake-VASLB in patients affected by ILD is feasible and seems safer than Intubated-VASLB

Decurarization After Thoracic Anesthesia using sugammadex compared to neostigmine (DATA trial): a multicenter randomized double-blinded controlled trial

Abstract Background Thoracic surgery is a high-risk surgery especially for the risk of postoperative pulmonary complications. Postoperative residual paralysis has been shown to be a risk factor for pulmonary complications. Nevertheless, there are few data in the literature concerning the use of neuromuscular blocking agent antagonists in patients undergoing lung surgery. Methods Seventy patients were randomized in three Italian centers to receive sugammadex or neostigmine at the end of thoracic surgery according to the depth of the residual neuromuscular block. The primary outcome was the time from reversal administration to a train-of-four ratio (TOFR) of 0.9. Secondary outcomes were the time to TOFR of 1.0, to extubation, to postanesthesia unit (PACU) discharge, postoperative complications until 30 days after surgery, and length of hospital stay. Results Median time to recovery to a TOFR of 0.9 was significantly shorter in the sugammadex group compared to the neostigmine one (88 vs. 278 s — P < 0.001). The percentage of patients who recovered to a TOFR of 0.9 within 5 min from reversal administration was 94.4% and 58.8% in the sugammadex and neostigmine groups, respectively (P < 0.001). The time to extubation, but not the PACU stay time, was significantly shorter in the sugammadex group. No differences were found between the study groups as regards postoperative complications and length of hospital stay. The superiority of sugammadex in shortening the recovery time was confirmed for both deep/moderate and shallow/minimal neuromuscular block. Conclusions Among patients undergoing thoracic surgery, sugammadex ensures a faster recovery from the neuromuscular block and earlier extubation compared to neostigmine