Innovations to Improve Lung Isolation Training for Thoracic Anesthesia: A Narrative Review.

A double-lumen tube or bronchial blocker positioning using flexible bronchoscopy for lung isolation and one-lung ventilation requires specific technical competencies. Training to acquire and retain such skills remains a challenge in thoracic anesthesia. Recent technological and innovative developments in the field of simulation have opened up exciting new horizons and possibilities. In this narrative review, we examine the latest development of existing training modalities while investigating, in particular, the use of emergent techniques such as virtual reality bronchoscopy simulation, virtual airway endoscopy, or the preoperative 3D printing of airways. The goal of this article is, therefore, to summarize the role of existing and future applications of training models/simulators and virtual reality simulators for training flexible bronchoscopy and lung isolation for thoracic anesthesia

El yacimiento arqueológico de Orpesa la Vella (Oropesa del Mar, Castellón). Resultados de las campañas de 2005 a 2008 y su contextualización

Tras un breve resumen de la primera etapa de intervenciones, se presentan los resultados de las campañas de excavación realizadas entre los años 2005 y 2008 en el yacimiento arqueológico de Orpesa la Vella (Oropesa del Mar, Plana Alta, Castellón). Finalmente se efectúa un ensayo de contextualización completa de la secuencia del yacimiento.First we present a brief summary of the interventions carried out previously in the archaeological site of Orpesa la Vella (Oropesa del Mar, Plana Alta, Castellón). Subsequently, the results of the excavation campaigns carried out between 2005 and 2008 are presented. Finally, we try to make a contextualization of the complete archaeological sequence

Identification of tomato accessions as source of new genes for improving heat tolerance: from controlled experiments to field

Background: Due to global warming, the search for new sources for heat tolerance and the identification of genes involved in this process has become an important challenge as of today. The main objective of the current research was to verify whether the heat tolerance determined in controlled greenhouse experiments could be a good predictor of the agronomic performance in field cultivation under climatic high temperature stress. Results: Tomato accessions were grown in greenhouse under three temperature regimes: control (T1), moderate (T2) and extreme heat stress (T3). Reproductive traits (flower and fruit number and fruit set) were used to define heat tolerance. In a first screening, heat tolerance was evaluated in 219 tomato accessions. A total of 51 accessions were identified as being potentially heat tolerant. Among those, 28 accessions, together with 10 accessions from Italy (7) and Bulgaria (3), selected for their heat tolerance in the field in parallel experiments, were re-evaluated at three temperature treatments. Sixteen tomato accessions showed a significant heat tolerance at T3, including five wild species, two traditional cultivars and four commercial varieties, one accession from Bulgaria and four from Italy. The 15 most promising accessions for heat tolerance were assayed in field trials in Italy and Bulgaria, confirming the good performance of most of them at high temperatures. Finally, a differential gene expression analysis in pre-anthesis (ovary) and post-anthesis (developing fruit) under heat stress among pairs of contrasting genotypes (tolerant and sensitive from traditional and modern groups) showed that the major differential responses were produced in post-anthesis fruit. The response of the sensitive genotypes included the induction of HSP genes, whereas the tolerant genotype response included the induction of genes involved in the regulation of hormones or enzymes such as abscisic acid and transferases. Conclusions: The high temperature tolerance of fifteen tomato accessions observed in controlled greenhouse experiments were confirmed in agronomic field experiments providing new sources of heat tolerance that could be incorporated into breeding programs. A DEG analysis showed the complex response of tomato to heat and deciphered the different mechanisms activated in sensitive and tolerant tomato accessions under heat stress

Ventilation and outcomes following robotic-assisted abdominal surgery: an international, multicentre observational study

Background: International data on the epidemiology, ventilation practice, and outcomes in patients undergoing abdominal robotic-assisted surgery (RAS) are lacking. The aim of the study was to assess the incidence of postoperative pulmonary complications (PPCs), and to describe ventilator management after abdominal RAS. Methods: This was an international, multicentre, prospective study in 34 centres in nine countries. Patients ≥18 yr of age undergoing abdominal RAS were enrolled between April 2017 and March 2019. The Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score was used to stratify for higher risk of PPCs (≥26). The primary outcome was the incidence of PPCs. Secondary endpoints included the preoperative risk for PPCs and ventilator management. Results: Of 1167 subjects screened, 905 abdominal RAS patients were included. Overall, 590 (65.2%) patients were at increased risk for PPCs. Meanwhile, 172 (19%) patients sustained PPCs, which occurred more frequently in 132 (22.4%) patients at increased risk, compared with 40 (12.7%) patients at lower risk of PPCs (absolute risk difference: 12.2% [95% confidence intervals (CI), 6.8–17.6%]; P<0.001). Plateau and driving pressures were higher in patients at increased risk, compared with patients at low risk of PPCs, but no ventilatory variables were independently associated with increased occurrence of PPCs. Development of PPCs was associated with a longer hospital stay. Conclusions: One in five patients developed one or more PPCs (chiefly unplanned oxygen requirement), which was associated with a longer hospital stay. No ventilatory variables were independently associated with PPCs. Clinical trial registration: NCT02989415

Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial

Background: Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. Methods/design The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m2 scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (predicted body weight) and randomly assigned to PEEP of 12 cmH2O with lung recruitment maneuvers (high PEEP) or PEEP of 4 cmH2O without recruitment maneuvers (low PEEP). The occurrence of PPCs will be recorded as collapsed composite of single adverse pulmonary events and represents the primary endpoint. Discussion To our knowledge, the PROBESE trial is the first multicenter, international randomized controlled trial to compare the effects of two different levels of intraoperative PEEP during protective low tidal volume ventilation on PPCs in obese patients. The results of the PROBESE trial will support anesthesiologists in their decision to choose a certain PEEP level during general anesthesia for surgery in obese patients in an attempt to prevent PPCs. Trial registration ClinicalTrials.gov identifier: NCT02148692. Registered on 23 May 2014; last updated 7 June 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1929-0) contains supplementary material, which is available to authorized users

Quantitative central corneal anatomy and anaesthetic eye drops effects: comparison between 0.4% oxybuprocaine and a combination of 0.1% tetracaine and 0.4% oxybuprocaine.

We aimed to analyse the changes in central corneal thickness values following the instillation of 0.4% oxybuprocaine eye drops and following a combination of 0.1% tetracaine and 0.4% oxybuprocaine eye drops. Orbscan pachymetry (Orbscan II Corneal Topography System; Orbscan, Inc., Salt Lake City, UT, USA) was carried out before and three minutes after the instillation of 0.4% oxybuprocaine eye drops, and before and three minutes after the instillation of a combination of 0.1% tetracaine and 0.4% oxybuprocaine eye drops in 35 healthy subjects (n=35; aged 20-30 years). After the instillation of 0.4% oxybuprocaine eye drops there was a mean increase in central corneal thickness of 25±11 microns. After the combination of 0.1% tetracaine and 0.4% oxybuprocaine eye drops it rose to 48±20 microns. The combination of 0.1% tetracaine and 0.4% oxybuprocaine anaesthetic eye drops causes higher increases in central corneal thickness values than 0.4% oxybuprocaine eye drops

The effect of a combination of 0.1% tetracaine HCl and 0.4% oxybuprocaine HCl on human central cornea thickness measurements.

A combination of 0.1% tetracaine HCl and 0.4% oxybuprocaine HCl is used when carrying out morphometrical corneal studies in vivo by means of ultrasound pachymetry. The aim of this was to determine the effect of a combination of 0.1% tetracaine HCl and 0.4% oxybuprocaine HCl anesthetic eye drops on central corneal thickness values. We carried out a prospective study involving 30 eyes of 30 healthy subjects. The mean age of the subjects was 26.13±2.62 years (age ranged from 20 to 30 years old). Central pachymetry was carried out prior to and three minutes after the instillation of two saline solution eye drops, and three minutes after the administration of a combination of 0.1% tetracaine HCl and 0.4% oxybuprocaine HCl anesthetic eye drops. The mean of three consecutive measurements of the central corneal thickness obtained with the Orbscan Topography System II (Orbscan, Inc., Salt Lake City, UT. USA) was used as the corneal thickness value. No significant differences were found (p=0.714) in the mean central corneal thickness values before and three minutes after saline solution eye drops had been instilled. Nevertheless, after anesthesia there was a significant increase in mean central corneal thickness (p<0.001). Increases ranged from 22 to 131 micrometers, with a mean of approximately 47 micrometers. Following the instillation of a combination of 0.1% tetracaine HCl and 0.4% oxybuprocaine HCl eye drops corneal thickness increase. Researchers must be aware of this effect of topical anesthetic eye drops on corneal morphometry in order to analyze corneal thickness results correctly

Airway Management of Patients with Suspected or Confirmed COVID-19: Survey Results from Physicians from 19 Countries in Latin America

Airway management during the COVID-19 pandemic has been one of the most challenging aspects of care that anesthesiologists and intensivists face. This study was conducted to evaluate the management of tracheal intubation in patients with suspected or confirmed COVID-19 infection. This is a cross-sectional and international multicenter study based on a 37-item questionnaire. The survey was available to physicians who had performed intubations and tracheostomies in patients with suspected or confirmed COVID-19 and had provided informed consent to participate. The primary outcome is the preference to use a specific device for tracheal intubation. Secondary outcomes are clinical practice variables, use of video laryngoscopes, difficult airway management, and safety features to prevent cross-infection. This study included 2411 physicians who performed an average of 11.90 and 20.67 tracheal intubations in patients diagnosed or suspected of having COVID-19 disease, respectively. Physicians were mainly from the specialties of Anesthesiology (61.2%) and Intensive Care (7.4%). COVID-19 infection diagnosed by positive PCR or serology in physicians participating in intubation in this study was 15.1%. Respondents considered preoxygenation for more than three minutes very useful (75.7%). The preferred device for tracheal intubation was the video laryngoscope (64.8%). However, the direct laryngoscope (57.9%) was the most commonly used, followed by the video laryngoscope (37.5%). The preferred device to facilitate intubation was the Eschmann guide (34.2%). Percutaneous tracheostomy was the preferred technique (39.5%) over the open tracheostomy (22%). The predicted or unpredicted difficult airway management in these patients was preferably performed with a video laryngoscope (61.7% or 63.7, respectively). Intubation was mostly performed by two or more expert airway physicians (61.6%). The use of personal protective equipment increased the practitioners' discomfort during intubation maneuvers. The video laryngoscope is the preferred device for intubating patients with COVID-19, combined with the Eschmann guide, flexible stylet within the endotracheal tube, or Frova guide to facilitate intubation. The sub-analysis of the two groups of physicians by the level of intubation experience showed a higher use of the video laryngoscope (63.4%) in the experts group and no significant differences between the two groups in terms of cross-infection rates in physicians, in their preference for the use of the video laryngoscope or in the number of intubations performed in confirmed or suspected COVID-19 patients

Thoracic Anesthesia of Patients With Suspected or Confirmed 2019 Novel Coronavirus Infection: Preliminary Recommendations for Airway Management by the European Association of Cardiothoracic Anaesthesiology Thoracic Subspecialty Committee

The novel coronavirus has caused a pandemic around the world. Management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. The thoracic subspecialty committee of European Association of Cardiothoracic Anaesthesiology (EACTA) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. It should be emphasized that both the management of the infected patient with COVID-19 and the self-protection of the anesthesia team constitute a complicated challenge. The text focuses therefore on both important topics