Fluid management during video-assisted thoracoscopic surgery for lung resection: A randomized, controlled trial of effects on urinary output and postoperative renal function

BackgroundIncreased perioperative fluid administration is an independent risk factor for lung injury after pulmonary resection. In clinical practice, fluid therapy is heavily guided by urinary output; however, diuretic response to plasma volume expansion has been reported to be blunted during anesthesia and surgery. We therefore hypothesized that in patients undergoing video-assisted thoracoscopic surgery, different regimens of intraoperative fluid management would not affect urinary output as would be expected in the nonsurgical scenario. Moreover, a restrictive perioperative fluid approach, as indicated in these operations, will not harm renal function.MethodsOne hundred two patients undergoing video-assisted thoracoscopic surgery were randomly allocated to receive intraoperatively either high (8 mL/[kg · h]; n = 51) or low (2 mL/[kg · h]; n = 51) amounts of Ringer's lactate solution. The primary end point was intraoperative urinary output. Secondary end points included postoperative creatinine serum levels and postoperative complication rate.ResultsDemographic and surgical data were comparable between groups. Regardless of the intraoperatively fluids administered (mean ± SD, 2131 ± 850 vs 1035 ± 652 mL in high and low groups, respectively; P < .0001), urinary output was similar (median 300 mL). Perioperative creatinine serum levels decreased significantly postoperatively and were not significantly different among the groups.ConclusionsIn patients undergoing video-assisted thoracoscopic surgery, intraoperative urinary output and postoperative renal function are not affected by administration of fluids in the range of 2 to 8 mL/(kg · h). The clinical practice of administering fluids to enhance diuresis in the perioperative period should therefore be abandoned

Long-term outcomes of coronary artery bypass grafting patients supported preoperatively with an intra-aortic balloon pump

ObjectiveMost studies describing the outcome of coronary artery bypass grafting patients supported preoperatively with an intra-aortic balloon pump (IABP) have reported early results. The purpose of our study was to evaluate the early and long-term results.MethodsOf 2658 isolated coronary artery bypass grafting procedures performed from 1996 to 2001, 215 were supported preoperatively with an IABP. The indications for IABP insertion were cardiogenic shock in 18 (8.4%), acute evolving myocardial infarction in 38 (17.7%), clinical instability in 84 (39.1%), and critical coronary lesions in 75 (34.9%).ResultsOperative mortality was 12.6%. The mortality of the cardiogenic shock patients was greater (22.2%; P = .174). Logistic regression analysis showed patient age (odds ratio, 1.057; 95% confidence interval, 1.010-1.108) and cardiopulmonary bypass (CPB) time (odds ratio, 1.020; 95% confidence interval, 1.008-1.031) were associated with increased operative mortality. An increased number of bypass grafts had a protective effect (odds ratio, 0.241; 95% confidence interval, 0.113-0.515). The actual early mortality was lower than the logistic EuroSCORE calculated mortality (12.6% vs 32.8%, P < .0001). The mean follow-up was 8 ± 4 years. The Kaplan-Meier 10-year survival was 49%. The Cox adjusted overall (early and late) survival and major adverse cardiac events-free survival of the different IABP subgroups was similar. Cox analyses showed peripheral vascular disease, off-pump coronary artery bypass surgery, age, CPB time, female gender, and fewer bypass grafts were associated with decreased survival.ConclusionsIn patients supported preoperatively with an IABP, better early and long-term results were strongly related to younger age, a shorter CPB time, and a greater number of bypass grafts. Avoiding the use of CPB (off pump) in these emergency cases is not recommended

Major Pulmonary Resection for Non-Small Cell Lung Carcinoma during the COVID-19 Pandemic&mdash;Single Israeli Center Cross-Sectional Study

Background: The highly contagious COVID-19 has created unprecedented challenges in providing care to patients with resectable non-small cell lung carcinoma (NSCLC). Surgical management now needs to consider the risks of malignant disease progression by delaying surgery, and those of COVID-19 transmission to patients and operating room staff. The goal of our study was to describe our experience in providing both emergent and elective surgical procedures for patients with NSCLC during the COVID-19 pandemic in Israel, and to present our point of view regarding the safety of performing lung cancer surgery. Methods: This observational cross-sectional study included all consecutive patients with NSCLC who operated at Tel Aviv Medical Center, a large university-affiliated hospital, from February 2020 through December 2020, during the COVID-19 pandemic in Israel. The patients&rsquo; demographics, COVID-19 preoperative screening results, type and side of surgery, pathology results, morbidity and mortality rates, postoperative complications, including pulmonary complications management, and hospital stay were evaluated. Results: Included in the study were 113 patients, 68 males (60.2%) and 45 females (39.8%), with a median age of 68.2 years (range, 41&ndash;89). Of these 113 patients, 83 (73.5%) underwent video-assisted thoracic surgeries (VATS), and 30 (26.5%) underwent thoracotomies. Fifty-five patients (48.7%) were preoperatively screened for COVID-19 and received negative results. Fifty-six postoperative complications were reported in 35 patients (30.9%). A prolonged air leak was detected in 11 patients (9.7%), atrial fibrillation in 11 patients (9.7%), empyema in 5 patients (4.4%), pneumonia in 9 patients (7.9%) and lobar atelectasis in 7 patients (6.2%). Three patients (2.7%) with postoperative pulmonary complications required mechanical ventilation, and two of them (1.6%) underwent tracheostomy. Two patients (1.6%) were postoperatively diagnosed as positive for COVID-19. Conclusions: Our data demonstrate the feasibility and efficacy of implementing precautionary strategies to ensure the safety of lung cancer patients undergoing pulmonary resection during the COVID-19 pandemic. The strategy was equally effective in protecting the surgical staff and healthcare providers, and we recommend performing lung cancer surgery during the pandemic era