Transoesophageal Doppler Monitoring For Fluid And Hemodynamic Treatment During Lung Surgery

Introduction: Patients undergoing lung resection are vulnerable to fluid overhydration. Recently, goal-directed fluid therapy using transoesophageal Doppler monitoring (TDM) has been shown to improve postoperative clinical outcome. The aim of this study was to assess the feasibility of TDM during open-chest procedures for guiding fluid and hemodynamic treatment. Methods: We performed an observational prospective study including 127 high-risk patients undergoing lung cancer resection. A restrictive fluid strategy was targeted to achieve a stroke volume index (SVI) ≥ 30ml/min/m2. Besides standard hemodynamic measurements, stroke volume index (SVI), corrected flow time (FTc), maximal acceleration (MA) and velocity (PV) were recorded during two-lung ventilation (TLV) and one-lung ventilation (OLV). Results: Doppler flow tracings could not be obtained in 4 patients during TLV (3.1%) and in 6 patients during OLV (4.9%). Preoperatively, 96 pts had SVI ≥ 30ml/min/m2 (N-SVI group) whereas 21 patients had SVI < 30ml/min/m2 (L-SVI group) associated with lower FTc values. After OLV, SVI transiently decreased (−17 ± 9%; P<0.05) in the N-SVI group whereas in the L-SVI group, SVI increased steadily until the end of surgery (+40 ± 12%). Other flow-related parameters as well as heart rate and mean arterial pressure remained unchanged. Surgical and medical characteristics did not differ between the two groups, except that larger volumes of colloids were administered intraoperatively in the L-SVI group (+2.2 ± 0.6ml/min/h compared with N-SVI group, P < 0.05). Conclusion: In thoracic surgical patients, TDM can be used to detect and correct low flow conditions and to guide hemodynamic support during the intraoperative perio

Impact of intraoperative lung-protective interventions in patients undergoing lung cancer surgery

INTRODUCTION: In lung cancer surgery, large tidal volume and elevated inspiratory pressure are known risk factors of acute lung (ALI). Mechanical ventilation with low tidal volume has been shown to attenuate lung injuries in critically ill patients. In the current study, we assessed the impact of a protective lung ventilation (PLV) protocol in patients undergoing lung cancer resection. METHODS: We performed a secondary analysis of an observational cohort. Demographic, surgical, clinical and outcome data were prospectively collected over a 10-year period. The PLV protocol consisted of small tidal volume, limiting maximal pressure ventilation and adding end-expiratory positive pressure along with recruitment maneuvers. Multivariate analysis with logistic regression was performed and data were compared before and after implementation of the PLV protocol: from 1998 to 2003 (historical group, n = 533) and from 2003 to 2008 (protocol group, n = 558). RESULTS: Baseline patient characteristics were similar in the two cohorts, except for a higher cardiovascular risk profile in the intervention group. During one-lung ventilation, protocol-managed patients had lower tidal volume (5.3 +/- 1.1 vs. 7.1 +/- 1.2 ml/kg in historical controls, P = 0.013) and higher dynamic compliance (45 +/- 8 vs. 32 +/- 7 ml/cmH2O, P = 0.011). After implementing PLV, there was a decreased incidence of acute lung injury (from 3.7% to 0.9%, P < 0.01) and atelectasis (from 8.8 to 5.0, P = 0.018), fewer admissions to the intensive care unit (from 9.4% vs. 2.5%, P < 0.001) and shorter hospital stay (from 14.5 +/- 3.3 vs. 11.8 +/- 4.1, P < 0.01). When adjusted for baseline characteristics, implementation of the open-lung protocol was associated with a reduced risk of acute lung injury (adjusted odds ratio of 0.34 with 95% confidence interval of 0.23 to 0.75; P = 0.002). CONCLUSIONS: Implementing an intraoperative PLV protocol in patients undergoing lung cancer resection was associated with improved postoperative respiratory outcomes as evidence by significantly reduced incidences of acute lung injury and atelectasis along with reduced utilization of intensive care unit resources

Médecine de catastrophe: mission Haïti

On January 12th, 2010, an earthquake of a magnitude of 7 on the Richter scale striked the southwest of Haiti, including the capital Port-au-Prince, and provoked immense human and material damages. Estimated number of victims is 300000 wounded, 230000 dead and 1000000 homeless. This disaster generated at once an immense and urgent need for sanitary resources. In this context, an emergency medical humanitarian mission was engaged by the Swiss Confederation (humanitarian aid depending on the Development and Cooperation Direction); this article describes this emergency mission, its progress, the committed staff and means, and the type of treated patients

Transoesophageal Doppler monitoring for fluid and hemodynamic treatment during lung surgery

INTRODUCTION: Patients undergoing lung resection are vulnerable to fluid overhydration. Recently, goal-directed fluid therapy using transoesophageal Doppler monitoring (TDM) has been shown to improve postoperative clinical outcome. The aim of this study was to assess the feasibility of TDM during open-chest procedures for guiding fluid and hemodynamic treatment. METHODS: We performed an observational prospective study including 127 high-risk patients undergoing lung cancer resection. A restrictive fluid strategy was targeted to achieve a stroke volume index (SVI) > or = 30 ml/min/m(2). Besides standard hemodynamic measurements, stroke volume index (SVI), corrected flow time (FTc), maximal acceleration (MA) and velocity (PV) were recorded during two-lung ventilation (TLV) and one-lung ventilation (OLV). RESULTS: Doppler flow tracings could not be obtained in 4 patients during TLV (3.1%) and in 6 patients during OLV (4.9%). Preoperatively, 96 pts had SVI > or = 30 ml/min/m(2) (N-SVI group) whereas 21 patients had SVI < 30 ml/min/m(2) (L-SVI group) associated with lower FTc values. After OLV, SVI transiently decreased (-17 +/- 9%; P < 0.05) in the N-SVI group whereas in the L-SVI group, SVI increased steadily until the end of surgery (+40 +/- 12%). Other flow-related parameters as well as heart rate and mean arterial pressure remained unchanged. Surgical and medical characteristics did not differ between the two groups, except that larger volumes of colloids were administered intraoperatively in the L-SVI group (+2.2 +/- 0.6 ml/min/h compared with N-SVI group, P < 0.05). CONCLUSION: In thoracic surgical patients, TDM can be used to detect and correct low flow conditions and to guide hemodynamic support during the intraoperative period

Comparison of cardiac output as assessed by transesophageal echo-Doppler and transpulmonary thermodilution in patients undergoing thoracic surgery

STUDY OBJECTIVE: To evaluate the accuracy of cardiac index (CI) as measured by echo-transesophageal Doppler monitoring (echo-TDM) with CI measured by the transpulmonary thermodilution technique. DESIGN: Prospective, observational study. SETTING: University hospital. PATIENTS: 16 patients scheduled for elective lung cancer resection. INTERVENTIONS: Patients underwent two-lung ventilation (TLV) and one-lung ventilation (OLV). MEASUREMENTS AND MAIN RESULTS: CI measurements were analyzed using Bland-Altman plots. Absolute values of CI as measured by both devices were highly correlated (r(2) ranging from 0.72 to 0.77), as were relative changes in CI after the start of OLV (r(2) = 0.48, P = 0.006). Before, during, and after OLV, TDM-CI biases were 0.46 +/- 0.28 L/min/m(2), 0.25 +/- 0.18 L/min/m(2), and 0.35 +/- 0.29 L/min/m(2), respectively. Limits of agreement remained stable throughout the three measurement periods (range -1.08 to 0.21 L/min/m(2)). The mean percentage error of CI measurements was 21.9% compared with the thermodilution technique. Although no adverse events were reported, 11% of measurement sets were incomplete due to poor signal detection. CONCLUSIONS: Echo-TDM is a safe technique, allowing continuous semi-invasive assessment of hemodynamic changes in most patients undergoing open-chest surgery. Doppler-derived CI values showed significant biases and moderate clinical agreement with transpulmonary thermodilution during TLV and OLV

Risk factors of acute kidney injury according to RIFLE criteria after lung cancer surgery

Perioperative acute kidney injury (AKI) is associated with increased mortality and morbidity. Our aim was to evaluate the incidence and determinants of AKI using the risk, injury, failure, loss of function, and end-stage kidney disease (RIFLE) criteria in thoracic surgical patients