Hypoxia during one lung ventilation in thoracic surgery

Background. The technique of one lung ventilation (OLV) is used with the purpose of achieving isolation of the diseased lung being operated upon, using a doublelumen endobronchial tube. Thoracic surgical procedures which are performed in the lateral decubitus position, nowadays could not be imagined without OLV. In spite of advantages regarding surgical exposure, OLV is associated with serious respiratory impairment. Hypoxemia is considered to be the most important challenge during OLV. The goal of this study was to establish the magnitude of intrapulmonary shunt, as well as the immensity of hypoxia during general anesthesia with OLV. Materials and Methods. In this prospective interventional clinical study thirty patients were enrolled who underwent elective thoracic surgery with a prolonged period of OLV. The patients received balanced general anesthesia with fentanyl/propofol/ rocuronium. A double-lumen endobronchial tube was inserted in all patients, and mechanical ventilation with 50% oxygen in air was used during the entire study. Arterial blood gases were recorded in a lateral decubitus position with two-lung ventilation, at the beginning of OLV (OLV 0) and at 10 and 30 min. (OLV 10, OLV 30, respectively) after initiating OLV in all patients. Standard monitoring procedures were used. Arterial oxygenation (PaO2), arterial oxygen saturation (SaO2) and venous admixture percentage - intrapulmonary shunt (Qs/Qt %) were measured, as well as mean arterial pressure and heart rate during the same time intervals. For the purpose of this study, the quantitative value of Qs/Qt% was mathematically calculated using the blood gas analyser AVL Compact 3. A p value <0.05 was taken to be statistically significant. Results. When OLV was instituted, arterial oxygenation decreased, whereas Qs/Qt% increased, about 10 min. after commencement, with improvement of oxygenation approximately half an hour afterwards. A statistically relevant difference (p<0.05) occurred in PaO2, SaO2 and Qs/Qt at the different time points. Conclusion. Hypoxia during OLV, with an increase in Qs/Qt, usually occurs after 10 min. of its initiation. After 30 min, the values of the Qs/Qt ratio regularly return to normal levels

Evaluation of Total Thyroidectomy for Treatment of Benign Diseases of Thyroid Gland

BACKGROUND: The controversy of using total thyroidectomy (TT) in treatment of benign thyroid diseases still remains controversial over the rates of complication, mostly recurrence nerve palsy and hypocalcemia, compared to non-total thyroidectomies. The latest reports in this field of research showed that that the number of complications of TT is decreasing as the skills of surgeons increase. AIM: In this study, we reviewed 209 cases of total thyroidectomies for benign thyroid diseases where such surgery was indicated. The results were evaluated whether they support the previous reports that TT is save method of treatment of diffuse multinodular goiters, Graves’ disease thyroid adenomas with diffuse goiters and thyroiditis. METHODS: Two hundred and nine patients, 36 males and 173 females, medium age 47 (17–77) operated with TT between 2016 and 2018 were included in the evaluation study. We evaluated the: Diagnosis, indications for operation, pre-operative medication administration, laryngeal recurrent nerve palsy, hypocalcemia, hypoparathyroidism, and patohistology findings. The follow-up for hypocalcemia and laryngeal nerve palsy was performed 1 year postoperatively. RESULTS: The age of the patients was between 17 and 77 years, medium-range 47 years old. Of 209 patients, 173 (83%) were female and 36 (17%) male with a gender ratio of 1:4.8 males to females. Diagnoses before surgery were established as follows: Multinodular euthyroid goiter (MNEG) n = 106 (48.80%), multinodular toxic goiter n = 12 (5.74%), Graves’s disease n = 6 (2.87%), adenoma with multinodular goiter n = 73 (34.92%), and n = 16 (7.65%) patients with thyroiditis. Recurrence laryngeal nerve palsy (RLNP) occurred in 6 patients (2.87%), temporary within 3 months after the operation in 4 patients (1.92%) and permanent palsy within 6 months and more after an operation in 2 patients (0.95%). Voice hoarseness immediately and within 1 month after the operation was registered in 32 patients (15.3%). RLNP and hoarseness were registered mostly in patients with pre-operative problems, mostly with extra big MNEG. One of the permanent injuries of RLN was bilateral and all others were one sided. All patients were operated with normal pre-operative vocal cord movement findings. Post-operative hypocalcemia was registered in 35 patients (16.74%). Temporary nonsignificant hypocalcemia in 10 (4.78%), temporary significant hypocalcemia in 17 (8.13%), temporary severe hypocalcemia in 6 patients (2.87%), and permanent hypocalcemia in 2 patients (0.95%). CONCLUSION: Many studies have shown that the rate of complications is almost even for TT and NTT done for benign and malignant diseases of thyroid gland. Our data have shown that the risk of post-operative complications with TT is proportional to the number of complicated pre-operative findings of benign thyroid glands

Arterial blood gas alterations in retroperitoneal and transperitoneal laparoscopy

Background: Due to its numerous benefits laparoscopic surgery become very popular among physicians, hospitals and patients nowadays. In the urologic pathology laparoscopy can be performed with retroperitoneal or transperitoneal approach. Insufflation of CO2 for achieving visibility in both of the approaches can be absorbed in the vessels and can lead to alterations in arterial blood gasses. Material and Method: Study population was elective urologic patients scheduled for laparoscopic surgery. Investigated arterial blood gas variables were determined in three time points: T0 before induction – basal, T1 after one hour of CO2 insufflation, and T2 at the end of the surgery. Results: Alterations in arterial blood gasses were seen in T1 and T2 for PaO2 in retroperitoneal vs transperitoneal group 173.3 ± 19 vs 196.6 ± 29 (p < 0.003) and 95.5 ± 5.4 vs 101.1 ± 8.2 (p < 0.001). The PaCO2 was also statistically significant in second observed time point T1 in retroperitoneal vs transperitoneal group 45.9 ± 4.1 vs 38.2 ± 0.3 (p < 0.002). Conclusion: The findings that we have presented can suggest that both approaches are safe although hypercarbia is observed in retroperitoneal group. Key Words: arterial blood gasses, retroperitoneal laparoscopy, transperitoneal laparoscopy, urologic laparoscopy. Corresponding author: Aleksandra Gavrilovska-Brzanov, University Clinic for Anesthesia, Reanimation and Intensive Care, Skopje, Republic of North Macedoni

Postoperative complications in patients undergoing thyroid surgery

Background and objectives: Postoperative complications from thyroid surgery are numerous and may be shown on different levels. Some of these complications may be detrimental for patients, so minimization of the risks should be always considered. We evaluated the postoperative complications in patients after surgery of the thyroid gland at the Clinic for Thoracic Surgery, Skopje. Material and method: In retrospective manner, all patients undergoing thyroid surgery during the one-year period (1. January- 31. December 2017) were evaluated. Patients were divided into two groups, whereas group ST included patients who underwent goiter removal and subtotal thyroidectomy while group TT included patients in who total thyroidectomy was done. In both groups we analyzed the demographic data and the occurrence of postoperative (in the first 48 hours) complications (stridor, hoarseness, hemorrhage, nerve dysfunction, tracheomalacia, hypocalcemia and the need for reintubation and tracheostomy). Results: Total data from 197 patients was evaluated. 120 patients had subtotal thyroidectomy while total thyroidectomy had 77 patients. Postoperative complications occurred in significantly larger number of patients in the TT group (64.9 vs. 40%). Hoarseness (8.4% vs. 18.5%), stridor (18.3% vs. 9.2%) tracheomalacia (5% vs. 1.2%) and hematoma (2.5% vs. 3.8%) occurred in respect to the groups. Hypocalcaemia occurred in significantly larger number of patients in TT group. Permanent nerve injury was found in one patient in the same group and tracheotomy was done only in one patient. Conclusion: Overall results from our study show that the complications after thyroid surgery occur in all patients who undergo thyroid surgery. However, more severe complications and outnumbered are complications in patients who undergo total thyroidectomy. Key words: complications, occurrence, thyroid surgery, total thyroidectomy