Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

End-tidal desflurane concentration for tracheal extubation in adults

OBJECTIVE

To determine the end-tidal desflurane concentration required for tracheal extubation in anaesthetised adults.

MATERIAL AND METHODS

After hospital Ethics Committee approval, eighteen ASA I-II adult patients (19-65 years of age), who had been scheduled for elective ambulatory surgery were included in the study. Anaesthesia was induced with propofol 2.5mg.kg^-1, fentanyl 2μg.kg^-1, and rocuronium 0.6mg.kg^-1 for intubation. Maintenance of anaesthesia was provided by desflurane in oxygen and air (40:60), and remifentanil at 0.05-0.25μg.kg^-1.min¹. Neuromuscular function was monitored with train-of-four (TOF) nerve stimulation and acceleromyography. At the end of the surgery neuromuscular blockade was reversed with sugammadex 2-4mg.kg^-1 in accordance with the TOF ratio. The concentration of desflurane at which extubation was attempted was determined by using Dixon's up-and-down method with 0.5% as a step size. Smooth extubation was defined as one without coughing, teeth clenching, gross purposeful movements, and no breath-holding or laryngospasm within 1min of tracheal extubation.

RESULTS

It was found that the end-tidal concentration of desflurane was 3.17±0.18% (95% CI: 3%-3.35%) for successful extubation in 50% of adults.

CONCLUSION

Extubation in patients receiving desflurane may be feasible at 0.62 minimum alveolar concentration.

[Aortic coarctation and postcoarctation mycotic aneurysm in a woman 20 weeks pregnant: anesthetic management]

A 28-year-old woman, 20 weeks pregnant, was diagnosed with aortic coarctation and postcoarctation mycotic aneurysm. After anesthetic induction, blood pressure was monitored in the radial artery of the right arm and the femoral artery of the right leg for two purposes: to verify hemodynamic stability as required in this type of operation and to determine the pressure gradient between the upper and lower limbs, which was approximately 40 mm Hg. To prevent spinal cord ischemia, an intradural catheter was inserted into the fourth and fifth lumbar space for spinal fluid drainage. A double lumen tube was used for intubation so that the left lung could be blocked, and a centrifugal pump was used instead of extracorporeal circulation. The aneurysm was resected through a left thoracotomy and an aortic prosthesis was placed. Satisfactory outcome was indicated by resolution of the pressure gradient, and fetal viability was verified by ultrasound. The mother suffered no neurological complications and the pregnancy continued to term uneventfully. We review the anesthetic procedure to follow in such cases.