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Licker M, Hagerman A, Jeleff A, Schorer R, Ellenberger C. The hypoxic pulmonary vasoconstriction: From physiology to clinical application in thoracic surgery. Saudi J Anaesth 2021; 15:250-263. [PMID: 34764832 PMCID: PMC8579502 DOI: 10.4103/sja.sja_1216_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 11/04/2022] Open
Abstract
More than 70 years after its original report, the hypoxic pulmonary vasoconstriction (HPV) response continues to spark scientific interest on its mechanisms and clinical implications, particularly for anesthesiologists involved in thoracic surgery. Selective airway intubation and one-lung ventilation (OLV) facilitates the surgical intervention on a collapsed lung while the HPV redirects blood flow from the "upper" non-ventilated hypoxic lung to the "dependent" ventilated lung. Therefore, by limiting intrapulmonary shunting and optimizing ventilation-to-perfusion (V/Q) ratio, the fall in arterial oxygen pressure (PaO2) is attenuated during OLV. The HPV involves a biphasic response mobilizing calcium within pulmonary vascular smooth muscles, which is activated within seconds after exposure to low alveolar oxygen pressure and that gradually disappears upon re-oxygenation. Many factors including acid-base balance, the degree of lung expansion, circulatory volemia as well as lung diseases and patient age affect HPV. Anesthetic agents, analgesics and cardiovascular medications may also interfer with HPV during the perioperative period. Since HPV represents the homeostatic mechanism for regional ventilation-to-perfusion matching and in turn, for optimal pulmonary oxygen uptake, a clear understanding of HPV is clinically relevant for all anesthesiologists.
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Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, CH-1205 GENEVA, Switzerland.,Faculty of Medicine, University of Geneva, Switzerland
| | - Andres Hagerman
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, CH-1205 GENEVA, Switzerland
| | - Alexandre Jeleff
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, CH-1205 GENEVA, Switzerland
| | - Raoul Schorer
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, CH-1205 GENEVA, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, CH-1205 GENEVA, Switzerland.,Faculty of Medicine, University of Geneva, Switzerland
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El-Tahan MR. Role of Thoracic Epidural Analgesia for Thoracic Surgery and Its Perioperative Effects. J Cardiothorac Vasc Anesth 2017; 31:1417-1426. [DOI: 10.1053/j.jvca.2016.09.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Indexed: 11/11/2022]
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Kar P, Durga P, Gopinath R. The effect of epidural dexmedetomidine on oxygenation and shunt fraction in patients undergoing thoracotomy and one lung ventilation: A randomized controlled study. J Anaesthesiol Clin Pharmacol 2016; 32:458-464. [PMID: 28096575 PMCID: PMC5187609 DOI: 10.4103/0970-9185.194771] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Aims: Role of epidural dexmedetomidine in providing analgesia is well documented, but its effect on oxygenation and shunt fraction is not well established. We studied the hypothesis that epidural dexmedetomidine may improve oxygenation and shunt fraction during one-lung ventilation (OLV). Material and Methods: After taking Institutional Ethics Committee approval, sixty patients undergoing thoracotomy and OLV were randomized to receive epidural ropivacaine with saline (RS group) or epidural ropivacaine with dexmedetomidine (RD group). Group RS received 7 ml of ropivacaine 0.5% with 1.5 ml normal saline (NS) bolus while RD group received 7 ml of 0.5% ropivacaine with 1 mcg/kg dexmedetomidine reconstituted in 1.5 ml NS. This was followed by infusion of 5 ml/h of 0.5% ropivacaine in RS group and 5 ml/h of 0.5% ropivacaine containing 0.2 mcg/kg of dexmedetomidine in RD group. Arterial and central venous blood gas parameters were obtained 15 minutes after intubation during two lung ventilation (TLV15), 15 and 45 min after OLV (OLV15, OLV45) and 15 minutes after reinstitution of two lung ventilation (ReTLV). Results: RD group had better oxygenation (254.2 ± 72.3 mmHg, 240.60 ± 59.26 mmHg) as compared to RS group (215.2 ± 64.3 mmHg, 190.7 ± 61.48 mmHg) at OLV15 (P – 0.04) and OLV45 (P – 0.004) respectively. Shunt fraction in RD group was (30.31 ± 7.89%, 33.76 ± 8.89%) and (35.14 ± 7.58%, 39.57 ± 13.03%) in RS group at OLV15 and OLV45, respectively. The increase in the shunt fraction from TLV15 was significantly greater in RS group than RD group both at OLV15 (P – 0.03) and OLV45 (P – 0.03). The sevoflurane and fentanyl requirement was lower in RD group. Conclusion: Epidural dexmedetomidine improves oxygenation and reduces shunt fraction during OLV, in patients undergoing thoracotomy. It also reduces intraoperative anesthetic and analgesic requirement.
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Affiliation(s)
- Prachi Kar
- Department of Anesthesia and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Padmaja Durga
- Department of Anesthesia and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Ramachandran Gopinath
- Department of Anesthesia and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Li XQ, Tan WF, Wang J, Fang B, Ma H. The effects of thoracic epidural analgesia on oxygenation and pulmonary shunt fraction during one-lung ventilation: an meta-analysis. BMC Anesthesiol 2015; 15:166. [PMID: 26584812 PMCID: PMC4653921 DOI: 10.1186/s12871-015-0142-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 11/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of our study is to compare the effects of thoracic epidural analgesia combined with general anesthesia (GA) vs. general anesthesia on oxygenation and pulmonary shunt fraction during one-lung ventilation (OLV). METHODS Literature research was firstly conducted for studies related to comparison of epidural anesthesia combined with GA vs. GA with reporting of hemodynamic and oxygenation variables and published from Jan 1990 to Jan 2014 in EMBAS, MEDLINE and Cochrane Central Register of Controlled Trials databases. The studies were reviewed and data were extracted and analyzed using fixed-effect and random-effect models. RESULTS There are 14 trials with 60 separate comparisons enrolling 653 patients for analysis. Regarding systemic hemodynamics, thoracic epidural analgesia decreased the mean arterial pressure and mean pulmonary arterial pressure with weighted mean difference 95% confidence interval (-6.64 [-9.57 to -3.71] vs. -6.33 [-9.25 to -3.41] and -3.18 [-5.07 to -1.28] vs. -2.05 [-3.35 to -0.75]) respectively at the two measurements time, however, only decreasing heart rate and systemic vascular resistance (-3.28 [-5.98 to -0.67] and -319.99 [-447.05 to -192.94]) over the first 30 min after OLV. For oxygenation variables, thoracic epidural analgesia is associated with significant reduction in partial arterial oxygen pressure, mixed arterial saturation of oxygenation and increased pulmonary venous admixture fraction compared to general anesthesia with weighted mean difference 95% confidence interval (-16.52 [-21.98 to - 11.05] vs. - 14.23 [-20.81 to - 7.65]), (0.74 [0.33 to 1.15] vs. - 0.63 [-1.23 to -0.04]) and (2.53 [1.35 to 3.72] vs. 2.77 [1.81 to 3.74]) respectively before and after 30 min of one-lung ventilation. A decrease in mixed venous saturation of oxygenation occurred after 30 min of OLV (-2.39 [-3.73 to -0.99]). Besides, a higher mean value of airway pressure was found in the thoracic epidural analgesia with weighted mean difference 95% confidence interval (1.95 [1.61 to 2.28] vs. 0.87 [0.54 to 1.20]) at the measurements. CONCLUSION Based on the existing limited data puts forward recommendations for cautious usage of thoracic epidural analgesia in case of underlying risks in lower systemic hemodynamics, decreased partial arterial oxygen pressure but increases pulmonary shunt during one-lung ventilation.
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Affiliation(s)
- Xiao-Qian Li
- Department of Anesthesiology, First Affiliated Hospital, China Medical University, Shenyang, 110001, , Liaoning, China.
| | - Wen-Fei Tan
- Department of Anesthesiology, First Affiliated Hospital, China Medical University, Shenyang, 110001, , Liaoning, China.
| | - Jun Wang
- Department of Anesthesiology, First Affiliated Hospital, China Medical University, Shenyang, 110001, , Liaoning, China.
| | - Bo Fang
- Department of Anesthesiology, First Affiliated Hospital, China Medical University, Shenyang, 110001, , Liaoning, China.
| | - Hong Ma
- Department of Anesthesiology, First Affiliated Hospital, China Medical University, Shenyang, 110001, , Liaoning, China.
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Effects of thoracic epidural anesthesia on pulmonary venous admixture and oxygenation with isoflurane or propofol anesthesia during one lung ventilation. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2012. [DOI: 10.1016/j.ejcdt.2012.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Sumler ML, Andritsos MJ, Blank RS. Anesthetic management of the patient with dilated cardiomyopathy undergoing pulmonary resection surgery: a case-based discussion. Semin Cardiothorac Vasc Anesth 2012; 17:9-27. [PMID: 22892328 DOI: 10.1177/1089253212453620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Interactions between the cardiovascular and respiratory systems are complex and profound. General anesthesia, muscle relaxation, and positive-pressure ventilation all impose physiological effects on cardiovascular function. In patients presenting for pulmonary resection, additional effects resulting from positioning, 1-lung ventilation, surgical procedures, and contraction of the pulmonary vascular bed may impose an additional physiological burden. For most patients with adequate pulmonary and cardiovascular reserve, these effects are well tolerated. However, the cardiothoracic anesthesiologist may be asked to provide anesthetic care for patients with significantly reduced cardiac function who require potentially curative pulmonary resection for lung cancer. These patients present a major perioperative challenge and a thoughtful approach to intraoperative management is required. The authors review a case of a patient with severely impaired biventricular function who presented for elective pulmonary lobectomy in an attempt to effect a curative resection of lung cancer and present a discussion of physiological and pathophysiological considerations for clinical management.
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Affiliation(s)
- Michele L Sumler
- University of Virginia Health System, Charlottesville, VA 22908, USA
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Abstract
PURPOSE OF REVIEW Hypoxemia during one-lung ventilation (OLV) has become less common; however, it may still occur in about 10% of cases. We review recent developments which may affect the incidence and treatment of hypoxemia during OLV. RECENT FINDINGS Changes in surgical techniques are affecting oxygenation during OLV. The increased use of the supine position may adversely affect the prevalence of hypoxemia, whereas the increased application of thoracoscopic techniques is limiting the treatment options. Treatment options such as global or selective recruitment maneuvers and drug effects of dexmedetomidine and epoprostenol on arterial oxygenation during OLV are discussed. Capnometry prior to, or early during OLV, may in fact be able to predict the degree of hypoxemia during OLV. Persistent controversies surrounding the effect of epidural anesthesia, ventilatory modalities and gravity are reviewed. SUMMARY Interesting concepts have emerged from case reports and small studies on the treatment and prediction of hypoxemia during OLV. Definitive studies on the most effective ventilatory mode remain elusive. End-organ effects of OLV are an exciting new concept that may shape clinical practice and research going forward.
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Fukuoka N, Iida H, Akamatsu S, Nagase K, Iwata H, Dohi S. The Association Between the Initial End-Tidal Carbon Dioxide Difference and the Lowest Arterial Oxygen Tension Value Obtained During One-Lung Anesthesia With Propofol or Sevoflurane. J Cardiothorac Vasc Anesth 2009; 23:775-9. [DOI: 10.1053/j.jvca.2009.03.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Indexed: 11/11/2022]
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Ozcan PE, Sentürk M, Sungur Ulke Z, Toker A, Dilege S, Ozden E, Camci E. Effects of thoracic epidural anaesthesia on pulmonary venous admixture and oxygenation during one-lung ventilation. Acta Anaesthesiol Scand 2007; 51:1117-22. [PMID: 17697309 DOI: 10.1111/j.1399-6576.2007.01374.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND In this clinical randomized study, the effects of four anaesthesia techniques during one-lung ventilation [total intravenous anesthesia (TIVA) with or without thoracic epidural anaesthesia (TEA) (G-TIVA-TEA and G-TIVA), isoflurane anaesthesia with or without TEA (G-ISO-TEA and G-ISO)] on pulmonary venous admixture (Qs/Qt) and oxygenation (OLV) were investigated. METHODS In 100 patients (four groups, 25 patients in each) undergoing thoracotomy, a thoracic epidural catheter was inserted pre-operatively. In G-TIVA-TEA and G-ISO-TEA, bupivacaine 0.1% + 0.1 mg/ml morphine was administered intra-operatively (10 ml of first bolus + 7 ml/h infusion). Propofol infusion or isoflurane concentration was adjusted to keep a bispectral index (BIS) of between 40 and 50 in all groups. FiO(2) was 0.8 during OLV and 0.5 before and after OLV. Partial arterial and central venous oxygen pressures (PaO(2) and PvO(2)), arterial and venous oxygen saturations and Qs/Qt values were recorded before, during and after OLV. RESULTS During OLV, PaO(2) was significantly higher and Qs/QT significantly lower in G-TIVA-TEA and G-TIVA compared with G-ISO-TEA and G-ISO (PaO2: 188 +/- 36; 201 +/- 39; 159 +/- 33; 173 +/- 42 mmHg, respectively; Qs/Qt: 31.2 +/- 7.4; 28.2 +/- 7; 36.7 +/- 7.1; 33.7 +/- 7.7%, respectively). No statistical changes were observed in patients with TEA compared with without TEA in any measurement. CONCLUSION During OLV, TEA does not significantly affect the oxygenation and Qs/Qt and can be used safely regardless of whether TIVA or inhalation techniques are used.
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Affiliation(s)
- P E Ozcan
- Department of Anaesthesiology, Istanbul Medical Faculty, Istanbul University, Capa 34093, Istanbul, Turkey
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Casati A, Alessandrini P, Nuzzi M, Tosi M, Iotti E, Ampollini L, Bobbio A, Rossini E, Fanelli G. A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery. Eur J Anaesthesiol 2006; 23:999-1004. [PMID: 16824243 DOI: 10.1017/s0265021506001104] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2006] [Indexed: 11/07/2022]
Abstract
BACKGROUND The aim of this prospective, randomized, blinded study was to compare analgesic efficacy of continuous paravertebral and epidural analgesia for post-thoracotomy pain. METHODS Forty-two ASA physical status II-III patients undergoing lung resection surgery were randomly allocated to receive post-thoracotomy analgesia with either a thoracic epidural (group EPI, n = 21) or paravertebral (group PVB, n = 21) infusion of 0.2% ropivacaine (infusion rate: 5-10 mL h-1). The degree of pain at rest and during coughing, haemodynamic variables and blood gas analysis were recorded every 12 h for the first 48 h. RESULTS The area under the curve of the visual analogue pain score during coughing over time was 192 (60-444) cm h-1 in group EPI and 228 (72-456) cm h-1 in group PVB (P = 0.29). Rescue morphine analgesia was required in four patients of group EPI (19%) and five patients of group PVB (23%) (P = 0.99). The PaO2/FiO2 ratio reduced significantly from baseline values in both groups without between-group differences. The median (range) percentage reduction of systolic arterial pressure from baseline was -9 (0 to -9)% in group PVB and -17 (0 to -38)% in group EPI (P = 0.02); while clinically relevant hypotension (systolic arterial pressure decrease >30% of baseline) was observed in four patients of group EPI only (19%) (P = 0.04). Patient satisfaction with the analgesia technique was 8.5 (8-9.8) cm in group EPI and 9 (7.5-10) cm in group PVB (P = 0.65). CONCLUSIONS Continuous thoracic paravertebral analgesia is as effective as epidural blockade in controlling post-thoracotomy pain, but is associated with less haemodynamic effects.
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Affiliation(s)
- A Casati
- University of Parma, Department of Anaesthesiology and Pain Therapy, Ospedale Maggiore di Parma, Parma, Italy.
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