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OBJECTIVE: To investigate the effect of improving the operative field and postoperative atelectasis of single-lung ventilation (SLV) in the surgical repair of coarctation of the aorta (CoA) in infants without the use of cardiopulmonary bypass (CPB). METHODS: This was a retrospective cohort study. The clinical data of 28 infants (aged 1 to 4 months, weighing between 4.2 and 6 kg) who underwent surgical repair of CoA without CPB from January 2019 to May 2022 were analyzed. Fourteen infants received SLV with a bronchial blocker (Group S), and the other 14 infants received routine endotracheal intubation and bilateral lung ventilation (Group R). RESULTS: In comparison to Group R, Group S exhibited improved exposure of the operative field, a lower postoperative atelectasis score (P<0.001), reduced prevalence of hypoxemia (P=0.01), and shorter durations of operation, mechanical ventilation, and ICU stay (P=0.01, P<0.001, P=0.03). There was no difference in preoperative information or perioperative respiratory and circulatory indicators before SLV, 10 minutes after SLV, and 10 minutes after the end of SLV between the two groups (P>0.05). Intraoperative bleeding, intraoperative positive end-expiratory pressure (PEEP), and systolic pressure gradient across the coarctation after operation were also not different between the two groups (P>0.05). CONCLUSION: This study demonstrates that employing SLV with a bronchial blocker is consistent with enhanced operative field, reduced operation duration, lower prevalence of intraoperative hypoxemia, and fewer postoperative complications during the surgical repair of CoA in infants without the use of CPB.

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This article reviews research highlights in the field of thoracic anesthesia. The highlights of this year included new developments in the preoperative assessment and prehabilitation of patients requiring thoracic surgery, updates on the use of devices for one-lung ventilation (OLV) in adults and children, updates on the anesthetic and postoperative management of these patients, including protective OLV ventilation, the use of opioid-sparing techniques and regional anesthesia, and outcomes using enhanced recovery after surgery, as well as the use of expanding indications for extracorporeal membrane oxygenation, specialized anesthetic techniques for airway surgery, and nonintubated video-assisted thoracic surgery.

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Introducción: la mayoría de los pacientes que se someten a cirugía torácica pueden ser clasificados en el grupo de alto riesgo para hipoxia, especialmente cuando se decide por una ventilación unipulmonar, debido al desequilibrio V/Q; por lo tanto, se han desa-rrollado nuevas estrategias ventilatorias y maniobras de rescate para hipoxia. Curso clínico: presentamos una paciente de 85 años de edad sin comorbilidades programada para toracotomía abierta y manejada con ventilación unipulmonar. Durante el mane-jo anestésico, se presenta hipoxia secundaria a desequilibrio V/Q y choque hipovolémi-co hemorrágico, con respuesta positiva a las maniobras de rescate para hipoxia. Con-clusión: es importante prevenir en la medida de lo posible la hipoxia en la ventilación unipulmonar, siguiendo las nuevas estrategias ventilatorias. Sin embargo, cuando se presenta una crisis, no debemos retrasar las maniobras de rescate de forma moderna. (AU)

Introduction: most of the patients undergoing thoracic surgery fit in the high risk group for hypoxia, especially when deciding to use one-lung ventilation due to the V/Q mis-match; therefore, new ventilation strategies and hypoxia rescue manoeuvres have been developed. Clinical course: we present an 85-year old female with no major co-morbidities scheduled for open thoracotomy and managed with one-lung ventilation. During the course of the anaesthetic management, hypoxia presents secondary to V/Q mismatch and haemorrhagic hypovolemic shock, with a positive response to hypoxia rescue manoeuvres. Conclusion: it is important to prevent as much as we can the hy-poxia in a one-lung ventilation following the new ventilation strategies. Although when facing a crisis, proper hypoxia management with a modern approach should not be de-layed. (AU)

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Selected highlights in thoracic anesthesia in 2020 include updates in the preoperative assessment and prehabilitation of patients undergoing thoracic surgery; updates in one-lung ventilation (OLV) pertaining to the devices used for OLV; the use of dexmedetomidine for lung protection during OLV and protective ventilation, recommendations for the care of thoracic surgical patients with coronavirus disease 2019; a review of recent meta-analyses comparing truncal blocks with paravertebral and thoracic epidural blocks; and a review of outcomes after initiating the enhanced recovery after surgery guidelines for lung and esophageal surgery.

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BACKGROUND AND OBJECTIVES: With the intensive study of lung protective ventilation strategies, people begin to advocate the individualized application of positive end-expiratory pressure (PEEP). This study investigated the optimal PEEP in patients during one-lung ventilation (OLV) and its effects on pulmonary mechanics and oxygenation. METHODS: Fifty-eight patients who underwent elective thoracoscopic lobectomy were randomly divided into two groups. Both groups received an alveolar recruitment maneuver (ARM) after OLV. Patients in Group A received optimal PEEP followed by PEEP decremental titration, while Group B received standard 5 cmH2O PEEP until the end of OLV. Relevant indexes of respiratory mechanics, pulmonary oxygenation and hemodynamics were recorded after entering the operating room (T0), 10 minutes after intubation (T1), pre-ARM (T2), 20 minutes after the application of optimal PEEP (T3), at the end of OLV (T4) and at the end of surgery (T5). Postoperative outcomes were also assessed. RESULTS: The optimal PEEP obtained in Group A was 8.8 ± 2.4 cmH2O, which positively correlated with BMI and forced vital capacity (FVC). Group A had a higher CPAT than Group B at T3, T4, T5 (p < 0.05) and a smaller ΔP than Group B at T3, T4 (p < 0.01). At T4, PaO2 was significantly higher in Group A (p < 0.01). At T3, stroke volume variation was higher in Group A (p < 0.01). Postoperative outcomes did not differ between the two groups. CONCLUSIONS: Our findings suggest that the individualized PEEP can increase lung compliance, reduce driving pressure, and improve pulmonary oxygenation in patients undergoing thoracoscopic lobectomy, with little effect on hemodynamics.

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One lung ventilation (OLV) often results in trauma to the unventilated contralateral lung. This study aims to evaluate the effects of different OLV regimens on the injury of the unventilated contralateral lung to identify the best conditions for OLV. Forty rabbits were divided into five groups: a sham group, OLV group I (fraction of inspired oxygen (FIO2) 1.0, tidal volume (VT) 8mL/kg, respiratory rate (R) 40 breaths/min and inspiratory/expiratory ratio (I:E) 1:2), OLV group II (FIO2=1.0, VT 8mL/kg, R 40 breaths/min, I:E 1:2, and positive end-expiratory pressure (PEEP) 5 cm H2O), OLV group III (FIO2 1.0, VT 6mL/kg, R 40 breaths/min, I:E 1:2 and PEEP 5 cm H2O) and OLV group IV (FIO2 0.8, VT 6mL/kg, R 40 breaths/min, I:E 1:2 and PEEP 5 cm H2O). Animals from all OLV groups received two-lung ventilation (TLV) to establish a baseline, followed by one of the indicated OLV regimens. The rabbits in the sham group were intubated through trachea and ventilated with fresh air. Arterial blood gas samples were collected, lung injury parameters were evaluated, and the concentrations of TNF-α and IL-8 in bronchoalveolar lavage fluid (BALF) and pulmonary surfactant protein A (SPA) in the unventilated lung were also measured. In OLV group I, the unventilated left lung had higher TNF-α, IL-8 and lung injury score but lower SPA than the ventilated right lung. In OLV groups I to III, the concentrations of TNF-α, IL-8 and lung injury score in the left lung decreased but SPA increased. No differences in these parameters between OLV groups III and IV were observed. Strategic ventilation designed for OLV groups III and IV reduced OLV-induced injury of the non-ventilated contralateral lung in rabbits.(AU)

Ventilação pulmonar unilateral (OLV) frequentemente resulta em trauma no pulmão contralateral não ventilado. Este estudo visa avaliar os efeitos de diferentes regimes de OLV sobre a lesão do pulmão contralateral não ventilado para identificar as melhores condições para OLV. Quarenta coelhos foram divididos em cinco grupos: um grupo falso, OLV grupo I (fração de oxigênio inspirado (FIO2) 1.0, volume corrente (VT) 8mL/kg, frequência respiratória (R) 40 respirações/min e relação inspiração/expiração (I:E) 1:2), OLV grupo II (FIO2=1.0, VT 8mL/kg, R 40 respirações/min, I:E 1:2, e pressão positiva expiratória final (PEEP) 5 cm H2O), OLV grupo III (FIO2 1.0, VT 6mL/kg, R 40 respirações/min, I:E 1:2 e PEEP 5 cm H2O) e OLV grupo IV (FIO2 0.8, VT 6mL/kg, R 40 respirações/min, I:E 1:2 e PEEP 5 cm H2O). Os animais de todos os grupos OLV receberam ventilação nos dois pulmões (TLV) para estabelecer uma linha de base, seguida por um dos regimes OLV indicados. Os coelhos do grupo falso foram intubados através da traqueia e ventilados com ar fresco. Amostras de gases no sangue arterial foram coletadas, parâmetros de lesão pulmonar foram avaliados e as concentrações de TNF-α e IL-8 no fluido de lavagem bronco alveolar (BALF) e proteína A do surfactante pulmonar (SPA) no pulmão não ventilado também foram medidas. No grupo OLV I, o pulmão esquerdo não ventilado tinha maior índice de TNF-α, IL-8 e lesão pulmonar, mas menor SPA do que o pulmão direito ventilado. Nos grupos OLV I a III, as concentrações de TNF-α, IL-8 e a pontuação de lesão pulmonar no pulmão esquerdo diminuíram, mas o SPA aumentou. Não foram observadas diferenças nestes parâmetros entre os grupos OLV III e IV. A ventilação estratégica projetada para os grupos OLV III e IV reduziu a lesão induzida por OLV do pulmão contralateral não ventilado em coelhos.(AU)

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INTRODUCTION: Minimally invasive esophagectomy aims to reduce complications compared to open esophagectomy. In this report of the first patient undergoing this procedure at Hospital Pasteur, we highlight the importance of multidisciplinary management, and the main anesthesiological objectives. OBJECTIVE: To present the case report highlighting the anesthetic management, together with the bibliographic review carried out in order to update the anesthetic action protocols, with the main objective of reducing the appearance of perioperative complications. MATERIAL AND METHOD: Bibliographic search in PubMed bibliographic databases. Initially, 67 articles were obtained, selecting 20 considered relevant by the authors. CLINICAL CASE: It was a 46-year-old patient coordinated for esophagectomy for squamous neoplasm. Rapid sequence induction, selective endobronchial intubation and anesthetic maintenance with Isoflurane and epidural analgesia were performed. The hydroelectric replacement was restricti- ve. The surgical technique was performed in 3 stages: thoracic time by thoracoscopy; a second laparoscopic abdominal stage and a third stage for left cervicotomy. Extubation was carried out in the operating room with transfer to the ICU where she remained for 6 days to manage analgesia and due to the presence of a mild infectious complication, with good subsequent evolution. CONCLUSION: The use of perioperative multidisciplinary management protocols has fundamental importance as a strategy aimed at reducing morbidity and mortality. Advances in surgical technique added to anesthetic management constitute strategies that aim to reduce perioperative complications.

INTRODUCCIÓN: La esofagectomía minimamente invasiva tiene como objetivo disminuir las complicaciones en comparación con la esofagectomía abierta. En este reporte del primer paciente sometido a este procedimiento en el Hospital Pasteur destacamos la importancia del manejo multidisciplinario, y los principales objetivos anestesiológicos. OBJETIVO: Presentar el reporte de caso destacando el manejo anestésico, junto con la revisión bibliográfica realizada en vistas a la actualización de protocolos de actuación anestésica, con objetivo principal de disminuir la aparición de complicaciones perioperatorias. MATERIAL Y MÉTODO: Búsqueda bibliográfica en las bases bibliográficas PubMed. Inicialmente se obtuvieron 67 artículos, seleccionando 20 considerados relevantes por los autores. CASO CLÍNICO: Se trató de una paciente de 46 años coordinada para esofagectomía por neoplasma epidermoide. Se realizó inducción en secuencia rápida, intubación endobronquial selectiva y mantenimiento anestésico con Isofluorano y analgesia peridural. La reposición hidroelectrolítica fue restrictiva. La técnica quirúrgica se realizó en 3 tiempos: tiempo torácico por toracoscopía; un segundo tiempo abdominal laparoscópico y un tercer tiempo para cervicotomía izquierda. La extubación se realizó en sala de operaciones con traslado a CTI donde permaneció por 6 días para manejo de la analgesia y por presencia de complicación infecciosa leve, con buena evolución posterior. CONCLUSIÓN: Resulta de fundamental importancia el uso de protocolos de manejo multidisciplinario perioperatorio como estrategia destinada a disminuir la morbimortalidad. Los avances en cuanto a la técnica quirúrgica sumado al manejo anestésico constituyen estrategias que apuntan a disminuir las complicaciones perioperatorias.

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Myasthenia Gravis (MG) is an autoimmune disease characterized by weakness and fatigability of skeletal muscles, with improvement following rest. It is a disease of great significance to the anesthesiologist because it affects the neuromuscular junction. Robotic thymectomy has come up in recent times due to the minimally invasive nature and its advantages. This presents a new set of challenges for the anesthesia team, and here we present the various anesthesia considerations and perioperative management in a series of 20 patients who underwent robotic thymectomy. As it is a recent upcoming procedure, there is a paucity of literature on this topic, and most of the available literature talks about One-Lung Ventilation (OLV) and thoracic epidurals. To our notice, this is the first literature without the use of OLV and thoracic epidural for the management of robotic thymectomy.

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Abstract Myasthenia Gravis (MG) is an autoimmune disease characterized by weakness and fatigability of skeletal muscles, with improvement following rest. It is a disease of great significance to the anesthesiologist because it affects the neuromuscular junction. Robotic thymectomy has come up in recent times due to the minimally invasive nature and its advantages. This presents a new set of challenges for the anesthesia team, and here we present the various anesthesia considerations and perioperative management in a series of 20 patients who underwent robotic thymectomy. As it is a recent upcoming procedure, there is a paucity of literature on this topic, and most of the available literature talks about One-Lung Ventilation (OLV) and thoracic epidurals. To our notice, this is the first literature without the use of OLV and thoracic epidural for the management of robotic thymectomy.

Resumo Miastenia Gravis (MG) é uma doença autoimune que se caracteriza por fraqueza e fadiga da musculatura esquelética, com melhora após o repouso. É uma doença de grande interesse para o anestesiologista, pois compromete a junção neuromuscular. Recentemente, a timectomia robótica tem sido empregada por apresentar as vantagens da abordagem minimamente invasiva. O procedimento introduz uma série de novos desafios para a equipe de anestesia. Relatamos aqui as várias considerações anestésicas e o cuidado perioperatório em uma série de 20 pacientes submetidos a timectomia robótica. Sendo um procedimento recente, há limitada literatura discutindo esse tópico e, além disso, a maior parte da literatura disponível concentra a atenção na Ventilação Monopulmonar (VMP) e na peridural torácica. A nosso ver, este é a primeiro relato na literatura sem o emprego de VMP e peridural torácica para o manejo da timectomia robótica.

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