As part of a cardiac fast-tracking program involving desflurane anesthesia, the use of intrathecal morphine in combination with a remifentanil infusion provided improved postoperative pain control, compared with IV sufentanil alone.

Purpose: Five thousand, two hundred and eight lung transplants were performed worldwide before April, 1996. This review will discuss lung transplantation from an historical perspective, its indications, donor and recipient selection criteria, donor lung preparation, su~cal considerations, perioperative anaesthetic management, and associated morbidity and mortality. Source: Recent literature on perioperative anaesthetic management of lung transplantation and experience from international centres including the Toronto Lung Transplant Group and the St. Louis Lung Transplant Group. Principal fiadings: Lung transplantation comprises of a family of operations, including single lung transplant, bilateral single lung transplant, lobar transplant and block heart-lung transplant. Improved donor lung preservation techniques have increased the duration of cold ischaemic time. The advent of bilateral single lung transplant has decreased the requirement for cardiopulmonary bypass, and airway complications have been reduced by adoption of~e telescoping bronchial anastomoses. Advances in perioperative monitoring (including transoesophgeai echocardiography), pulmonary vasodilators (e.g., nitric oxide and prostaglandin El), carcliopulmonary bypass and ventilatory management, and a better understanding of the pathophysiological processes during the procedure have improved perioperative anaesthetic management. Also, advances in broad spectrum antibiotics and immunosuppressant drugs have improved the outcome by better management of the complications of infection and rejection. Conclusion: Lung transplantation improves the quality of life with marginal improvement in life expectancy of the recipients. It is an expensive procedure requiring continued resources for long term management of these patients.Objectif : jusqu'en avril 1996, cinq mille, deux cent huit transplantations de poumons avaient dEj,~ Et~ effectuL~,s ,~ travers le monde. Ce survol permettra de discuter de la transpl@~tion pulmonalre darts sa perspective historique, ses indications, les crit&es de s~lection du receveur et du donneur, la preparation du poumon du donneur, les consid&ations chirurgicales, la gestion p&iol~ratoire de ranesth~sie et la mortaiit~ et la morbidit~ assod~es. Source : Les publications r&entes traitant de la gestion p&iop&atoire de la transplantation pulmonaire et de l'exl:~rience acquise par des centres intemationaux dont le Toronto Lung Transplant Group et le St.Louis Lung Transplant Group. Princlpales r: la transplantation pulmonaire englobe une famille d'interventions dont la transplantation unipulmonaire, bilat&ale simple, Iobaire et coeur-poumons en bloc. I:am61ioration des techniques de pr6servation des poumons du donneur a permis ram~lioration de la durEe de risch6mie froide. I'av~nement de la transplantation bilat~rale simple a rEduit la n~cessitE de la circulation extracorporelle et rintroduction des anastomoses t~lescopiques a permis de r~duire les complications particuli&es aux voles a~dennes. Le perfectionnement du monitorage p~nop&a...

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We studied the comparative effects of ketorolac versus bupivacaine supplementation of hydromorphone (HM) patient-controlled epidural analgesia (PCEA) on the HM requirement, postoperative pain, and pulmonary function in 62 consenting patients after thoracotomy procedures. Patients were randomly assigned to receive one of three different combinations of analgesic medications after the operation according to a double-blind, placebo-controlled study. The treatment groups consisted of: Group 1 (n = 23): PCEA HM 3-mL (0.15 mg) bolus doses + saline 1 mL intravenously (IV) q6h, Group 2 (n = 20): PCEA HM (0.15 mg) in 0.125% bupivacaine 3-mL bolus doses + saline 1 mL IV q6h, and Group 3 (n = 19): PCEA HM 3-mL (0.15 mg) bolus doses + ketorolac 1 mL (30 mg) IV q6h. Epidural HM and supplemental analgesic requirements, pain visual analog scale (VAS) scores, the incidence of nonincisional pain, and side effects were recorded at 24 and 48 h after surgery. Bedside pulmonary function tests were performed using a Puritan Bennett 100TM (Puritan-Bennett Corp., Wilmington, MA) spirometer before and 24 and 48 h after surgery. IV ketorolac supplementation of HM PCEA significantly reduced the incidence of nonincisional pain and the HM requirement over 48 h compared with the HM PCEA alone group (7% vs 26%; 3 +/- 1.6 mg vs 5.3 +/- 2.8 mg). Both ketorolac and bupivacaine supplementation of HM PCEA reduced the severity of pain on coughing and on movement compared with HM PCEA alone on postoperative day (POD) 1. Significant reductions in forced vital capacity, forced expiratory volume in 1 s, forced expiratory flow 25%-75% of the vital capacity, and peak expiratory flow rate (PEFR) were noted on PODs 1 and 2 in all three treatment groups. The decrease in PEFR on PODs 1 and 2 was significantly less with ketorolac compared with bupivacaine supplementation. We conclude that ketorolac supplementation of HM PCEA reduces the incidence of nonincisional pain and HM requirement compared with HM PCEA alone and may have a beneficial effect on pulmonary function compared with bupivacaine supplementation of HM PCEA in postthoracotomy patients.