No abstract

To the Editor,Airway management during tracheal resection is one of the great challenges confronting anesthesiologists, especially when carinal resection is involved. When ventilation through the mainstem bronchi is not an option due to surgical exposure, extracorporeal oxygenation techniques become a vital tool. Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a preferred mode of assuring adequate oxygenation in patients with normal right ventricular function. However, its oxygenation efficacy is lower than either cardiopulmonary bypass (CPB) or venoarterial ECMO (VA-ECMO). 1 We describe herein a case where an airway exchange catheter (AEC) was effective in assisting oxygenation during carinal resection with VV-ECMO.A 52-yr-old male presented with hoarseness, chronic cough, and hemoptysis. Flexible bronchoscopy revealed a squamous cell carcinoma located in the distal trachea just proximal to the carina and occluding about 50% of the tracheal lumen. The patient's medical history was significant for hypertension, gastroesophageal reflux disease, and lumbar disc displacement. Preoperative pulmonary function tests showed a reduced FEV1/FVC ratio compatible with mild airflow obstruction, normal diffusion capacity, and normal measured lung volumes. Mediastinoscopy and distal tracheal and carinal resection with primary anastomosis were planned. In the operating room, after thoracic epidural catheter placement, general anesthesia was induced slowly with titration of sodium thiopental while the patient maintained spontaneous respiration. Once an adequate level of anesthesia was obtained using additional volatile anesthetic, a single-lumen endotracheal intubation was performed under direct laryngoscopy. Pancuronium was administered after adequate ventilation had been confirmed. Traditional lung isolation techniques were not an option due to the presence of the mass lesion at the carina and both main stem bronchi. Thus, the VV-ECMO was planned to assure adequate gas exchange during surgery. While the patient was in the supine position, mediastinoscopy was performed, followed by VV-ECMO cannula placement. The VV-ECMO was instituted via femoral and right internal jugular venous access with a flow rate of 3 LÁmin -1 . In order to assure proper cannula positioning to avoid recirculation phenomenon, the surgical team measured the location of the cannula tips from the insertion site. The patient was then repositioned into the left lateral decubitus position. The trachea and carina were dissected via the extended right thoracotomy incision. After the surgeon obtained adequate exposure to the trachea and carina, ventilation was stopped and VV-ECMO was initiated. With the VV-

The adjusted difference in mean 72-hour postoperative using a time-weighted average pain score was estimated at +0.17 [-0.40, +0.74] units on the verbal response scale. This was not statistically significant (P=0.50). Opioid use was estimated by the percent difference in mean 72-hour total postoperative intravenous morphine equivalent dose at -8.1% [-46%, +56%], which was not statistically significant (P=0.72). In conclusion, after controlling for all available factors, we found no significant difference that postoperative pain-as defined by either pain scores or opioid requirements-differed between patients taking ACEIs and patients not taking ACEIs.

ObjectiveTo determine the effect of vitamin D on postoperative outcomes in cardiac surgical patients.DesignRetrospective study.SettingSingle institution-teaching hospital.ParticipantsAdult cardiac surgical patients with perioperative 25-hydroxyvitamin D measurements.InterventionsNone. We gathered information from the Cardiac Anesthesiology Registry that was obtained at the time of the patients’ visit/hospitalization.Measurements and Main ResultsWe used data of 18,064 patients from the Cardiac Anesthesiology Registry; 426 patients with 25-hydroxyvitamin D measurements met our inclusion criteria. Association with Vitamin D concentration and composite of 11 cardiac morbidities was done by multivariate (i.e., multiple outcomes per subject) analysis. For other outcomes separate multivariable logistic regressions and adjusting for the potential confounders was used. The observed median vitamin D concentration was 19 [Q1-Q3∶12, 30] ng/mL. Vitamin D concentration was not associated with our primary composite of serious cardiac morbidities (odds ratio [OR], 0.96; 95% CI, 0.86–1.07). Vitamin D concentration was also not associated with any of the secondary outcomes: neurologic morbidity (P = 0.27), surgical (P = 0.26) or systemic infections (P = 0.58), 30-day mortality (P = 0.55), or length of initial intensive care unit (ICU) stay (P = 0.04).ConclusionsOur analysis suggests that perioperative vitamin D concentration is not associated with clinically important outcomes, likely because the outcomes are overwhelmingly determined by other baseline and surgical factors.