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LETTERS TO THE EDITOR
Table 1. Demographic Characteristics and Outcome of 57 Patients Undergoing Colonic Resection and Enhanced Recovery (Fast-Track Program) With Thoracic Epidural Analgesia (T6-T8) and With a Removed Bladder Catheter at the End of Surgery POUR (n ¼ 12)
Female Male Age (years) Urinary infections Discharge 4D3 Satisfaction (0-10) Intraoperative diuresis Ambulation time (minutes) Walking distance (meters)
Is Urinary Drainage Necessary in Patients With Thoracic Epidural Analgesia? A Prospective Analysis: Reply
No POUR (n ¼ 45)
50% (6) 50% (6) 61 ⫾ 14 0% 0% 8.7 ⫾ 1.3 725 ⫾ 850 225 ⫾ 28 366 ⫾ 186
47% (21) 53% (24) 57 ⫾ 13 4% (2) 8% (3) 8.9 ⫾ 2.0 403 ⫾ 176 280 ⫾ 112 395 ⫾ 173
NOTE. p 4 0.05 for all comparisons. Abbreviation: POUR, postoperative urinary retention.
extubation. We have observed only a moderate incidence of POUR and a low incidence of urinary infections. In addition, no correlation between POUR and worse outcome has been shown. Our data suggests that thoracic epidural analgesia is not an absolute indication of urinary drainage. Patrice Forget, MD, PhD Laurent Veevaete, MD Fernande Lois, MD Marc De Kock, MD, PhD Christophe Remue, MD Daniel Leonard, MD, PhD Alex Kartheuser, MD, MSc, PhD Cliniques Universitaires Saint-Luc Université Catholique de Louvain Brussels, Belgium
REFERENCES 1. Zaouter C, Ouattara A: How long is a transurethral catheter necessary in patients undergoing thoracotomy and receiving thoracic epidural analgesia? Literature review. J Cardiothorac Vasc Anesth 2014 Oct 3 [Epub ahead of print]. 2. Basse L, Werner M, Kehlet H: Is urinary drainage necessary during continuous epidural analgesia after colonic resection? Reg Anesth Pain Med 25:498-501, 2000 3. Kim JY, Lee SJ, Koo BN, et al: The effect of epidural sufentanil in ropivacaine on urinary retention in patients undergoing gastrectomy. Br J Anaesth 97:414-418, 2006 4. Ladak SS, Katznelson R, Muscat M, et al: Incidence of urinary retention in patients with thoracic epidural analgesia (TPCEA) undergoing thoracotomy. Pain Manag Nurs 10:94-98, 2009 5. Lassen K, Soop M, Nygren J, et al: Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 144: 961-969, 2009 6. Pellegrino L, Lois F, Remue C, et al: Insights into fast-track colon surgery: A plea for a tailored program. Surg Endosc 27: 1178-1185, 2013 http://dx.doi.org/10.1053/j.jvca.2015.01.032
To the Editor: Thank you for giving us the opportunity to reply to the letter by Dr. Forget et al. We strongly agree with them claiming that “early drain removal encourages independence and facilitates patients being out of bed.” However, their experience raises several issues that we would like to clarify since we consider that they carry substantial importance when it comes to proper management of ultra-rapid transurethral catheter removal defined as urinary drainage removed before endotracheal extubation. As a matter of fact, urinary retention is a common complication after anesthesia and surgery. Surprisingly, a recent review reported a wide range of its incidence starting at 5% and reaching up to 70%.1 This wide range could be explained by 2 main factors. First, the concentration of local anesthetic injected in the epidural space during the past 20 years has decreased significantly.2 Second, there are different methods used to diagnose postoperative urinary retention (POUR), which have considerable variances in accuracy. It has been shown that in almost 50% of cases there is an important overestimation of bladder distention when the urinary bladder volume is assessed by palpation compared to its evaluation measured by ultrasound.1 In addition, dullness and pain could be masked by conduction blockade provided by epidural analgesia. Thus, it could be advocated that, based on these considerations, the incidence of 21% of POUR that Dr. Forget and his colleagues observed in their trial could have been different if ultrasound technologies were used to determine the presence of bladder overdistention and, consequently, decide whether recatheterization was necessary. A literature review reported that POUR imputable to conduction blockade provoked by epidural analgesia has an incidence of 14.7%.1 Such incidence includes investigations using lumbar and thoracic epidural analgesia. Since segments L1-S4 innervate the bladder, lower urinary tract dysfunction leading to POUR might be attributable more often to a low epidural catheter, which might have lumbar anesthetic solution spread. Therefore, it could be claimed that if only high thoracic epidural analgesia were considered, such incidence could be lower. This statement is confirmed by the results published in our review finding that high thoracic epidural catheter located between T3 and T8 seems to be responsible for 5.5 % of POUR.3 Another interesting point that could further decrease POUR incidence is to measure patients’ maximum bladder capacity preoperatively. In fact, rather than catheterizing the bladder when a fixed predetermined patient-independent amount of urinary bladder threshold is detected, a safer approach would be to insert an intermittent indwelling catheter when patients’ maximum bladder capacity is reached. This method could significantly reduce both the incidence of POUR and unnecessary recatheter-
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LETTERS TO THE EDITOR
ization.4 This approach remains very simple and cost effective. We believe that adopting this approach would bring another important piece to the puzzle of enhanced recovery after surgery. In summary, we judge that proper ultra-rapid transurethral catheter removal in patients with a thoracic epidural analgesia should include measuring patients’ maximum bladder capacity preoperatively. The latter should be assessed postoperatively employing ultrasound devices and used, as the threshold, to reinsert a urinary catheter to avoid bladder over-distention. We consider that this strategy is the most accurate to manage POUR and can reduce significantly avoidable bladder recatheterization. We conclude asserting Dr. Forget et al’s correspondence adds value to our review, reinforcing the message that further prospective studies need to be conducted to ascertain that transurethral catheter removal at the end of surgical interventions before patients’ extubation is safe. This consideration is of paramount importance since early bladder catheter removal is associated with faster recovery. In the light of low POUR incidence in the thoracic surgical population,3 we strongly believe that the latter is the one that will benefit the most from ultra-rapid transurethral catheter removal. Cédrick Zaouter, MD, MSc* Alexandre Ouattara, MD, PhD*†‡ *CHU de Bordeaux, Service d’Anesthésie-Réanimation II Bordeaux, France †Univ. Bordeaux, Adaptation cardiovasculaire à l'ischémie ‡INSERM, Adaptation cardiovasculaire à l'ischémie Pessac, France
REFERENCES 1. Baldini G, Bagry H, Aprikian A, et al: Postoperative urinary retention: Anesthetic and perioperative considerations. Anesthesiology 110:1139-1157, 2009 2. Zaouter C, Kaneva P, Carli F: Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic epidural analgesia. Regional Anesthesia and Pain Medicine 34:542-548, 2009 3. Zaouter C, Ouattara A: How long is a transurethral catheter necessary in patients undergoing thoracotomy and receiving thoracic epidural analgesia? Literature Review. J Cardiothorac Vasc Anesth, 2014 4. Brouwer TA, Rosier PF, Moons KG, et al: Postoperative bladder catheterization based on individual bladder capacity: A Randomized Trial. Anesthesiology, 2014
replacing the tracheostomy tube with a shortened version of a double-lumen endotracheal tube or using a single-lumen tube combined with Fogarty catheter or endobronchial blocker (BB) or introducing a BB through the tracheostomy tube.2–5 BB can be considered appropriate for many cases, but it has some disadvantages in its use like technical difficulties, frequent dislodgment, limited suction, and slow lung collapse.5 In this case report, authors describe how to obtain lung isolation in a patient with a recent tracheostomy using an EZ-Blocker. A 72-year-old woman (60 kg; 160 cm; BMI 23.4) with a large venous hemangioma extended from the base of the tongue to the left part of the free edge of the epiglottis, including the left aryepiglottic fold, and the right laryngeal vestibule (Fig 1), was scheduled for left lung surgery for a left upper lobe adenocarcinoma. The location of the hemangioma would have made orotracheal intubation difficult and the hemorrhagic risk of direct laryngoscopy was elevated, so it was decided to proceed to a surgical tracheostomy the same day of lung surgery. Under local anesthesia, the ear, nose, and throat surgeon performed the tracheostomy and a ShileyTM (Convidien, Boulder, CO) tracheostomy tube 8.0 mm ID cuffed with disposal inner cannula was inserted, and general anesthesia was induced with propofol, fentanyl, and rocuronium bromide and maintained with desflurane. Analgesia was obtained with 0.5% ropivacaine boluses through the epidural catheter and intravenous fentanyl. In order to achieve one-lung ventilation, an EZ-Blockers (AnaesthetIQ, Rotterdam, The Netherlands) was used. An endoscopic video camera was attached to the head of a flexible 3.4 mm fiber optic bronchoscope (Pentax FI-10BS), and the EZ-Blockers was advanced under direct vision into the tracheostomy tube until the carina was visualized. Since the tracheostomy tube lied more deeply in the trachea than the endobronchial tube, lacking enough space to permit the Y-shaped distal part of the EZ-Blocker to deploy properly could have been a real problem. The distance between the distal end of the tracheostomy tube and the carina on the chest x-ray image was about 3.6 cm, smaller than that actually required.6 Before introducing the BB, the tracheostomy tube was retracted for 1 cm, and the distal tips of the Y extensions were gently curved outward, and the device was maintained in a horizontal
http://dx.doi.org/10.1053/j.jvca.2015.01.033
EZ-Blocker and One-Lung Ventilation via Tracheostomy To the Editor: Patients with a tracheostomy tube can be considered at risk of having a difficult airway during one-lung ventilation and isolation.1 One-lung ventilation can be achieved by
Fig 1.
Hemangioma extension.
LETTERS TO THE EDITOR
Table 1. Demographic Characteristics and Outcome of 57 Patients Undergoing Colonic Resection and Enhanced Recovery (Fast-Track Program) With Thoracic Epidural Analgesia (T6-T8) and With a Removed Bladder Catheter at the End of Surgery POUR (n ¼ 12)
Female Male Age (years) Urinary infections Discharge 4D3 Satisfaction (0-10) Intraoperative diuresis Ambulation time (minutes) Walking distance (meters)
Is Urinary Drainage Necessary in Patients With Thoracic Epidural Analgesia? A Prospective Analysis: Reply
No POUR (n ¼ 45)
50% (6) 50% (6) 61 ⫾ 14 0% 0% 8.7 ⫾ 1.3 725 ⫾ 850 225 ⫾ 28 366 ⫾ 186
47% (21) 53% (24) 57 ⫾ 13 4% (2) 8% (3) 8.9 ⫾ 2.0 403 ⫾ 176 280 ⫾ 112 395 ⫾ 173
NOTE. p 4 0.05 for all comparisons. Abbreviation: POUR, postoperative urinary retention.
extubation. We have observed only a moderate incidence of POUR and a low incidence of urinary infections. In addition, no correlation between POUR and worse outcome has been shown. Our data suggests that thoracic epidural analgesia is not an absolute indication of urinary drainage. Patrice Forget, MD, PhD Laurent Veevaete, MD Fernande Lois, MD Marc De Kock, MD, PhD Christophe Remue, MD Daniel Leonard, MD, PhD Alex Kartheuser, MD, MSc, PhD Cliniques Universitaires Saint-Luc Université Catholique de Louvain Brussels, Belgium
REFERENCES 1. Zaouter C, Ouattara A: How long is a transurethral catheter necessary in patients undergoing thoracotomy and receiving thoracic epidural analgesia? Literature review. J Cardiothorac Vasc Anesth 2014 Oct 3 [Epub ahead of print]. 2. Basse L, Werner M, Kehlet H: Is urinary drainage necessary during continuous epidural analgesia after colonic resection? Reg Anesth Pain Med 25:498-501, 2000 3. Kim JY, Lee SJ, Koo BN, et al: The effect of epidural sufentanil in ropivacaine on urinary retention in patients undergoing gastrectomy. Br J Anaesth 97:414-418, 2006 4. Ladak SS, Katznelson R, Muscat M, et al: Incidence of urinary retention in patients with thoracic epidural analgesia (TPCEA) undergoing thoracotomy. Pain Manag Nurs 10:94-98, 2009 5. Lassen K, Soop M, Nygren J, et al: Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 144: 961-969, 2009 6. Pellegrino L, Lois F, Remue C, et al: Insights into fast-track colon surgery: A plea for a tailored program. Surg Endosc 27: 1178-1185, 2013 http://dx.doi.org/10.1053/j.jvca.2015.01.032
To the Editor: Thank you for giving us the opportunity to reply to the letter by Dr. Forget et al. We strongly agree with them claiming that “early drain removal encourages independence and facilitates patients being out of bed.” However, their experience raises several issues that we would like to clarify since we consider that they carry substantial importance when it comes to proper management of ultra-rapid transurethral catheter removal defined as urinary drainage removed before endotracheal extubation. As a matter of fact, urinary retention is a common complication after anesthesia and surgery. Surprisingly, a recent review reported a wide range of its incidence starting at 5% and reaching up to 70%.1 This wide range could be explained by 2 main factors. First, the concentration of local anesthetic injected in the epidural space during the past 20 years has decreased significantly.2 Second, there are different methods used to diagnose postoperative urinary retention (POUR), which have considerable variances in accuracy. It has been shown that in almost 50% of cases there is an important overestimation of bladder distention when the urinary bladder volume is assessed by palpation compared to its evaluation measured by ultrasound.1 In addition, dullness and pain could be masked by conduction blockade provided by epidural analgesia. Thus, it could be advocated that, based on these considerations, the incidence of 21% of POUR that Dr. Forget and his colleagues observed in their trial could have been different if ultrasound technologies were used to determine the presence of bladder overdistention and, consequently, decide whether recatheterization was necessary. A literature review reported that POUR imputable to conduction blockade provoked by epidural analgesia has an incidence of 14.7%.1 Such incidence includes investigations using lumbar and thoracic epidural analgesia. Since segments L1-S4 innervate the bladder, lower urinary tract dysfunction leading to POUR might be attributable more often to a low epidural catheter, which might have lumbar anesthetic solution spread. Therefore, it could be claimed that if only high thoracic epidural analgesia were considered, such incidence could be lower. This statement is confirmed by the results published in our review finding that high thoracic epidural catheter located between T3 and T8 seems to be responsible for 5.5 % of POUR.3 Another interesting point that could further decrease POUR incidence is to measure patients’ maximum bladder capacity preoperatively. In fact, rather than catheterizing the bladder when a fixed predetermined patient-independent amount of urinary bladder threshold is detected, a safer approach would be to insert an intermittent indwelling catheter when patients’ maximum bladder capacity is reached. This method could significantly reduce both the incidence of POUR and unnecessary recatheter-
e32
LETTERS TO THE EDITOR
ization.4 This approach remains very simple and cost effective. We believe that adopting this approach would bring another important piece to the puzzle of enhanced recovery after surgery. In summary, we judge that proper ultra-rapid transurethral catheter removal in patients with a thoracic epidural analgesia should include measuring patients’ maximum bladder capacity preoperatively. The latter should be assessed postoperatively employing ultrasound devices and used, as the threshold, to reinsert a urinary catheter to avoid bladder over-distention. We consider that this strategy is the most accurate to manage POUR and can reduce significantly avoidable bladder recatheterization. We conclude asserting Dr. Forget et al’s correspondence adds value to our review, reinforcing the message that further prospective studies need to be conducted to ascertain that transurethral catheter removal at the end of surgical interventions before patients’ extubation is safe. This consideration is of paramount importance since early bladder catheter removal is associated with faster recovery. In the light of low POUR incidence in the thoracic surgical population,3 we strongly believe that the latter is the one that will benefit the most from ultra-rapid transurethral catheter removal. Cédrick Zaouter, MD, MSc* Alexandre Ouattara, MD, PhD*†‡ *CHU de Bordeaux, Service d’Anesthésie-Réanimation II Bordeaux, France †Univ. Bordeaux, Adaptation cardiovasculaire à l'ischémie ‡INSERM, Adaptation cardiovasculaire à l'ischémie Pessac, France
REFERENCES 1. Baldini G, Bagry H, Aprikian A, et al: Postoperative urinary retention: Anesthetic and perioperative considerations. Anesthesiology 110:1139-1157, 2009 2. Zaouter C, Kaneva P, Carli F: Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic epidural analgesia. Regional Anesthesia and Pain Medicine 34:542-548, 2009 3. Zaouter C, Ouattara A: How long is a transurethral catheter necessary in patients undergoing thoracotomy and receiving thoracic epidural analgesia? Literature Review. J Cardiothorac Vasc Anesth, 2014 4. Brouwer TA, Rosier PF, Moons KG, et al: Postoperative bladder catheterization based on individual bladder capacity: A Randomized Trial. Anesthesiology, 2014
replacing the tracheostomy tube with a shortened version of a double-lumen endotracheal tube or using a single-lumen tube combined with Fogarty catheter or endobronchial blocker (BB) or introducing a BB through the tracheostomy tube.2–5 BB can be considered appropriate for many cases, but it has some disadvantages in its use like technical difficulties, frequent dislodgment, limited suction, and slow lung collapse.5 In this case report, authors describe how to obtain lung isolation in a patient with a recent tracheostomy using an EZ-Blocker. A 72-year-old woman (60 kg; 160 cm; BMI 23.4) with a large venous hemangioma extended from the base of the tongue to the left part of the free edge of the epiglottis, including the left aryepiglottic fold, and the right laryngeal vestibule (Fig 1), was scheduled for left lung surgery for a left upper lobe adenocarcinoma. The location of the hemangioma would have made orotracheal intubation difficult and the hemorrhagic risk of direct laryngoscopy was elevated, so it was decided to proceed to a surgical tracheostomy the same day of lung surgery. Under local anesthesia, the ear, nose, and throat surgeon performed the tracheostomy and a ShileyTM (Convidien, Boulder, CO) tracheostomy tube 8.0 mm ID cuffed with disposal inner cannula was inserted, and general anesthesia was induced with propofol, fentanyl, and rocuronium bromide and maintained with desflurane. Analgesia was obtained with 0.5% ropivacaine boluses through the epidural catheter and intravenous fentanyl. In order to achieve one-lung ventilation, an EZ-Blockers (AnaesthetIQ, Rotterdam, The Netherlands) was used. An endoscopic video camera was attached to the head of a flexible 3.4 mm fiber optic bronchoscope (Pentax FI-10BS), and the EZ-Blockers was advanced under direct vision into the tracheostomy tube until the carina was visualized. Since the tracheostomy tube lied more deeply in the trachea than the endobronchial tube, lacking enough space to permit the Y-shaped distal part of the EZ-Blocker to deploy properly could have been a real problem. The distance between the distal end of the tracheostomy tube and the carina on the chest x-ray image was about 3.6 cm, smaller than that actually required.6 Before introducing the BB, the tracheostomy tube was retracted for 1 cm, and the distal tips of the Y extensions were gently curved outward, and the device was maintained in a horizontal
http://dx.doi.org/10.1053/j.jvca.2015.01.033
EZ-Blocker and One-Lung Ventilation via Tracheostomy To the Editor: Patients with a tracheostomy tube can be considered at risk of having a difficult airway during one-lung ventilation and isolation.1 One-lung ventilation can be achieved by
Fig 1.
Hemangioma extension.
