The Open Anesthesia Journal


Formerly: The Open Anesthesiology Journal

ISSN: 2589-6458 ― Volume 13, 2019
RESEARCH ARTICLE

Perioperative Hemodynamic Changes During Video-Assisted Thoracoscopic Decortication for empyema



Fang-Ting Chen1, *, An-Hsun Chou1, 2, *, Chun-Yu Chen1, 2, Pei-Chi Ting1, Ming-Wen Yang1, Chun-Hui Lee1, Yun-Hui Teng1
1 Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
2 College of Medicine, Chang Gung University, Taoyuan, Taiwan

Abstract

Background and Objective:

Hemodynamic consequences during video-assisted thoracoscopic surgery (VATS) with decortication during empyema drainage are unclear. The aim of the study was to assess the perioperative hemodynamic changes decortication during empyema drainage.

Methods:

A prospective study enrolled 23 patients with empyema who underwent decortication. Hemodynamic parameters were continuously obtained at 15 time points: supine two lung ventilation after induction, lateral decubitus position and two lung ventilation, lateral decubitus position and one-lung ventilation, every 5 min after decortication upto 60 minutes and at the end of surgery. We divided patients into three groups according to microorganisms, group 1: patients with no growth of organism; group 2: patients with staphylococcus aureus and pseudomonas; group 3: patients with streptococcus, yeast and fungus, gram-positive bacilli, and mycobacterium tuberculosis. The hemodynamic variables were recorded by the third-generation Vigileo/FloTracTM system and variables for each time interval were compared with the baseline by Wilcoxon Signed Ranks Test.

Results:

In group 1, hemodynamic parameters showed no significant changes over time. However, in group 2 and 3, both CO and CI increased 10 to 15 minutes after decortication and remained elevated during the remainder of surgery. However, SVR and SVRI decreased 10 to 15 minutes after decortication in both groups, especially, with a more significant decrease noted in group 2 than group 3.

Conclusion:

Close perioperative hemodynamic monitoring during decortication in empyema patients is required because of potential hemodynamic disturbances especially patients with toxic microorganisms.

Keywords: Empyema, Decortication, Video-assisted thoracoscopic surgery (VATS), FloTrac/VigileoTM, One lung ventilation, Hemodynamic changes and anesthesia.


Article Information


Identifiers and Pagination:

Year: 2017
Volume: 11
First Page: 88
Last Page: 96
Publisher Id: TOATJ-11-88
DOI: 10.2174/1874321801711010088

Article History:

Received Date: 18/04/2017
Revision Received Date: 07/07/2017
Acceptance Date: 18/07/2017
Electronic publication date: 31/07/2017
Collection year: 2017

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© 2017 Chen et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* These authors contributed equally to this work
* Address correspondence to this author at the Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center No. 5, Fusing St, Guishan District, Taoyuan City 33305, Taiwan; Tel: 886-3-328 1200 ext 3624; Fax: 886-3-3281200 ext 2787; E-mail : f5455@cgmh.org.tw





1. INTRODUCTION

Thoracic empyema is an inflammatory process related to collection of pus between the visceral and parietal pleural layers, often a complication of pneumonia, surgery, iatrogenic procedure, or chest trauma [1Mandal AK, Thadepalli H, Mandal AK, Chettipally U. Outcome of primary empyema thoracis: therapeutic and microbiologic aspects. Ann Thorac Surg 1998; 66(5): 1782-6.[http://dx.doi.org/10.1016/S0003-4975(98)00601-8] [PMID: 9875789] -5Chapman SJ, Davies RJ. The management of pleural space infections. Respirology 2004; 9(1): 4-11.[http://dx.doi.org/10.1111/j.1440-1843.2003.00535.x] [PMID: 14982595] ]. Treatment for an

empyema consists of antibiotics and early drainage [6Vaziri M, Abed O. Management of thoracic empyema: review of 112 cases. Acta Med Iran 2012; 50(3): 203-7.[PMID: 22418990] ]. Except in its earliest phase, chest tube drainage alone rarely provides adequate therapy. Pleural decortication is necessary for patients with pleural loculations. This is accomplished by removing the fine peel on the lung, draining the infected fluid, and allowing the underlying lung to expand. Recently, video-assisted thoracoscopic surgery (VATS) for the decortication procedure has been a minimally invasive alternative which provides reduced morbidity, postoperative pain, and hospital stay [7Shin JA, Chang YS, Kim TH, et al. Surgical decortication as the first-line treatment for pleural empyema. J Thorac Cardiovasc Surg 2013; 145(4): 933-9.[http://dx.doi.org/10.1016/j.jtcvs.2012.07.035] [PMID: 22929218] -9Homvises B. Efficacy of video-assisted thoracoscopic surgery (VATS) for management of empyema thoracis. J Med Assoc Thai 2012; 95(Suppl. 1): S28-32.[PMID: 23964441] ].

General anesthesia with one-lung ventilation (OLV) using a double-lumen endobronchial tube is needed during VATS decortication. One lung ventilation (OLV) is performed routinely during thoracic surgery. Some of the consequences with the technique of endobronchial intubation are associated with OLV. A marked decrease in arterial oxygenation is the consequence of nonventilated and collapse lung. Hypoxia during OLV may be caused by inhibition of hypoxic pulmonary vasoconstriction which can lead to increase pulmonary vascular resistance [10Brock H, Rieger R, Gabriel C, Pölz W, Moosbauer W, Necek S. Haemodynamic changes during thoracoscopic surgery the effects of one-lung ventilation compared with carbon dioxide insufflation. Anaesthesia 2000; 55(1): 10-6.[http://dx.doi.org/10.1046/j.1365-2044.2000.01123.x] [PMID: 10594427] , 11Dingley J, Hope DA, Vaughan RS. The use of a non-invasive method to measure intrapulmonary shunt during one-lung anaesthesia. Anaesthesia 1996; 51(7): 654-7.[http://dx.doi.org/10.1111/j.1365-2044.1996.tb07848.x] [PMID: 8758158] ]. OLV superimposed by the inflammatory process of empyema, likely to carry a high risk of hemodynamic changes. Close hemodynamic monitoring using invasive devices (arterial lines, central venous catheter, etc) during the decortication procedure is essential for patients with empyema. However, report on hemodynamic evaluation for patients undergoing surgery for treatment of empyema is still lacking.

Recently, less invasive techniques have become available for hemodynamic parameter monitoring. The Vigileo/FloTracTM system (Edwards Lifesciences, Irvine, CA, USA) provides continuous monitoring that uses arterial pressure waveform analysis to estimate cardiac output (CO) and other hemodynamic parameters [12Suehiro K, Okutani R. Stroke volume variation as a predictor of fluid responsiveness in patients undergoing one-lung ventilation. J Cardiothorac Vasc Anesth 2010; 24(5): 772-5.[http://dx.doi.org/10.1053/j.jvca.2010.03.014] [PMID: 20638869] -14Auler JO Jr, Torres ML, Cardoso MM, et al. Clinical evaluation of the flotrac/Vigileo system for continuous cardiac output monitoring in patients undergoing regional anesthesia for elective cesarean section: a pilot study. Clinics (Sao Paulo) 2010; 65(8): 793-8.[http://dx.doi.org/10.1590/S1807-59322010000800009] [PMID: 20835557] ]. In a previous study demonstrated that second generation of FloTrac software underestimates CO than the transpulmonary thermodilution using (PiCCO plusR, Pulsion Medical Systems, Munich, Germany) in septic patients [15Sakka SG, Kozieras J, Thuemer O, et al. Measurement of cardiac output: a comparison between transpulmonary thermodilution and uncalibrated pulse contour analysis. Br J Anaesth 2007; 99(3): 337-42.[http://dx.doi.org/10.1513/pats.200510-113JH] [PMID: 16493154] ]. The new third-generation FloTrac software was developed from a human database containing many recordings from septic and liver transplant patients who were often vasodilated. In a recent multicenter study investigate the accuracy of the third-generation software in patients with sepsis, particularly patients with low total systemic vascular resistance which is concerned in second-generation software [16De Backer D, Marx G, Tan A, et al. Arterial pressure-based cardiac output monitoring: a multicenter validation of the third generation software in septic patients. Intensive Care Med 2011; 37(2): 233-40.[http://dx.doi.org/10.1378/chest.115.3.611] [PMID: 10084462] ]. In this study, they demonstrated that precision and accuracy of third-generation FloTrac software are as good as that of PAC thermodilution in critically ill patients. Therefore, the aim of this study is to assess the hemodynamic changes during VATS decortication for patients with empyema using the third-generation Vigileo /FloTracTM system.

2. METHODS

This study was evaluated and approved by the Ethics Institutional Review Board of Chang Gung Memorial Hospital, and written informed consent was obtained from patients undergoing VATS for empyema decortication.

2.1. Patients

Twenty-five patients with empyema who underwent VATs for treatment of empyema from January to December 2016 were studied. Exclusion criteria included patients younger than 20 years, documented coronary disease, valvular heart disease, and use of any inotropic or vasopressor drugs before surgery. The diagnosis of empyema was made using clinical presentation (such as cough, dyspnea, fever, leukocytosis, and chest pain); radiographic studies include anteroposterior and lateral chest radiographs which demonstrate parenchymal infiltrate or consolidations, and pleural space fluid; chest computed tomography (CT) scan which show fluid density collection in the pleural space、thicken pleural and pus-like thick purulent pleural fluid obtained by thoracentesis.

2.2. Anesthetic Management

General anesthesia was induced with fentanyl (4–10 μg/kg) and propofol (0.5–1.5 mg/kg). Cisatracurium (0.1–0.2 mg/kg) was given to facilitate orotracheal intubation. After induction of anesthesia, a left-sided, double-lumen endobronchial tube (Bronchocath, Mallinckrodt, Athlone, Ireland) of appropriate size was placed and its correct position was confirmed by auscultation and eventually by bronchoscopy. Anesthesia was maintained with 2–3% sevoflurane with a 1.0–1.3 minimal alveolar concentration level. Mechanical ventilation with 100% oxygen was started with tidal volumes of 10 ml/kg and an initial respiratory rate of 9–10 breaths/min. During OLV, tidal volumes were reduced to 6–8 ml/kg to maintain peak inspiratory pressures < 35 cm H2O, and the respiratory rate was increased to avoid respiratory acidosis. A radial arterial pressure line was placed contralateral to the operated hemithorax. We placed a central venous catheter into the right internal jugular vein. Then, the artery catheter and central venous catheter were connected to the Vigileo/FloTracTM system. Patient data (age, gender, body weight, and height) were entered later. While the check of arterial line and central venous pressure waveform fidelity was done, the Vigileo/FloTracTM system was zeroed and hemodynamic parameter measurement initiated.

2.3. Study Protocol and Data Collection

The first measurement of hemodynamic variables was performed immediately after induction of anesthesia and insertion of a central venous catheter and an arterial pressure line. The hemodynamic variables, including mean arterial pressure (MAP), heart rate (HR), mean pulmonary arterial pressure (MPAP), CO, cardiac index (CI), stroke volume (SV), stroke volume index (SVI), systemic vascular resistance (SVR), systemic vascular resistance index (SVRI), stroke volume variation (SVV), and central venous pressure (CVP) were recorded by the Vigileo/FloTracTM system. Those hemodynamic variables were obtained at various time points: T0 (supine two lung ventilation after induction); T1 (lateral decubitus position and two lung ventilation); T2 (lateral decubitus position and 5 min after OLV); T3–T14 (every 5 min after decortication begins up to 60 min); and T15 (end of surgery).

The following data were collected for each patient: age, sex, body weight, comorbidities, causes of empyema, hemodynamic changes during decortication, pathogens isolated from cultures of the pleural fluid, duration of ICU and hospital stays, postoperative infection, and mortality.

2.4. Statistical Analysis

All data were entered into a Microsoft Excel (Microsoft Corp., Redmond, WA, USA) spreadsheet and statistically analyzed using SPSS version 17.0 (SPSS Inc., Troy, NY, USA). Preoperative and postoperative variables were assessed using descriptive statistics for the mean and standard deviation of continuous variables and frequency tables for categorical variables. Hemodynamic variables for each time interval were compared with the baseline by Wilcoxon signed-rank test. P < 0.05 was considered to represent a statistically significant difference.

3. RESULTS

The study included twenty five patients who had undergone elective or emergent decortication surgery. We excluded two patients because they needed a vasopressor to maintain stable hemodynamics during decortication. Therefore, twenty three patients were enrolled for analysis. The demographic data of study patients are shown in Table (1). The mean age and body weight of the patients were 55.8 ± 19.1 years and 63 ± 13.9 kg, respectively. There were 17 male patients (73%) and six female patients (26%). Most of the patients received elective surgery (65%) and the remaining 35% received emergent surgery. The most frequent comorbidities noted was essential hypertension (52%) and diabetes mellitus (21%). The empyema was associated with pneumonia in the majority of cases (91%) and with surgery in the remaining 2 patients.

Table 1
Baseline characteristics of study patients.


Table (2) displays the perioperative and postoperative variables of the study patients. Mean arterial oxygen partial pressure (PaO2) after induction was 333.2 ± 27.05 mmHg which dropped to 207.4 ± 34.3 mmHg 15 min after OLV. 65% of the patients were extubated within 24 h and two patients were extubated more than 72 h. Most of the patients (73%) stayed in ICU for less than 3 days and six patients (26%) stayed more than 3 days. For hospital stays, 11 patients (48%) were discharged from hospital within 14 days and 12 patients (52%) stayed more than 14 days. Overall, there were three deaths, a mortality rate of 13%. One patient died within 7 days and the other two were hospitalized for more than 30 days. Overwhelming sepsis was the cause of death in these patients. Pleural fluid was obtained from all patients and analyzed for organisms. Seven of the patients (30%) showed no growth at the time of decortication. The organisms identified included Staphylococcus aureus (three patients, 13%), Pseudomonas (three patients, 13%), Streptococcus (three patients, 13%), yeast and fungus (two patients, 8.7%), Gram-positive bacilli (two patients, 8.7%), and Mycobacterium tuberculosis (three patients, 13%).

Table (3) displays the average hemodynamic data at the defined time intervals. CO and CI were significantly increased 10 to 15 min after decortication and remained increased for the whole procedure compared to baseline T0 . Importantly, SVR and SVRI were significantly decreased 10 to 15 min after decortication and remained decreased for the whole procedure compared to baseline T0 . However, no significant effects on HR, MAP, CVP, SV, SVI and SVV were observed during the whole procedure.

Table 2
Perioperative and postoperative variables of study patients.


We then divided patients into three groups according to microorganisms from pleural aspirate and observed the perioperative hemodynamic data. Those with no growth of organism at the time of decortication were defined as group 1, patients with Staphylococcus aureus and Pseudomonas organisms were defined as group 2, and patients with Streptococcus, yeast and fungus, Gram-positive bacilli, and Mycobacterium tuberculosis were defined as group 3. Fig. (1) displays the hemodynamic data including CO, CI, SVR, and SVRI at the defined time intervals in the three groups. In group 1, CO, CI, SVR, and SVRI remained stable throughout the procedure. However, in groups 2 and 3, both CO and CI increased 10 to 15 min after decortication and remained increased for the whole procedure compared to baseline T0. However, SVR and SVRI decreased 10 to 15 min after decortication compared to baseline T0 in both groups; in particular they were more significantly decreased in group 2.

4. DISCUSSION

This observational study describes hemodynamic responses to decortication for empyema patients, evaluated using a Vigileo/FloTracTM system. Empyema is one of the oldest of diseases and is associated with considerable morbidity and a high mortality rate more than 10% [6Vaziri M, Abed O. Management of thoracic empyema: review of 112 cases. Acta Med Iran 2012; 50(3): 203-7.[PMID: 22418990] ]. With early diagnosis and antibiotic therapy of pneumonia, uncomplicated and simple parapneumonic effusion do not generally progress to empyema. However, in some patients, parapneumonic effusion becomes more complicated and leads to empyema [17Light RW. Parapneumonic Effusions and Empyema. Proc Am Thorac Soc 2006; 3(1): 75-80.[http://dx.doi.org/10.1513/pats.200510-113JH] [PMID: 16493154] ]. The organizational stage of empyema requires surgical intervention, which usually takes the form of decortication [18Yim APC. Paradigm shift in empyema management. Chest 1999; 115(3): 611-2.[PMID: 10084462] ].

Table 3
Perioperative hemodynamic data obtained at each time point.


Decortication is a surgical procedure in which the fibrous wall of the empyema cavity, the cortex, rind, or peel, is stripped of the adjacent visceral and parietal pleura along with the evacuation of pus, blood clots, and fibrin material from the pleural cavity. This eliminates the pleural sepsis and allows the underlying lung to expand [19Katariya K, Thurer RJ. Surgical management of empyema. Clin Chest Med 1998; 19(2): 395-406.[http://dx.doi.org/10.1016/S0272-5231(05)70086-1] [PMID: 9646990] , 20Light RW, Rodriguez RM. Management of parapneumonic effusions. Clin Chest Med 1998; 19(2): 373-82.[http://dx.doi.org/10.1016/S0272-5231(05)70084-8] [PMID: 9646988] ]. This is accompanied by an increased risk of hemodynamic disturbance. VATS with decortication has shown reliably good outcomes in the management of pleural empyema in several series in recent decades [21Petrakis IE, Kogerakis NE, Drositis IE, Lasithiotakis KG, Bouros D, Chalkiadakis GE. Video-assisted thoracoscopic surgery for thoracic empyema: primarily, or after fibrinolytic therapy failure? Am J Surg 2004; 187(4): 471-4.[http://dx.doi.org/10.1016/j.amjsurg.2003.12.048] [PMID: 15041493] , 22Waller DA, Rengarajan A, Nicholson FH, Rajesh PB. Delayed referral reduces the success of video-assisted thoracoscopic debridement for post-pneumonic empyema. Respir Med 2001; 95(10): 836-40.[http://dx.doi.org/10.1053/rmed.2001.1176] [PMID: 11601751] ]. However, its routine use is out of reach for most hospitals because it carries an obvious operative risk and morbidity.

VATS with decortication is performed under general anesthesia and OLV. Mostly, to achieve OLV a double-lumen bronchial tube is used and allows the lung to collapse passively. Alteration in pulmonary gas exchange during OLV has been investigated in a clinical trial. Although a marked decrease in arterial oxygenation is the consequence of a nonventilated and collapsed lung, a study demonstrated that hemodynamic variables during OLV remained stable through the procedure [10Brock H, Rieger R, Gabriel C, Pölz W, Moosbauer W, Necek S. Haemodynamic changes during thoracoscopic surgery the effects of one-lung ventilation compared with carbon dioxide insufflation. Anaesthesia 2000; 55(1): 10-6.[http://dx.doi.org/10.1046/j.1365-2044.2000.01123.x] [PMID: 10594427] ]. In our study, during OLV, we also found that hemodynamic variables remained stable before decortication. However, the hemodynamic consequences of decortication in empyema patients are to a great extent unknown. Furthermore, no conclusive recommendations exist as to which kind of hemodynamic monitoring should be preferred in the situation. Therefore, we studied the hemodynamic changes during decortication in empyema patients under OLV in order to derive recommendations for the application of hemodynamic monitoring in this specific perioperative situation. Evidence supports that a large amount of toxic materials and cytokines accumulate in pleural fluid [23Marchi E, Vargas FS, Acencio MM, et al. Proinflammatory and antiinflammatory cytokine levels in complicated and noncomplicated parapneumonic pleural effusions. Chest 2012; 141(1): 183-9.[http://dx.doi.org/10.1378/chest.10-3181] [PMID: 21680642] , 24Akarsu S, Kurt AN, Dogan Y, Yilmaz E, Godekmerdan A, Aygun AD. The differential diagnostic values of cytokine levels in pleural effusions. Mediators Inflamm 2005; 2005(1): 2-8.[http://dx.doi.org/10.1155/MI.2005.2] [PMID: 15770060] ]. During decortication, these toxic materials and cytokines enter the blood stream which leads to hemodynamic changes. The relationship between cytokines and hemodynamic instability has been extensively studied. A study showed an association between increased levels of TNF-α and decreased systemic vascular resistance and left ventricular stroke work index [25Caorsi C, Quintana E, Valdés S, Muñoz C. Continuous cardiac output and hemodynamic monitoring: high temporal correlation between plasma TNF-alpha and hemodynamic changes during a sepsis-like state in cancer immunotherapy. J Endotoxin Res 2003; 9(2): 91-5.[http://dx.doi.org/10.1177/09680519030090020301] [PMID: 12803881] ]. These hemodynamic changes were thought to be mediated by nitric oxide release secondary to increased cytokine levels [26Pizcueta P, Piqué JM, Fernández M, et al. Modulation of the hyperdynamic circulation of cirrhotic rats by nitric oxide inhibition. Gastroenterology 1992; 103(6): 1909-15.[http://dx.doi.org/10.1016/0016-5085(92)91451-9] [PMID: 1451984] , 27Kilbourn RG, Gross SS, Jubran A, et al. NG-methyl-L-arginine inhibits tumor necrosis factor-induced hypotension: implications for the involvement of nitric oxide. Proc Natl Acad Sci USA 1990; 87(9): 3629-32.[http://dx.doi.org/10.1073/pnas.87.9.3629] [PMID: 2333306] ]. A study demonstrated that a patient given an interleukin-2 (IL-2) infusion showed a 63.4% decrease in systemic vascular index [28Caorsi C, Quintana E, Valdés S, Muñoz C. Continuous cardiac output and hemodynamic monitoring: high temporal correlation between plasma TNF-alpha and hemodynamic changes during a sepsis-like state in cancer immunotherapy. J Endotoxin Res 2003; 9(2): 91-5.[http://dx.doi.org/10.1177/09680519030090020301] [PMID: 12803881] ]. This is confirmed in our study, as SVR and SVRI decreased significantly 10–15 min after the beginning of decortication and remained decreased for the whole procedure. In our study, we excluded 2 of the study patients. CO increased in these patients, however, SVR and SVRI decreased very low and inability to maintain blood pressure. They received vasopressor for blood pressure restoration during the procedure. Persistence hypotension, along with the presence of hypoperfusion abnormalities may lead to organ dysfunction and mortality. Therefore, closed perioperative hemodynamic monitoring throughout the procedure is required in these patients because of potential hemodynamic disturbance.

Fig. (1)
Perioperative hemodynamic data obtained at each time point according to the different groups of microorganism. (A) Cardiac output, (B) cardiac index, (C) systemic vascular resistance, (D) systemic vascular resistance index. T0 : supine two lung ventilation after induction; T1: lateral decubitus position and two lung ventilation; T2: lateral decubitus position and one-lung ventilation; T3–T14: every 5 min after decortication up to 60 min; T15: end of surgery. Bars depict the SD. Measurements which are statistically different from the baseline value are marked by an asterisk.


Microorganisms of various classifications have the capability of establishing different hemodynamic response. In our present study, we demonstrated that for group 2 microorganisms including the aerobic Gram-negative bacillus Pseudomonas and Gram-positive bacterium Staphylococcus aureus, SVR and SVRI were decreased more significantly than in groups 1 and 3. In the aerobic Gram-negative bacillus Pseudomonas, lipopolysaccharides are an essential component of the outer membrane. Studies in animal models and in human volunteers have documented that this cell wall component is the biologic equivalent of an “endotoxin,” producing inflammatory and hemodynamic profiles associated with Gram-negative bacterial sepsis and septic shock [29Opal SM. Endotoxins and other sepsis triggers. Contrib Nephrol 2010; 167: 14-24.[http://dx.doi.org/10.1159/000315915] [PMID: 20519895] ]. In the Gram-positive bacterium Staphylococcus aureus, cell components have been identified and these appear to be biologically equivalent to endotoxins in stimulating the inflammatory response from host cells associated with sepsis and septic shock. The peptidoglycan layer outside the cell membrane of Gram-positive bacteria as well as non-peptidoglycan polymers, the teichoic acids, have been shown to stimulate the release of cytokines, specifically tumor necrosis factor and IL-1 [30Wray GM, Foster SJ, Hinds CJ, Thiemermann C. A cell wall component from pathogenic and non-pathogenic gram-positive bacteria (peptidoglycan) synergises with endotoxin to cause the release of tumour necrosis factor-alpha, nitric oxide production, shock, and multiple organ injury/dysfunction in the rat. Shock 2001; 15(2): 135-42.[http://dx.doi.org/10.1097/00024382-200115020-00010] [PMID: 11220642] ]. The release of endotoxins, exotoxins, and cytokines from pleural fluid into the circulation appears to be a major mechanism by which bacteria can cause hemodynamic instability during decortication. This interplay of endotoxins and exotoxins with vessel endothelium results in vasodilatation, a decrease in vasomotor tone. A possible mediator of this vasodilatation may be the nitric oxides, possibly of endothelial cell origin but also of macrophage origin, induced by the interaction of endotoxins or exotoxins on these cells. This was evidenced in our study by significantly decreased SVR and SVRI in patients with group 2 microorganisms.

CONCLUSION

In conclusion, this study demonstrated that decortication in empyema patients was associated with decreased in SVR and SVRI throughout the procedure. Careful monitoring throughout the procedure is required because of potential hemodynamic disturbances especially in toxic microorganisms. The Vigileo/ FloTracTM system is minimally invasive and easy to set up and use. Moreover, precision of third-generation FloTrac software has been preserved and accuracy has been improved. This minimally invasive device designed to measure hemodynamic parameters may be considered to further improve hemodynamic control and outcomes in decortication for empyema patients.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

This study was evaluated and approved by the Ethics Institutional Review Board of Chang Gung Memorial Hospital, and written informed consent was obtained from patients.

HUMAN AND ANIMAL RIGHTS

No animals were used for studies that are base of this research. All clinical investigations were conducted in accordence with the declaration of Helsinki principles.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

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Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


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(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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