Anesthesia and fast-track in video-assisted thoracic surgery (VATS): from evidence to practice

Abstract

In thoracic surgery, the introduction of video-assisted thoracoscopic techniques has allowed the development of fast-track protocols, with shorter hospital lengths of stay and improved outcomes. The perioperative management needs to be optimized accordingly, with the goal of reducing postoperative complications and speeding recovery times. Premedication performed in the operative room should be wisely administered because often linked to late discharge from the post-anesthesia care unit (PACU). Inhalatory anesthesia, when possible, should be preferred based on protective effects on postoperative lung inflammation. Deep neuromuscular blockade should be pursued and carefully monitored, and an appropriate reversal administered before extubation. Management of one-lung ventilation (OLV) needs to be optimized to prevent not only intraoperative hypoxemia but also postoperative acute lung injury (ALI): protective ventilation strategies are therefore to be implemented. Locoregional techniques should be favored over intravenous analgesia: the thoracic epidural, the paravertebral block (PVB), the intercostal nerve block (ICNB), and the serratus anterior plane block (SAPB) are thoroughly reviewed and the most common dosages are reported. Fluid therapy needs to be administered critically, to avoid both overload and cardiovascular compromisation. All these practices are analyzed singularly with the aid of the most recent evidences aimed at the best patient care. Finally, a few notes on some of the latest trends in research are presented, such as non-intubated video-assisted thoracoscopic surgery (VATS) and intravenous lidocaine.

Risk factors for post‐operative pulmonary complications in lung cancer patients after video‐assisted thoracoscopic lung resection: Results of the German Thorax Registry

“…Conclusions on regional anesthesia techniques for VATS based on this study cohort should be drawn with caution because of 2 reasons. First, according to current literature less invasive regional anesthesia techniques (PVB or ICB) provide sufficient pain relief or have at least an opioid sparing effect in lung surgery accompanied by a low risk for complications, however, a general post‐operative pain assessment was not included in this data analysis . Second, the retrospective character of this study does not prove causality.…”

Anesthetic management of a patient with a continuous-flow left ventricular assist device for video-assisted thoracoscopic surgery: a case report

“…In our case, for postoperative pain control, intravenous patient-controlled analgesia with fentanyl was used and a single shot of ICNB was applied by the thoracic surgeons before closing the chest; this was favored due to the lower incidence of serious adverse events such as epidural hematoma, despite poorer pain control than that after thoracic epidural anesthesia [29].…”

ERAS Protocols in Anesthesiology and Perioperative Medicine, ERAS and Anesthesia

“…Midazolam kısa etki profili nedeniyle avantaj oluştursa da etkisinin birçok faktör ile uzayabildiği ve derlenme süresini uzatabileceği yine akılda tutulmalıdır. Özellikle yaşlı hastalarda rutin uygulamadan kaçınılması önerilmektedir (9) . (9) .…”

“…Özellikle yaşlı hastalarda rutin uygulamadan kaçınılması önerilmektedir (9) . (9) . Nitröz oksit bulantı ve kusmayı arttırması, üçüncü boşluklarda birikmesi, trombotik morbiditeleri arttırması nedeniyle dezavantajlıdır (10) .…”