The Anesthetic Management of Patients Undergoing Nonintubated Video-Assisted Thoracic Surgery

Abstract

Purpose of Review This review focuses on describing the procedural and anesthetic management of patients undergoing nonintubated video-assisted thoracoscopy surgery. Recent Findings Most thoracic surgery is performed under general endotracheal anesthesia with either a double lumen endotracheal tube or a bronchial blocker. In an attempt to lessen the incidence and severity of postoperative complications, the nonintubated videoassisted thoracoscopic technique was developed, where the surgical procedure is performed under regional anesthesia with sedation. Currently, this technique is recommended for the elderly and in patients with severe cardiopulmonary disease who are at increased risk of complications after general anesthesia. It is the role of the anesthesia team to assist in the decisions whether the patient is a candidate and which block should be performed and to carefully monitor these patients in the operating room. Summary Nonintubated video-assisted thoracic surgery is an emerging technique with the goal of reducing postoperative complications. The anesthetic technique is highly variable and ranges from general anesthesia with a laryngeal mask airway with a truncal block to thoracic epidural anesthesia with minimal to no block. It is important to have excellent communication with the surgical team and the patient to ensure a safe, successful procedure.Keywords Video-assisted thoracic surgery . Uniportal technique . Thoracic epidural analgesia . Paravertebral block . Intercostal block . Serratus anterior block . Erector spinae plane block . Pendular respiration . Artificial pneumothorax Upon completion of this lesson, the reader should be able to: 1. Define the concept of nonintubated video-assisted thoracic surgery. 2. Discuss the potential advantages of NIVATS. 3. Consider the patient population that would benefit from the NIVATS technique. 4. Review the patient, anesthetic, and surgical contraindications for NIVATS. 5. Discuss the procedures that can be performed using the NIVATS technique. 6. Discuss the preoperative assessment for NIVATS. 7. Review the anesthetic technique for NIVATS. 8. Review the regional blocks used for NIVATS. 9. Demonstrate the goals of the intraoperative management for patients undergoing the NIVATS procedure. 10. Recognize and treat complications that can occur during NIVATS. This article is part of the Topical Collection on Thoracic Anesthesia

Non-intubated Uniportal Subxiphoid Video-Assisted Thoracoscopic Surgery for Extended Thymectomy in Myasthenia Gravis Patients: A Case Series

“…Epidural analgesia is prerequisite for any consistent pain control. The cough reflex might be stimulated by an increased airway hyper-reactivity as a result of epidural anesthesia-induced sympathectomy [10]. To resolve this issue, remifentanil and dexmedetomidine both act as antitussives and have little http://www.jchestsurg.org JCS effect on hypoxic pulmonary vasoconstriction.…”

“…To resolve this issue, remifentanil and dexmedetomidine both act as antitussives and have little http://www.jchestsurg.org JCS effect on hypoxic pulmonary vasoconstriction. Using a laryngeal mask prevents most other respiratory insufficiencies [10]. Compared internationally, the postoperative hospital stay was rather extended for the following reasons: (1) the accounting system of German health insurance provides minimum and maximum lengths for in-hospital stays, and (2) German outpatient care is-again on the basis of health insurance issues-somewhat underdeveloped.…”

“…Opening both pleural cavities inevitably leads to (1) hypoventilation, (2) decrease of pulmonary perfusion, (3) decrease of functional residual capacity, and (4) hypercapnia [ 9 ]. An inserted laryngeal mask can mitigate these adverse effects by (1) administering a higher concentration of inspired oxygen, (2) enhancing the monitoring of end-tidal carbon dioxide and facilitating its removal, and (3) providing pressure-support ventilation [ 10 ].…”

“…(5) using a flexible wound retractor to keep the incision open; (6) opening the right-side mediastinal pleura; (7) dissecting the pericardial and epiphrenic fat pad, with the phrenic nerve being the dorsal boundary of dissection; (8) proceeding upwards to the level of the internal thoracic vein in an en-bloc fashion, avoiding any attempt to dissect the thymus gland separately (Fig. 1C); (9) skeletonizing the superior vena cava, both innominate veins, and the aorta; (10) dividing the upper poles close to the thyroid gland; (11) dissecting along the left phrenic nerve similarly; (12) placing the specimen in an Endobag and removing it via the subxiphoid incision (Fig. 1D); and (13) inserting a chest tube (Fig.…”

Anästhesie bei nicht intubierter videoassistierter Thoraxchirurgie (NiVATS)

“…Die Patienten zeigen intraoperativ häufig eine Hyperkapnie, weshalb Patienten mit schweren kardiovaskulären Vorerkrankungen und insbesondere einem bekannten pulmonalen Hypertonus auszuschließen sind. Aber auch bei Patienten mit erhöhtem intrakraniellem Druck, mit schlecht eingestelltem Hypertonus und mit Risikofaktoren für die Entwicklung von Arrhythmien kann eine Hyperkapnie einen negativen Einfluss haben [17]. Eine präoperative kardiale und pulmonale Optimierung sollte, wenn eben möglich, erfolgen.…”