Perioperative anesthetic considerations for video-assisted thoracoscopic surgery, an updated narrative review

Introduction

Over the past thirty years, there has been a rapid evolution in thoracic surgery resulting in a shift from routinely performing open thoracotomies to that of video-assisted thoracoscopic surgery (VATS). Within the scope of VATS, there are different surgical techniques, thus necessitating concomitant changes in the anesthetic approach to these patients. While the management of the airway, fluid and ventilation does not significantly differ for an open thoracotomy as compared to VATS, the perioperative management of pain has been a topic of recent study and debate.

The objective of this narrative review is to provide a thorough up-to-date evidence-based description of best practices for comprehensive intraoperative anesthetic management and perioperative multimodal analgesic regimens. As VATS are performed in a variety of hospitals with varying capabilities, this review is intended for anesthesiologists of all backgrounds. For lower volume centers or hospitals affected by shortages of materials or medications, there may be elements of this review that anesthesiologists can combine to improve the care of their patients. This paper will focus on airway management pertaining to lung isolation and devices used, one-lung ventilation (OLV) with management of hypoxemia, fluid administration strategies, and multimodal analgesia including non-opioid parenteral medications and regional anesthesia. In recent years, there have been various group consensus statements and Enhanced Recovery After Surgery (ERAS) protocols put forth regarding VATS patient care, however there is often conflicting recommendations, and actual real-world applications can be confusing. Therefore, this review offers practitioners a comprehensive base from which they can delve further into the nuances at their leisure. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-24-39/rc).

Methods

The PubMed (https://pubmed.ncbi.nlm.nih.gov/) and Google Scholar (https://scholar.google.com) databases and the Cochrane Library were searched up to December 2024. Search terms included “video-assisted thoracoscopic surgery, minimally invasive thoracic surgery, anesthesia, lung isolation, one-lung ventilation, double-lumen endotracheal tube, bronchial blocker, perioperative pain management, acute postoperative pain, persistent post-thoracotomy pain, chronic postsurgical pain, and multimodal analgesia”. Results were limited to English language articles. Articles were reviewed at authors’ discretion and included practice guidelines, randomized controlled trials, meta-analyses, retrospective studies, and case reports. Table 1 shows the literature search strategy.

Intraoperative care during VATS

Lines and monitoring

Standard noninvasive monitoring for patients undergoing VATS is the same as for any patient undergoing a general anesthetic. It includes monitoring temperature, circulation with noninvasive blood pressure cuff measurements and continuous electrocardiogram, oxygenation with pulse oximetry, and ventilation with continuous waveform capnography.

Invasive monitoring for blood pressure using an intraarterial catheter is added for many patients, especially those undergoing extensive pulmonary resection or those at risk of significant bleeding. There are no standard guidelines on the use of intraarterial catheters during VATS, so the decision on whether to place one is largely provider- or institution-specific. Intraarterial catheters also afford easy access to sample arterial blood gases, which is useful during OLV to monitor oxygenation and ventilation.

Some devices use an intraarterial catheter to monitor stroke volume variation (SVV) and pulse pressure variation (PPV), which indicate hemodynamic response to fluid administration. Monitoring these parameters, however, has not been shown to be useful during VATS. This is likely because SVV and PPV monitors rely on algorithms based on PPV caused by two-lung ventilation within a closed thoracic cavity (1).

Central venous catheters and pulmonary artery catheters are rarely used in VATS. Patients undergoing VATS seldom demonstrate hemodynamic instability, a need for prolonged vasopressor infusion, or resuscitation with a large amount of fluid and blood products. Although blood loss is usually minimal, one or two large-bore peripheral catheters are used for intravenous (IV) access. When a patient does experience intraoperative hemodynamic instability, transesophageal echocardiography can be utilized to help diagnose the cause (2).

Airway management

Airway management for VATS requires expertise in lung isolation, OLV, and flexible fiberoptic bronchoscopy (FFB). Although a cardiothoracic anesthesiologist is not required to administer anesthesia for VATS, familiarity with the anatomy of the tracheobronchial tree is needed for airway management. One trial showed that only 39 percent of anesthesiologists with little or no thoracic experience were able to successfully achieve lung isolation (3).

Anesthesiologists must have an extensive knowledge of the devices used to facilitate OLV. There are numerous devices for lung isolation, but a left-sided double lumen tube (DLT) is often preferred (4). After placement of any device, FFB is performed to confirm correct placement (5).

A DLT has separate tracheal and bronchial lumina (Figure 1) (6). These lumina both have cuffs, which are color coded (clear for tracheal and blue for bronchial) and can be individually inflated with air to ventilate, isolate, or permit suctioning of either or both lungs (7,8). A left-sided DLT is preferred to a right-sided DLT due to its ease of positioning. The left-sided DLT has a bronchial lumen which is placed in the left mainstem bronchus, taking advantage of the longer length of this bronchus when compared to the right (9). Due to the more proximal takeoff of the right upper lobe bronchus when compared to the left, it is often more difficult to properly place a right-sided DLT, running the risk of inadequate ventilation to the right upper lobe. A right-sided DLT must be precisely placed to ensure the side orifice on the bronchial lumen aligns with the right upper lobe bronchus. This is technically difficult and prone to malpositioning. Appropriate DLT sizing can be determined by patient height, however, if a computed tomography (CT) scan of the chest is available for review, it can be beneficial to measure tracheal and mainstem bronchi diameter as unexpected discrepancy between airway diameter and tube size can occur, leading to difficult intubation (10). A CT scan can also be examined to assess the length of the right mainstem bronchus as anatomic variations exist that can impact lung isolation strategies.

Figure 1 Typical left-sided DLT and appropriate position within the trachea and left mainstem bronchus. Arrows indicate where to clamp each of the tracheal and bronchial lumina (6). Adapted from Pellechi J et al., Updates to Thoracic Procedures: Perioperative Care and Anesthetic Considerations. License: https://creativecommons.org/licenses/by/3.0/. No changes were made to image. DLT, double lumen tube.

A left sided DLT is typically placed utilizing direct laryngoscopy to guide the endobronchial tip though the vocal cords. The tube is then maneuvered 90 degrees left into the left mainstem bronchus. Once in place, FFB is used to fine-tune the placement of the tube. First, the bronchoscope is advanced through the tracheal lumen to visualize the carina with the blue bronchial cuff just beyond in the left mainstem bronchus. The right bronchus is examined, using the characteristic three branches of the right upper lobe bronchus to verify that it is indeed the right lung. The bronchoscope is also advanced through the bronchial lumen to confirm the left upper lobe bronchus is not occluded by the DLT being advanced too far. Although auscultation can be used to confirm DLT positioning, FFB remains the gold standard. DLT malpositioning is a common complication of relying on auscultation to confirm placement, with one study finding approximately 40 percent of DLTs were not in the correct position when relying on auscultation alone (11). Improper placement of the DLT can not only decrease the success of attempts at lung isolation, it is also the most common cause of hypoxemia during OLV (12). Newer DLTs with a built-in camera have been introduced. The camera affords confirmation of correct DLT placement and can be used continuously during the operation. Their use has not been widely adopted, in part due to cost, but also because tubes with camera are bulkier and stiffer than standard DLTs and secretions can accumulate on the camera and obscure the view.

Another device that can be used to achieve lung isolation and OLV is the bronchial blocker (BB). A BB is a thin, rigid catheter with an inner lumen and cuff at the tip through which suction or continuous positive airway pressure (CPAP) can be applied to the surgical lung. There are a wide variety of commercially available BBs, and they are all typically placed through a single-lumen endotracheal tube (ETT) or tracheostomy tube into the mainstem bronchus of the operative lung using FFB guidance. The cuff at the tip of the BB is then inflated, allowing OLV of the non-operative lung.

Although BBs provide a similar surgical exposure as DLTs, there are several advantages to DLTs in comparison to BBs (Table 2). DLTs can be placed more easily and faster than BBs and are often selected by anesthesiologists with less experience with OLV due to comfort and familiarity. On average, DLTs can be placed 51 seconds faster than BBs with a greater proportion of DLTs noted to be in the correct position [odds ratio 2.70, 95% confidence interval (CI): 1.18–6.18] (15). Some data has shown DLTs provide a more rapid onset of lung isolation than BBs, however, other studies have shown conflicting results (16,17). Rapidity and quality of lung isolation with a BB can be increased by providing an apneic period, with or without gentle suction to the ETT, prior to BB cuff inflation. Also, maintenance of 100 percent fraction of inspired oxygen (FiO₂) and occlusion of the BB inner lumen prior to plural opening can improve speed and quality of lung isolation. Regardless of the speed of lung isolation, once it is achieved, the quality of surgical exposure is similar between the DLTs and BBs (18). BBs are more likely to migrate out of optimal position, often requiring intraoperative repositioning using FFB (7). This occurs more often when the BB is placed in the shorter right mainstem bronchus. When using a DLT, one is afforded better access to the surgical lung and FFB can be used to perform targeted suctioning of secretions or blood.

BBs are preferred to DLTs in certain situations. When a patient arrives to the operating room with a single-lumen ETT in place, it may be advantageous to avoid tube exchanges and place a BB since the airway is already secured. It is also likely that a patient presenting for VATS with an ETT in situ will need postoperative mechanical ventilation, necessitating a single-lumen ETT at the end of the surgery. A BB is also useful when a patient with a tracheostomy presents for VATS. The blocker can be placed down a cuffed tracheostomy tube versus reinforced single-lumen ETT, for fresh versus mature tracheostomy respectively (13,19,20). BBs can also be passed through a nasotracheal tube in patients for which oral intubation is deemed difficult or impossible. Perhaps the most common reason a BB is chosen over a DLT is a patient presenting for VATS with an anticipated difficult airway. Utilizing video laryngoscopy and FFB, a single-lumen ETT with BB is much easier to insert when compared to a DLT in a difficult to intubate patient. Video laryngoscopy, although extremely effective in facilitating intubation with a single-lumen ETT, has proven to be less effective when intubating with a DLT due to the angles and bends of the DLT. When an awake intubation is necessary, the use of a BB is safer and easier than placement of a DLT (21). Patients presenting with abnormal upper anatomy may be at risk of airway trauma when placing a larger and more rigid DLT, so a single lumen ETT with BB can be utilized instead.

Single-lumen endobronchial tubes can be used to achieve lung isolation however these are typically reserved for distal tracheal and carinal surgery or tracheal stenosis (14).

When utilizing a DLT for lung isolation and OLV, the overall incidence of complications is low (9). However, tracheal injury and airway trauma can occur during intubation attempts. Airway rupture is a rare but devastating complication of DLT placement. Incidence of tracheal rupture is <0.2 percent (22), however this number is derived from the use of older, stiffer DLTs and current rates may be lower. When tracheal rupture does occur, mortality is as high as 42 percent (23,24), and is usually treated with surgical repair. Possible contributors to tracheal rupture include use of a stylet, multiple attempts to position the DLT, difficult intubation and bronchial cuff overdistension (23). Half of patients who have a DLT experience a postoperative sore throat, but this can be mitigated with an ultrasound-guided block of the internal branch of the superior laryngeal nerve (25). The incidence of tracheal rupture and sore throat appears to be lower when a BB is used instead of a DLT (15).

Once, the airway has been secured and proper placement of the lung isolation device is confirmed with FFB, general anesthesia is maintained with either inhaled volatile anesthetics or total intravenous anesthesia (TIVA). This is frequently in combination with neuraxial or regional anesthesia and multimodal pain modalities, which are discussed in more depth below. Of note, a 2013 Cochrane review of 20 trials found that use of TIVA did not change outcomes when compared to inhaled anesthesia (26).

VATS performed with an awake and spontaneously ventilating patient is an emerging method for lung cancer resection that does not require intubation. Thoracic epidural blockade along with IV sedation and analgesia has proven to be a safe and effective anesthetic for patients undergoing awake VATS, however, it requires surgeons, anesthesiologists, and operating suites familiar with this procedure (27).

Positioning

Positioning for VATS typically requires the patient to be in the lateral decubitus position, with the operative side facing up. This is achieved with padding and a beanbag device, which can be used to cradle the patient in a stable position. Care is taken to ensure there is no displacement of invasive lines, tubes, or monitoring equipment. The bed is flexed to open the intercostal spaces, allowing easier surgical access to the lung. Overzealous flexion of the bed is avoided as this can cause stretch injury to the long thoracic nerve. After final positioning, a bronchoscope is used to reconfirm proper tube position. Properly positioned DLTs can become mispositioned up to 32 percent of the time after turning the patient from supine to a lateral position (12).

Fluid management

VATS is not typically associated with a large amount of blood loss, so a restrictive fluid administration strategy is usually adequate. In general, infusion of intraoperative crystalloid does need not exceed 6 mL/kg per hour. For most VATS, this totals 1 to 2 liters of crystalloid. A restrictive fluid administration strategy has been repeatedly associated with a lower incidence of postoperative lung injury when compared to a more liberal fluid administration strategy (28-30). Although restrictive fluid administration decreases postoperative pulmonary complications, care must be taken to maintain end-organ perfusion, as there is a risk of acute kidney injury (31).

Lung isolation & OLV

OLV refers to the deviation from the normal physiologic state of two lung ventilation to provide surgical exposure to the operative lung during VATS (4). Due to the confined operative field, it is a requirement for VATS. To achieve selective ventilation to the dependent lung, the DLT lumen ventilating the operative lung is clamped and gentle suction may be applied to facilitate lung collapse (7).

There are several physiologic changes caused by OLV, mainly a change in ventilation and perfusion matching. Normally, during two lung ventilation, ventilation and perfusion of the lungs are matched quite well. All ventilation to the operative lung is stopped during OLV, which should create a 50 percent pulmonary shunt and resultant hypoxemia. However, several factors prove to be advantageous to decrease the true shunt fraction to only 20 to 30 percent (32). Hypoxic pulmonary vasoconstriction occurs within seconds as a response to low oxygen concentration in the lung, triggering the pulmonary vessels to constrict and decrease blood flow to hypoxic areas of the lung. It reduces shunt through the operative, nonventilated lung by up to 50 percent, resulting in a reduction of hypoxemia (33,34). Lateral decubitus positioning leads to an increase in perfusion to the dependent, ventilated lung, further reducing ventilation and perfusion mismatch. Also, surgical manipulation of the operative lung can physically obstruct blood flow to the nonventilated lung.

Despite the body’s ability to decrease shunt fraction during OLV, persistent hypoxemia (oxygen saturation less than 90 percent) is commonly encountered during OLV, occurring in approximately 5 percent of cases (32). Because hypoxemia is usually caused by pulmonary shunt, it will typically resolve with resumption of two lung ventilation. However, re-expansion of the operative lung is disruptive to VATS, so several other techniques aimed at improving oxygenation or decreasing shunt fraction are attempted first (Table 3). In order, a series of maneuvers are employed starting with increasing the FiO₂ to 100 percent (35). Fiberoptic bronchoscopy is then used to both confirm correct placement of the DLT or BB and perform suctioning if secretions or blood are encountered. Once proper DLT or BB placement has been confirmed, recruitment maneuvers can be performed to the ventilated lung by giving brief periods of high-pressure ventilation in effort to re-expand atelectatic lung (36,37). Cardiac output should be optimized, ensuring hypovolemia, pump failure, or increased pulmonary vascular resistance (PVR) is not causing decreased cardiac output. Hypercapnia and auto-positive end-expiratory pressure (PEEP) can both lead to increased PVR. Anemia must also be treated to optimize oxygen carrying capacity of the blood. After ensuring decreased cardiac output is not the cause of hypoxemia, PEEP can be judiciously added to the ventilated lung, which can improve oxygenation by decreasing atelectasis (38,39). PEEP appears to be more effective in those without obstructive disease (40). When used, PEEP should not be over 10 cmH₂O, as this can cause blood to be shunted away from the ventilated lung to the operative lung resulting in worsened hypoxemia. CPAP 5 to 10 cmH₂O applied to the operative lung can provide oxygen and decrease shunt fraction, however, any pressure to the operative lung will partially re-expand the lung (41). Low flow oxygen via a suction catheter to the nonventilated lung as well as high frequency jet ventilation to the nonventilated lung have both been shown to improve hypoxemia, although also at the potential detriment of surgical exposure due to operative lung inflation (43,44). If none of the maneuvers correct the hypoxemia, it may be necessary to perform intermittent two lung ventilation. Finally, for refractory hypoxemia, the surgeon can apply a clamp to the pulmonary artery of the operative lung, shunting all blood to the ventilated lung (42).

Although most hypoxemia encountered during OLV is due to pulmonary shunt, it is important to rule out other causes. Point-of-care ultrasound (POCUS) is gaining traction as a method to rapidly diagnose causative factors in the setting of hemodynamic instability and impaired oxygenation. POCUS focusing on the lung has been shown to accurately diagnose atelectasis, pneumothorax, and pleural effusion, albeit in the post anesthesia care area setting and not intraoperatively (45). POCUS has also proved useful in confirming correct placement of a DLT and has been proposed as an alternative to FFB when a bronchoscope is not available (46).

OLV used during VATS can result in lung injury, but there are several ventilation approaches that can be used to minimize the risk. These approaches were adapted from ventilation strategies used to treat acute respiratory distress syndrome (ARDS) in the intensive care unit (47). Key components of this strategy include low tidal volume ventilation, using 4 to 6 mL/kg expected body weight (48), permissive hypercapnia (49), judicious addition of 5–10 cmH₂O PEEP to the ventilated lung (50), limiting plateau inspiratory pressures to less than 30 cmH₂O (26), and use of lowest acceptable FiO₂ to maintain oxygen saturation above 90 percent (51-53). Although these strategies were extrapolated from treatment algorithms for ARDS, studies have shown a lower incidence of postoperative pulmonary dysfunction (54), reduced inflammatory markers (55), and shorter length of hospital stay (56) when lung protective methods were used during OLV as compared to conventional ventilation strategies.

After OLV, it is necessary to re-expand the operative lung. This is accomplished by removing the clamp on the operative lung lumen of the DLT and slowly giving breaths at increasing pressures less than 30 cmH₂O, ideally under thoracoscopic visualization to ensure full expansion of the lung. Recruitment maneuvers may need to be completed several times, after which protective lung ventilation strategies are continued.

Perioperative pain control for VATS

Background

Perioperative pain management recommendations for VATS patients generally consist of a combination of multimodal analgesia and either neuraxial or peripheral nerve blocks. When compared to open thoracotomy, VATS, as a minimally invasive technique, has been noted to have lower rates of persistent post-thoracotomy pain (25–35% incidence with VATS compared to 33–70% with thoracotomy) and lower rates of neuropathic pain postoperatively (18% compared to 48%) (57). While the naming of VATS as minimally invasive surgery would lead one to think that post-operative pain would be minimized, it is more in reference to the size of surgical incisions (58). Prior studies have analyzed different surgical techniques and have shown that three-port VATS is associated with higher risk for the development of persistent post-thoracotomy pain (59). Despite the exact surgical technique, the rate of developing persistent post-thoracotomy and neuropathic pain is still considerable with long term impact on patients’ lives. The International Association on the Study of Pain defines persistent postoperative pain as clinical discomfort lasting more than 2 months after surgery. In patients undergoing thoracic surgery who developed persistent postoperative pain, there is a 56% prevalence in of prolonged postoperative opioid use (60). Considering this, perioperative pain management is a critical factor in the patients’ overall postoperative disposition when undergoing VATS (61). Inadequate acute pain control is hypothesized to lead to the development of chronic postoperative surgical pain (CPSP) in addition to acute postoperative complications such as impairment of respiratory function with prolonged recovery (62). Poor and irregular breathing due to pain can lead to inability to clear secretions due to decreased cough, splinting, atelectasis and pneumonia in the acute postoperative phase. This can have more detrimental effects such as re-intubation, prolonged hospitalization, and increased morbidity and mortality.

Types of pain after VATS

The development of pain after VATS is commonly due to the following factors: direct tissue trauma due to the surgical incision, tension placed on intercostal nerves by instruments, post-thoracotomy ipsilateral shoulder pain, presence of chest tubes causing pleural irritation, inflammatory reactions, and visceral and neuropathic pain (63). These different etiologies of pain can result in neuropathic pain and nociceptive pain specifically the somatic subtype.

Approach to pain management after VATS

Multimodal analgesia continues to emerge across different types of surgical procedures as a comprehensive pain regimen. It not only mitigates acute postoperative pain and decrease rates of chronic post-surgical pain, but also serves to decrease chronic opioid use postoperatively. Multimodal analgesia as defined by the Centers for Medicare and Medicaid Services is the use of two or more drugs and/or interventions (i.e., regional neuraxial and peripheral nerve blocks) not including systemic opioids to provide analgesia. Opioids are considered part of the multimodal perioperative regimen as a rescue agent. The prior reliance on opioids as the primary analgesic has led to unwanted dose related side effects such as sedation, respiratory depression with decreased oxygenation, nausea, vomiting, delayed gastrointestinal function and urinary retention. These side effects lead to increased mortality, length of stay, readmission rates and higher costs of care for patients receiving opioids compared to those who do not (64), and, interestingly, occur at equal rates for patient-controlled analgesia (PCA) versus traditional as needed administration (65). The acknowledgment of pain as the fifth vital since and aggressive treatment with opioids coincided with the misuse and overprescription of opioids during the perioperative period. The pendulum of perioperative pain management continues to vacillate as we have moved away from heavy opioid use as the primary analgesic, to opioid-free anesthetics, and now to what appears to be a more balanced regimen. The idea of a balanced multimodal analgesic regimen incorporates regional analgesia and non-opioid analgesics, reserving opioids as rescue agents. Moving beyond the acute and chronic pain goals, the choice of analgesic medication regimens may impact patient response to disease states. For example, the approach to perioperative pain will likely be tailored to each individual patient considering genetic factors with the knowledge of how specific medications may impact cancer regression or recurrence (66).

Prior to recent consensus practice guidelines for the management of pain for thoracic surgery patients, there was no consensus regarding the ideal pain control regimen, specifically for VATS patients, and it was largely extrapolated from open thoracotomy practices. Currently, there is significant heterogeneity of what constitutes multimodal analgesia and optimal practice for VATS pain management is still evolving (Table 4). With the available guidelines and data available, each practitioner must decide which modality would be best based on patient, surgical and institutional factors.

Non-opioid analgesics

Systemic non-opioid analgesics used as adjuncts in multimodal regimens include a combination of the following: acetaminophen/paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) or cycloxygenase-2 (COX-2) specific inhibitors, N-methyl-D-aspartate (NMDA) receptor antagonists (ketamine and magnesium), alpha-2 adrenergic agonists (dexmedetomidine), local anesthetics (IV lidocaine), gabapentinoids (gabapentin and pregabalin), and corticosteroids (dexamethasone).

The Procedure-Specific Pain Management (PROSPECT) guidelines (69) recommended the use of pre- or intraoperative paracetamol, NSAIDs or COX-2 inhibitors, and dexmedetomidine, with opioids used as rescue analgesics in the postoperative period. Due to procedure-specific lack of evidence, gabapentinoids, corticosteroids, magnesium, IV lidocaine, transcutaneous electrical nerve stimulation (TENS), wound infiltration, intrapleural analgesia, intercostal nerve blocks and thoracic epidurals are not recommended for VATS patients in the pre- or intraoperative period. In addition, during the postoperative period, gabapentinoids, IV lidocaine, dexmedetomidine and TENS are not recommended for VATS patients.

In comparison, the practice advisory guidelines put forth by the Society of Cardiovascular Anesthesiologists’ (SCA) Quality, Safety, and Leadership (QSL) Committee’s Opioid Working Group has several recommendations regarding systemic analgesics used for the interoperative management of thoracic patients (67). Acetaminophen, NSAIDs and dexmedetomidine may be considered as part of a multimodal regimen. Gabapentin and pregabalin have not been shown to decrease acute postoperative pain for VATS or decrease CPSP after thoracic surgery. The use of steroids, ketamine, magnesium, IV lidocaine and clonidine are uncertain to be of benefit in a multimodal acute pain strategy. Finally, regarding the addition of opioids, the recommendation is for consideration of an opioid-sparing regimen in thoracic surgery cases.

The European Society of Thoracic Surgeons put forth guidelines for Enhanced Recovery after Thoracic Surgery with strong recommendations for the use of a multimodal and regional analgesic approach (68). These guidelines recommend the use of acetaminophen and NSAIDs for all patients in whom they are not contraindicated. In addition, they advocate for the consideration of ketamine in chronic pain patients who are on opiates prior to surgery as well as the use of dexamethasone. This group recommends against the use of gabapentin.

In surgical patients undergoing general anesthesia, the efficacy of multimodal agents has been studied extensively in the perioperative period. Acetaminophen and NSAIDs are well established analgesics that can be given routinely as part of a multimodal regimen. When given together, these medications are synergistic, with greater effect on modulating pain than when given individually, in addition to being well tolerated with few contraindications (70).

The use of gabapentinoids as an adjunct remains controversial given conflicting recommendations. Consensus guidelines from the American Pain Society, American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists recommend consideration of gabapentin and pregabalin as a component of multimodal analgesia, especially for patients undergoing surgeries associated with substantial pain (71). However, the benefits as an adjunct in multimodal analgesia have become more unclear due to significant side effects such as sedation, dizziness and respiratory depression when combined with opioids, which limit their usage (71,72). Given disparate group consensus statements, a recent meta-analysis found, despite affirming a small opioid sparing effect, there was not a clinically significant analgesic effect postoperatively or decreased incidence of development of postsurgical subacute or chronic pain (95% CI: −9 to −3 and 0.74–1.07, respectively) (73). The use of gabapentinoids may be most beneficial when used selectively in patients with the following conditions: pre-existing chronic pain, gabapentinoid use preoperatively, opioid tolerance and those undergoing surgery with moderate to high pain expected postoperatively.

Perioperative use of ketamine (NMDA receptor antagonist) has multiple beneficial effects when given perioperatively, including decreased pain intensity, decreased opioid requirements, and may prevent hyperalgesia and chronic postsurgical pain. A 2018 Cochrane analysis of perioperative ketamine administration in any type of surgical procedure showed a decrease in postoperative opioid consumption by 13 mg morphine equivalents in the first 48 hours postoperatively (95% CI: 10–15, moderate quality evidence) (74). This review found perioperative ketamine administration to be beneficial for thoracic surgery patients. Ketamine has also been shown to be associated with improved recurrence-specific survival in a recent study analyzing the effects of intraoperative opioid exposure in patients with lung adenocarcinoma (75).

Dexmedetomidine has been found to decrease postoperative pain intensity and opioid consumption at 24 hours when given perioperatively (95% CI: −10.16 to −3.35 and −5.20 to −1.03 respectively) in patients undergoing general anesthesia (76). Other studies have also found an opioid sparing effect and reduced pain scores in the acute postoperative period with the use of perioperative dexmedetomidine (77-79). Any beneficial long- term effects have yet to be determined.

Glucocorticoids, specifically dexamethasone, have been shown to decrease perioperative pain severity and analgesic requirements at 24 hours postoperatively, however the clinical significance is unclear despite statistical significance (mean difference −0.87 mg morphine equivalents 95% CI: −4.39 to −0.26) (80). One of the main concerns associated with corticosteroids includes the risk for perioperative hyperglycemia, however, only a mild increase in postoperative glucose is noted in allcomers, including diabetic patients (mean difference 13 mg/dL, 95% CI: 6 to 21) (77). In addition, increased postoperative infection risk has not been shown (level 1) (81). Perineural versus IV dexamethasone has been studied extensively in regard to nerve block prolongation. Network meta-analysis has found that when administered perineurally, there is a prolonged block duration by approximately 5 hours when compared to IV administration. A plateau effect was seen at 4 mg dexamethasone perineurally, which is equivalent to 8 mg IV (82). Given the benefits of attenuating postoperative pain, postoperative nausea, and minimal changes in blood glucose levels, dexamethasone should be incorporated into multimodal pain control regimens.

IV lidocaine as a component of ERAS protocols and as an adjunct in multimodal analgesic regimens was evaluated in a Cochrane review. Uncertainty was found as to whether lidocaine provided a beneficial impact on early postoperative pain scores, gastrointestinal recovery, postoperative nausea, and opioid consumption. It was also found that lidocaine probably has no clinically relevant effects on pain scores after 24 hours (83). When looking at the use of IV lidocaine, specifically for VATS, when added to intra- and postoperative multimodal regimens including NSAIDs, opioid and intercostal nerve block, Yao et al. did not find any beneficial effect of systemic lidocaine on postoperative pain scores or opioid consumption (84). IV lidocaine is perhaps of use in patients undergoing VATS with contraindications to other analgesics (85).

Regional analgesia

Regional analgesia consists of either neuraxial anesthesia or peripheral fascial plane nerve blocks. The addition of regional analgesia in the multimodal approach is generally supported for procedures with severe postoperative pain in attempt to decrease the opioid usage required. The use of neuraxial techniques with thoracic epidural analgesia (TEA) or paravertebral block (PVB) is commonly described as the gold standard for open thoracotomy or for a minimally invasive procedure with a high chance of converting to open thoracotomy. The advent of fascial plane truncal blocks allows for an alternative to the more technically challenging procedures of a thoracic epidural and PVBs while also avoiding rare but serious adverse events. In addition, they allow anesthesiologists to offer an alternative pain control modality, in addition to systemic analgesics, to patients with relative contraindications to neuraxial anesthesia (e.g., anticoagulation) (86). The fascial plane truncal blocks described and studied specific to VATS most commonly include, but are not limited to, ultrasound-guided serratus anterior plane block (SAPB) and erector spinae plane (ESP) block.

The PROSPECT group strongly recommends the use of regional analgesia as a component of multimodal analgesia for VATS patients. PVB and ESP are both recommended, with the reasoning that ESP was shown to be non-inferior when compared to PVB in two studies. For prolonged analgesia, facial plane catheters or the addition of a peri-neural adjuvant such as preservative-free dexmedetomidine can be used for either block. The SAPB, whether superficial or deep, is recommended as a second line block due to insufficient evidence for efficacy when compared to PVB or ESP. However, the SAPB is easy to perform, and has shown a decrease in opioid consumption when compared with systemic analgesics alone or incision site local anesthetic infiltration. TEA is not recommended for VATS by this group as the potential complications outweigh the benefits of pain control.

The SCAs’ QSL Committee’s Opioid Working Group has also made recommendations for regional analgesia. TEA and PCA were found to offer equivocal analgesia, therefore either technique can be offered for acute pain management. Regarding PVB versus TEA for patients undergoing thoracic surgery, PVB was found to have comparable analgesia with more favorable side effect profile. Fascial plane blocks such as ESP and SAPB should be considered as part of a perioperative pain control regimen. Incisional wound infiltration catheters were not recommended as they were found to be inferior to other regional techniques. Intercostal nerve blocks were also found to be inferior when compared to other regional anesthesia techniques. However, they may be of benefit in VATS patients who did not receive a fascial plane block or neuraxial technique. Of note, when compared to intercostal nerve blocks performed with plain bupivacaine, intercostal nerve blocks performed with liposomal bupivacaine are not associated with decreased pain scores or a difference in opioid usage up to 36 hours postoperatively (87). Liposomal bupivacaine was not recommended for use as an opioid sparing agent. Finally, intercostal nerve cryoablation is not recommended due to association with increased incidence of persistent post-thoracotomy pain.

The European ERAS protocol also emphasizes the importance of regional analgesia with its recommendation that PVB offers equivalent analgesia when compared to TEA for thoracic surgeries. When comparing the findings of SCA recommendations to the European ERAS protocol, there is a difference in guidance for intercostal blocks. The later suggests that intercostal catheters may be as effective as TEA, also reducing post-thoracotomy pain when compared to placebo. The reference study did note that intercostal blocks should be considered when neuraxial or paravertebral were not feasible (88). Since that time, the development of alternative fascial plane blocks has flourished, and this recommendation may not be included in updated protocols.

Considerations regarding emerging regional anesthesia techniques

When considering regional analgesic techniques, it is important to be cognizant of the difference in mechanism of action between block types. Neuraxial and paravertebral techniques target nerve bundles with smaller volumes of local anesthetics and have more consistent results when compared to fascial plane blocks, which have a less clear mechanism of action and rely on a larger volume of local anesthetic, with or without adjuncts. Fascial plane blocks are often compared to placebo or to each other rather than being compared to neuraxial blocks, which are considered the “gold standard” for thoracotomy. In many cases, when compared to placebo or sham blocks, this is often in isolation from multimodal regimens of non-opioid analgesics in attempt to show block efficacy. There is significant heterogeneity in the studies performed, and, in the context of smaller study sizes, it is hard to understand the true benefit and clinical significance from each facial plane block. To understand the actual patient benefit, either in terms of reduced opioid use or perceived pain perception, it is important to consider the use of additional multimodal analgesics when comparing studies on the effects of different fascial plane blocks. Additionally, one must consider that many of these studies often have short term end points addressing statistical significance in decreasing opioid usage. This research approach neglects the entirety of perioperative pain in VATS patients as it does not elucidate if the fascial plane blocks are beneficial in functional post-operative clinical outcomes or diminishes long term opioid use and the development of chronic post-surgical pain.

Strengths and limitations

The main strength of this paper is that it provides an up-to-date and detailed perioperative guide for anesthesiologists. The main limitation to this paper is that, as a narrative review, it is not comprehensive in the extent of the literature search as a systematic literature review.

Conclusions

This paper provides a targeted review of the anesthetic approach to VATS. We reviewed articles published in English of randomized control trials, meta-analysis, review articles and consensus guidelines regarding anesthetic care of VATS patients. This paper addresses management of the airway, invasive lines, OLV strategies, multimodal analgesia with non-opioid medications and regional nerve block techniques. The perioperative care of VATS patients continues to evolve as various group consensus statements and ERAS protocols are published. These recommendations must then be tailored to each facility depending on a variety of factors including surgical technique, patient population, procedural capabilities, and departmental resources. Future research is still needed to identify any modifications that can be made to perioperative anesthetic care of patients undergoing VATS to reduce the incidence of chronic postoperative pain and postoperative pulmonary complications.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Gregory Trachiotis) for the series “Preoperative Planning and Assessment for VATS Lung Cancer Resection” published in Video-assisted Thoracoscopic Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-24-39/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-24-39/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-24-39/coif). The series “Preoperative Planning and Assessment for VATS Lung Cancer Resection” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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