Medical Management After Video-Assisted Thoracoscopic Surgery (VATS)
For optimal pain management after VATS, a multimodal approach is recommended that includes regional analgesic techniques (paravertebral block or erector spinae plane block) combined with systemic analgesics (paracetamol and NSAIDs), with opioids reserved only for rescue therapy. 1
Regional Analgesia Recommendations
First-Choice Options
- Paravertebral block is recommended as a first-line regional technique for VATS due to its efficacy in reducing postoperative pain and opioid requirements 1, 2
- Erector spinae plane block is equally recommended as a first-choice option, providing effective analgesia with potentially fewer complications than thoracic epidural 1
Second-Choice Option
- Serratus anterior plane block can be used as an alternative when the first-choice blocks are contraindicated or technically difficult 1
Not Recommended
- Thoracic epidural analgesia is not recommended for VATS procedures as it is considered too invasive relative to the degree of pain and may delay mobilization 1
Systemic Analgesia Protocol
Basic Analgesics
- Paracetamol should be administered pre-operatively or intra-operatively and continued at regular intervals postoperatively 1
- NSAIDs or COX-2 inhibitors should be initiated pre-operatively or intra-operatively and continued postoperatively unless contraindicated (renal impairment, heart failure, bleeding risk) 1, 3
Adjuvant Medications
- Intravenous dexmedetomidine is recommended intraoperatively when basic analgesics cannot be administered, providing analgesic and opioid-sparing effects 1
- Dexamethasone (4-8 mg IV) can be considered as an adjunct to reduce inflammation and improve analgesia 3
Rescue Analgesics
- Opioids should be used only as rescue analgesics for breakthrough pain, not as primary analgesics 1
- For immediate post-procedure breakthrough pain, intravenous fentanyl in divided doses is preferred 3
- Oral tramadol can be used as a step-down rescue analgesic for ongoing moderate pain 3
Implementation Timeline
Immediate Post-VATS (0-24 hours)
- Administer regional block (paravertebral or erector spinae plane) if not performed pre/intraoperatively 1, 2
- Continue scheduled paracetamol and NSAIDs at regular intervals 1
- Use opioids only for breakthrough pain with appropriate monitoring 1, 3
Early Recovery Phase (24-72 hours)
- Continue multimodal analgesia with paracetamol and NSAIDs 1
- Begin transitioning from IV to oral analgesics as tolerated 2
- Assess for resolution of regional block and need for rescue analgesics 1
Late Recovery Phase (>72 hours)
- Continue oral analgesics as needed, with emphasis on non-opioid options 1
- Monitor for development of chronic post-surgical pain, which can occur after VATS despite being less common than with thoracotomy 1
Clinical Considerations and Caveats
- VATS, while less painful than thoracotomy, is still associated with significant acute and chronic postoperative pain that can negatively affect recovery 1
- Early VATS intervention (when applicable for trauma cases) is associated with shorter ICU stays, shorter hospital length of stay, and fewer complications compared to delayed intervention 4
- Uniportal VATS techniques may result in less postoperative pain and fewer neurological complications compared to traditional three-port approaches 5
- Patients undergoing VATS should be monitored for persistent air leaks, which may require additional interventions 6
- The multimodal approach should be tailored based on patient comorbidities, particularly avoiding high-dose NSAIDs in patients with renal impairment or bleeding risk 3