What are the anesthetic considerations and management for thoracic surgery?

Anesthetic Considerations and Management for Thoracic Surgery

General Anesthesia Technique

For thoracic surgery, general anesthesia with endotracheal intubation utilizing volatile halogenated anesthetics combined with opioid supplementation is the standard approach, with anesthetic management directed toward early postoperative extubation in low- to medium-risk patients. 1

Induction and Maintenance

• Volatile anesthetic-based regimens (isoflurane, sevoflurane, desflurane) are preferred as they facilitate early extubation, reduce patient recall, and provide myocardial protection during ischemia-reperfusion 1

• Intravenous agents for induction include propofol or etomidate, often combined with benzodiazepines for premedication 1

• Opioid supplementation with fentanyl or sufentanil is used as an adjuvant rather than high-dose primary technique, supporting fast-track recovery protocols 1

• Nondepolarizing neuromuscular blockers with intermediate duration (rocuronium, vecuronium) are preferred over pancuronium to avoid prolonged neuromuscular depression and delayed extubation 1

Airway Management

• Double-lumen endotracheal tubes or bronchial blockers enable one-lung ventilation for surgical exposure 1

• Do not routinely change double-lumen tubes to single-lumen tubes at the end of procedures complicated by significant upper airway edema or hemorrhage 1

Monitoring Requirements

Essential Monitoring

The choice of anesthetic techniques, agents, and patient monitoring should be tailored to facilitate surgical and perfusion techniques while monitoring hemodynamics and organ function. 1

• Invasive arterial pressure monitoring is required in one or more sites depending on surgical plan for cannulation and perfusion 1

• Central venous access allows measurement of cardiac filling pressures and provides routes for vasoactive drug and fluid administration 1

• Temperature monitoring in at least two locations estimating brain/core (esophageal, nasopharyngeal, tympanic) and visceral (bladder, rectal) temperature 1

Advanced Monitoring

• Transesophageal echocardiography (TEE) is reasonable in all open surgical repairs of the thoracic aorta unless specific contraindications exist, and for endovascular procedures for monitoring, procedural guidance, and leak detection 1

• A fellowship-trained cardiac anesthesiologist credentialed in perioperative TEE is recommended for high-risk patients 1

• Motor or somatosensory evoked potential monitoring can be useful when data will guide therapy, with decisions based on patient needs, institutional resources, urgency, and surgical techniques 1

Regional Anesthesia Considerations

Thoracic Epidural Anesthesia

• Thoracic epidural combined with general anesthesia provides superior oxygenation during one-lung ventilation compared to total intravenous anesthesia alone, potentially benefiting patients with preexisting cardiopulmonary disease 2

• Thoracic epidural is NOT first-line for routine thoracic surgery due to concerns about neuraxial bleeding (particularly with heparinization, antiplatelet agents, and CPB-induced thrombocytopenia), local anesthetic toxicity, and logistical issues 1

• Regional anesthetic techniques are contraindicated in patients at risk of neuraxial hematoma formation due to thienopyridine antiplatelet therapy, low-molecular-weight heparins, or clinically significant anticoagulation 1

Alternative Regional Techniques

• Outside the United States, total intravenous anesthesia via propofol and opioid infusions with benzodiazepine supplementation, with or without high thoracic epidural, is commonly used 1

• Selective use of thoracic epidural may be considered in patients with severe pulmonary dysfunction or chronic pain syndromes 1

Fast-Track Anesthesia and Early Extubation

Anesthetic management directed toward early postoperative extubation and accelerated recovery is recommended for low- to medium-risk patients undergoing uncomplicated procedures. 1

Implementation Strategy

• Early extubation strategies allow shorter time to extubation, decreased ICU length of stay, and variable effects on hospital length of stay 1

• Immediate extubation in the operating room with ultra-fast-tracking or rapid recovery protocols can be used safely in selected patients, with reintubation rates <1% 1

• Factors predicting fast-track failure include previous cardiac surgery, intra-aortic balloon counterpulsation use, and possibly advanced patient age 1

Critical Caveat

• Routine use of early extubation strategies in facilities with limited backup for airway and advanced respiratory support is potentially harmful 1

Multimodal Analgesia Protocol

Regional Analgesia (First-Line)

Paravertebral block is the primary recommended regional technique for thoracotomy pain management due to superior efficacy and fewer side effects compared to thoracic epidural analgesia. 3

• Erector spinae plane (ESP) block is equally recommended as a first-choice alternative, demonstrating non-inferiority with potentially easier placement and fewer complications 3, 4

• Continuous catheter infusion is preferred over intermittent bolus techniques for regional anesthesia 3

• For VATS procedures, paravertebral block or ESP block are first-line options, with serratus anterior plane block as an alternative 4

Systemic Analgesia Foundation

• Paracetamol (acetaminophen) should be administered pre-operatively or intra-operatively and continued at regular intervals postoperatively as foundational multimodal analgesia 3, 4, 5

• NSAIDs or COX-2 inhibitors should be initiated pre-operatively or intra-operatively and continued postoperatively unless contraindicated by renal impairment, heart failure, or bleeding risk 3, 4, 5

• Short-course NSAID therapy improves pain control, enhances recovery, and reduces hospital length of stay 3

• Cyclooxygenase-2 inhibitors are NOT recommended for CABG procedures 1

Opioid Management

• Opioids should be used exclusively as rescue analgesics for breakthrough pain, not as primary analgesics in the multimodal regimen 3, 4, 5

• For immediate post-procedure breakthrough pain, intravenous fentanyl in divided doses is the preferred opioid 3, 4

• IV morphine is the standard preferred starting opioid for opioid-naïve patients requiring rescue analgesia 5

Preemptive Analgesia for Procedures

Preemptive analgesia and/or nonpharmacologic interventions should be administered prior to chest tube removal. 1

• Significantly lower pain scores are reported with IV morphine plus relaxation, topical valdecoxib, or IV sufentanil/fentanyl prior to chest tube removal 1

• For other invasive and potentially painful procedures, preemptive analgesic therapy and/or nonpharmacologic interventions may also be administered 1

Hemodynamic Management

Myocardial Oxygen Balance

• Anesthetic management must maintain favorable balance of myocardial oxygen supply and demand to prevent or minimize myocardial injury 1

• Close interaction between anesthesiologist and surgeon is required, particularly during heart or great vessel manipulation that may induce hemodynamic instability 1

Off-Pump Considerations

• During off-pump procedures, hemodynamic alterations from heart displacement, verticalization, and stabilizer device application (causing changes in heart rate, cardiac output, systemic vascular resistance) require careful monitoring and appropriate management 1

Alternative Anesthetic Approaches

Non-Intubated Thoracic Surgery

• Non-intubated techniques during which surgery is performed on spontaneously ventilating patients awake under minimal sedation with local/regional anesthesia, or under general anesthesia with supraglottic airway device, are emerging as valid alternatives for selected cases 6, 7

• The concept allows creation of spontaneous pneumothorax as the surgeon enters the chest, providing excellent lung isolation without positive pressure ventilation on the dependent lung 6

• General anesthesia with supraglottic airway provides more stable airway and facilitates oxygenation if unexpected conversion to open thoracotomy is needed 6

Patient Selection for Non-Intubated Techniques

• Begin with minor VATS procedures in selected low-risk patients when starting non-intubated techniques 6

• Early elective conversion should be employed for any unexpected surgical difficulty or cardiopulmonary problem during the learning curve to reduce emergency conversion risk and complications 6

Critical Implementation Points

Pain Control and Pulmonary Function

Pain control directly impacts pulmonary function and rehabilitation—inadequate analgesia causes splinting, atelectasis, and impaired ability to participate in respiratory physiotherapy, which are crucial for recovery after thoracic surgery. 3, 5

Multidisciplinary Coordination

• Multidisciplinary efforts are indicated to ensure optimal analgesia level throughout the perioperative period 1

• Efforts to improve interdisciplinary communication and patient safety in the perioperative environment (formalized checklist-guided multidisciplinary communication) are recommended 1

Surgical Technique Considerations

• Harvesting a pedicled intercostal muscle flap before chest retraction and replacing it during closure can reduce intercostal nerve compression and improve immediate postoperative pain 3

Common Pitfalls to Avoid

• Do not rely on vital signs alone to assess pain in critically ill patients—vital signs are not reliable predictors of pain and do not correlate with patients' self-report 1

• Avoid high-dose NSAIDs in patients with renal impairment, heart failure, or bleeding risk 3, 4, 5

• Do not use opioids as primary analgesics—this increases respiratory depression risk in patients who may already have compromised pulmonary function 5

• Avoid routine pulmonary artery catheterization—the general perioperative literature does not support its routine use for thoracic aortic surgery 1