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In This Article

  • Summary
  • Abstract
  • Introduction
  • Protocol
  • Results
  • Discussion
  • Disclosures
  • Acknowledgements
  • Materials
  • References
  • Reprints and Permissions

Summary

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Abstract

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

Introduction

In the past decade, non-intubated video-assisted thoracic surgery (NIVATS) anesthesia has gradually been accepted in clinical practice1,2,3. Although this novel strategy enhances the rapid recovery of patients and avoids the complications of general anesthesia (GA) and one-lung ventilation4, many surgeons regard this approach as less desirable than the traditional lung isolation technique.

Blood oxygen levels decline with age, and some patients may have decreased or borderline pulmonary function. GA may be associated with an increased risk of complications in such patients, including delayed emergence from anesthesia, airway complications, hoarseness, hypoxia, and arytenoid dislocation5,6,7,8,9. In contrast, multiple studies have documented shorter hospital stays among patients managed with NIVATS, as well as a reduction in respiratory complications compared to general anesthesia among low-risk patients10; additionally, successful surgery has even been reported in high-risk patients with very poor pulmonary function11,12,13.

Spontaneous ventilation during surgery is achieved with carefully administered local anesthesia or a regional nerve block supplemented with sedation, but the cough reflex with unexpected lung movement can be problematic during NIVATS. There is little emphasis on and no standard treatment for mediastinal flutter, irritating cough, or tachypnoea, which may disrupt a surgical procedure. In preliminary observations, the results showed that sevoflurane could decrease the respiratory rate and the occurrence of mediastinal flutter during NIVATS while maintaining spontaneous breathing14. Therefore, it could be hypothesized that sevoflurane inhalation may prevent coughing and reduce the requirement for mechanical ventilation, thereby reducing post-operative pulmonary complications (PPCs).

Firstly, this report presents a step-by-step protocol detailing the execution of non-intubated video-assisted thoracoscopic surgery. Secondly, a retrospective study was conducted to investigate the potential benefits of non-intubated anesthesia on post-operative outcomes.

Protocol

The study was approved by the Ethics Committee of the Affiliated Hospital of Ningbo University School of Medicine (KY20181215) on December 10, 2018.

1. Inclusion criteria

  1. Include all patients (aged >18 years) undergoing pulmonary bullae resection, pulmonary wedge resection, or lobectomy.

2. Exclusion criteria

  1. Exclude patients based on an American Society of Anesthesiologists (ASA) physical status classification of >315.
  2. Exclude patients with a body mass index (BMI)16 >30 kg/m2.
  3. Exclude patients with oesophageal cancer, total pneumonectomy, and open-heart surgery with resection of the ribs.
  4. Exclude patients with a previous medical history of bronchiectasis, destroyed lung, or chronic obstructive pulmonary disease (COPD).
  5. Exclude patients with definite multiple pulmonary infections or inflammation prior to surgery, as well as other severe systemic diseases.
  6. Exclude patients with coagulation disorders and severe psychiatric or neurological disorders.

3. Preparation before the anesthesia

  1. Fast the patient for 8 h before the surgery.
  2. Adjust the operating room temperature to be between 24 Β° C and 26 Β° C.
  3. Insert a 20 G top-winged infusion needle into the non-surgical dorsal vein of the hand.
  4. Monitor the electrocardiography, blood pressure, pulse oxygen saturation (SpO2), and respiratory rate of the patient.
  5. Apply a bispectral index (BIS) quatro sensor to the forehead of each patient.
    NOTE: Continuously monitor the radial arterial pressure and central venous pressure, if necessary.

4. Ultrasound-guided thoracic paravertebral blockade

  1. Place the patient in a lateral decubitus position.
  2. Place the ultrasound probe directly above the spinous processes of the third thoracic and seventh thoracic vertebrae, and obtain a cross-sectional image of the spinous processes.
    NOTE: In the middle of the image is the hyperechoic spinous process with a posterior acoustic shadow, and the bony structures with a posterior acoustic shadow on either side of the spinous process are, in order, the vertebral plate and the transverse process.
  3. Move the ultrasound probe laterally to show the transverse process in its entirety.
  4. Move the ultrasound probe outward to visualize the transverse process, transverse rib joints, and ribs.
  5. Move the ultrasound probe caudally until the transverse process, the pleura, and the thoracic paravertebral space between them are detected in the image.
  6. Locally anesthetize the skin by injecting 2 mL of 1% lidocaine.
  7. Insert the block needle from lateral to medial with the in-plane approach under ultrasound guidance.
  8. Carefully increase the aspiration before the injection. Ensure that no blood reflux is observed.
    ​NOTE: The purpose of this step is to prevent systemic toxicity from the local anesthetic.
  9. Inject 2 mL of saline, and then visualize the anterior displacement of the pleura and the widening of the thoracic paravertebral space with the ultrasound.
  10. Inject 15 mL of 0.375% ropivacaine at the levels of T3 and T7.

5. Anesthetic induction

  1. Spray 1% levobupivacaine (3 mL) onto the throat.
  2. Inject 1.5 Β΅g/kg of fentanyl and 1-1.5 mg/kg of propofol.
  3. For continuous oxygen administration, place a facial mask, or insert a laryngeal mask airway (double-tube mask; #3 for 30-50 kg, #4 for 50-70 kg, #5 for 70-100 kg). Oxygen enters the patient's airway via the facial mask or laryngeal mask.
    ​NOTE: Adjust the injection dose to achieve a BIS value between 40-6016.

6. Maintenance of anesthesia

  1. Maintain an oxygen flow rate of 0.5-1 L/min.
  2. Maintain the concentration of sevoflurane at 1.5%-2.0% after the artificial pneumothorax.
    NOTE: Inject 0.5 Β΅g/kg of fentanyl if the intraoperative spontaneous respiratory rate is higher than 20 breaths/min or when there is mediastinal flutter or coughing. Sevoflurane enters the patient's airway via the facial mask or laryngeal mask.
  3. Monitor the inhaled oxygen concentration and the end-tidal carbon dioxide (ETCO2Β < 60 mmHg).
  4. Monitor the body temperature. Monitor the level of consciousness, and maintain a BIS value of 40-6016,17.
  5. Inject 20Β΅g/kg of atropine if the patient develops sinus bradycardia (HR ≀ 50 beats/min).
  6. Continuously perfuse 2 Β΅g/kg/h of norepinephrine using an infusion pump if the systolic blood pressure is lower than 30% or 90 mmHg.
  7. Perform arterial blood gas analysis 15 min before the end of the surgery.
  8. Inject 1 mg/kg of flurbiprofen 30 min before the end of the surgery.

7. Thoracoscopic vagal block techniques and pleural infiltration anesthesia

  1. Use a 24 G top-winged infusion needle to produce an infiltration of 0.375% ropivacaine (3 mL) near the vagus nerve at the level of the lower trachea when performing right-sided procedures.
  2. Use a 24 G top-winged infusion needle to produce an infiltration of 0.5% ropivacaine (3 mL) near the vagus nerve at the level of the aortopulmonary window when performing left-sided procedures.
  3. Spray 10 mL of 2% lidocaine onto the surface of the visceral pleura using a 10 mL syringe.

8. Conversion from non-intubated anesthesia to intubated general anesthesia

  1. Convert the non-intubated anesthesia to intubated general anesthesia if the patient meets one of the following conditions:
    -Severe hypoxemia (pulse oximetry < 80%)
    -Severe hypercapnia (PaCO2 > 80 mmHg)
    -Hemodynamic instability: intractable arrhythmias and right ventricular failure
    -Persistent coughing resulting in surgery becoming difficult or impossible
    -Intraoperative bleeding requiring thoracotomy

9. Post-operative care

  1. After fully waking, ask the patient to take a deep breath and cough to re-expand the collapsed lung.
  2. Connect a patient-controlled intravenous analgesia (PCA) pump to the intravenous catheter with a 100 mL solution in a PCA reservoir bag (containing 1 Β΅g/kg of sufentanil and a 0.9% sodium chloride injection), and titrate 2 mL/h of the PCA solution.
  3. Remove the chest drain when there is no air leak on coughing, no obvious fluid pneumothorax on the review of the chest X-ray, and a 24 h drainage of <300 mL.

Results

Clinical data were retrospectively collected on 58 consecutive patients undergoing non-intubated video-assisted thoracoscopic surgery from January 2016 to December 2022. The patients were given a preoperative visit by the anesthesiologist and provided with a detailed explanation of the contents of the anesthesia informed consent form prior to the anesthesia. The patients were allowed to choose one of the two groups (the NIVATS group or GA group) of anesthesia, and they signed an informed consent form.

Discussion

The advantages of this protocol are as follows: (i) providing a sevoflurane inhalation anesthesia regimen to reduce the cough reflex during thoracoscopic surgery; (ii) minimizing over-sedation while providing a safe and pain-free operating environment for patients undergoing thoracic surgery; (iii) minimizing the patient's spontaneous breathing and mediastinal oscillations during the procedure, taking into account the associated technical challenges. This was achieved by providing pre-emptive intraoperative local ane...

Disclosures

The authors have nothing to disclose.

Acknowledgements

This work was supported by the third batch of the Ningbo Health Youth Technical Cadre program (Dr. Binbin Zhu), and the Zhejiang Medical Association Clinical Research Fund Project (Dr. Bin Gao) (2018ZYC-A66).

Materials

NameCompanyCatalog NumberComments
20-G top-winged infusion needleBD Intima II383012Puncture with a 20-G top-winged infusion needle into the dorsal vein of the non-operative side of the hand.
24-G top-winged infusion needleBD Intima II383033Thoracoscopic vagal block techniques
AnesthesiaΒ machineDragerA300Maintenance of respiratory function; Inhalation anesthesia; Monitor for electrocardiography, blood pressure, pulse oxygen saturation (SpO2), end-tidal carbon dioxide and respiratory rate
AtropineJiuquan Dadeli PharmaH62020772Control of heart rate
BISCOVIDIENB277243Monitor the level of consciousness
Disposable nerve block needleTuoren Medical DeviceΒ 202303007Nerve block
Facial maskEmedicaEM01-105SProvides an effective non-invasive breathing circuit
Fentanyl.Renfu Pharma21D04021Analgesia
FlurbiprofenDaan PharmaH20183054Analgesia
Laryngeal maskΒ Ambu Aura-i2012-2664652Airway management to preserve voluntary breathing
LevobupivacaineRundu PharmaH20050403Local Anaesthesia
LidocaineKelun PharmaF221129CLocal skin infiltration
NorepinephrineLijun PharmaH61021666Control of blood pressure
Portable color doppler ultrasoundSonoSiteM-TurboGuided nerve block
PropofolGuorui PharmaH20030114Sedation and hypnosis
RopivacaineAspen Pharma6091403219940Paravertebral nerve block
SalineKelun Pharmac221201E1Assisted subsonic localisation
SevofluraneΒ Shanghai Hengrui Pharmaceutical Co.,Ltd9081931Anesthesia induction and maintenance
SufentanilJiangsu Enhua Pharmaceutical Co., LtdH20203650Postoperative analgesia

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