Background

Non-intubated thoracic surgery has evolved since the early beginning of 21.century. In University Medical Centre Ljubljana we started with simple non-intubated procedures in October 2015. Many contributung factors are imperative for early start with good results. Surgical technique in VATS procedures has to be fully established. Anesthesiologist, involved in such procedures, has to be confident in thoracic anesthesia with emphasis on airway management. Good technical equipment is fundamental. On the other hand, patient have to be preciselly selected with writen informed conset.

Key words: non-intubated VATS, intercostal blockade, dexmedetomidine, bispectral index, videolaryngoscope

Management

  • Selected surgical procedures for non-intubated VATS

Lungpleural byopsy, bulae resection, peripheral pulmonary metastases, pulmonary unknown infiltrates for diagnostic value.

  • Patient selection: ASA≤3, no severe respiratory or cardiac disease, no difficult airway criteria, BMI ≤ 25.
  • Monitoring vital signs: Periferal intravenous and arterial catheter were inserted. Monitored vital functons were ECG, invasive blood pressure, oxygen saturation, bispectral index (BIS), CO2 trace. Oxygen was suplemented by nasal catheter, face or Ventury mask. CO2 was monitored by nasal canulla.
  • Management of sedation and analgesia: Premedication with midasolam 7,5 mg orally 1h before procedure. Dexmedetomidine 1,0 (to 0,7) mcg/kg/h continously i.v., with supplemental boluses of sufentanyl 10-20 mcg i.v.

Intercostal block with 0,5% Chirocaine 0,2 mg/kg before surgical incision, performed by surgeon.

Discussion

Some small thoracic procedures simply forced us to avoid general anesthesia and double lumen intubation due to reduce costs and invasiveness of anesthetic approach.

We’ve found sedation with dexmedetomidine very effective, providing moderate sedation (BIS 70-80) with perserved spontaneus breathing. Intercostal block with incremental doses of sufentanyl appeared suffficient for simple non-intunbated procedures. Overal cost for sedated modality of VATS, without double lumen intubation, are reduced for more than 60% comparing with general anesthesia.

Without a shadow of a doubt, non-intubated VATS surgery is far more challenged for anaesthesiologist than general anesthesia. Keep the patient spontaneusly breathing, maintaining adequate level of sedation and analgesia at the same time, is the main objective. Patients’ ventilation is additionaly impared because of a loss of lung volume during open surgical pneumothorax. Hypercapnia, which is inevitable, is usually well tollerated and oxygen could be supplemented. No chance, we have to be able for emergent intubation in lateral possition and fast transfer to general anesthesia.

We do have educated and asertive thoracic surgeons, well trained in VATS procedures. During non-intubated VATS they are exposed to worse tehnical conditions. Asynchronous breathing and coughing of the patient, elevated diaphragm are adverse effects of non-intubated procedures.

Conclusion

We agree, that simple procedures in stable patients could and shoud be done in sedation perpetuating spontaneus breathing. It’s feasible that over time, the indications will increase. It’s seems that general anesthesia and positive pressure ventilation shoud better be avoided in particilary debilitated or sick patients for whom an intubated anesthesia carry high risk. But it’s always time for reasonable steps.

Fig.1: Patient position and monitoring during non-intubated VATS

Fig.2: Lungs are perfectly collapsed

Fig.3: Vital signs during non-intubated VATS

Fig.4: Blood gas analysis during non-intubated VATS

 

Mojca Drnovsek Globokar, MD
Clinical Department of Anaesthesiology and Intensive Care, University Medical Centre Ljubljana, Slovenia

Tomaz Stupnik MD,PhD
Clinical Department of Thoracic Surgery, University Medical Centre Ljubljana, Slovenia

Corresponding author's e-mail: mojca.drnovsek@kclj.si

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