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Bach K, Volberg C, Wiesmann T, Wulf H, Schubert AK. [Perioperative pain therapy in minimally invasive thoracic surgery]. DIE ANAESTHESIOLOGIE 2023; 72:726-736. [PMID: 37725143 PMCID: PMC10550863 DOI: 10.1007/s00101-023-01329-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 09/21/2023]
Abstract
Thoracic surgery is often associated with severe postoperative pain levels. Even though these are less pronounced in thoracoscopic approaches, mechanical irritation, compression or injury of intercostal nerves and placement of chest tubes can cause pain levels, which must be treated. An adequate pain therapy in thoracic surgery is essential as insufficient inspiration due to inadequate analgesia may result in postoperative complications. Epidural anesthesia was considered the gold standard in thoracotomy for a long time. For video-assisted thoracoscopy, however, it is sometimes no longer recommended due to its benefit-risk ratio. Alternative thoracic blocks are the paravertebral block, the erector spinae plane block and the serratus anterior block, for which research has found heterogeneous results.This article summarizes the current recommendations for perioperative management of thoracoscopic surgery and gives an overview of the PROSPECT recommendations as well as the current Association of the Scientific Medical Societies in Germany (AWMF) guidelines for perioperative and postoperative pain therapy. In particular, individual regional anesthesia techniques and their current evidence are reviewed.
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Affiliation(s)
- Katharina Bach
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland.
| | - Christian Volberg
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
| | - Thomas Wiesmann
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Diakoneo Diak Klinikum Schwäbisch Hall, Schwäbisch Hall, Deutschland
| | - Hinnerk Wulf
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
| | - Ann-Kristin Schubert
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
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Hachenberg T. Neue Entwicklungen in der Thoraxchirurgie: Bedeutung für Anästhesie und Schmerztherapie. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:391-393. [PMID: 35728589 DOI: 10.1055/a-1819-9814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Grott M, Eichhorn M, Eichhorn F, Schmidt W, Kreuter M, Winter H. Thoracic surgery in the non-intubated spontaneously breathing patient. Respir Res 2022; 23:379. [PMID: 36575519 PMCID: PMC9793515 DOI: 10.1186/s12931-022-02250-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 11/12/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The interest in non-intubated video-assisted thoracic surgery (NIVATS) has risen over the last decade and numerous terms have been used to describe this technique. They all have in common, that the surgical procedure is performed in a spontaneously breathing patient under locoregional anaesthesia in combination with intravenous sedation but have also been performed on awake patients without sedation. Evidence has been generated favouring NIVATS compared to one-lung-ventilation under general anaesthesia. MAIN BODY We want to give an overview of how NIVATS is performed, and which different techniques are possible. We discuss advantages such as shorter length of hospital stay or (relative) contraindications like airway difficulties. Technical aspects, for instance intraoperative handling of the vagus nerve, are considered from a thoracic surgeon's point of view. Furthermore, special attention is paid to the cohort of patients with interstitial lung diseases, who seem to benefit from NIVATS due to the avoidance of positive pressure ventilation. Whenever a new technique is introduced, it must prove noninferiority to the state of the art. Under this aspect current literature on NIVATS for lung cancer surgery has been reviewed. CONCLUSION NIVATS technique may safely be applied to minor, moderate, and major thoracic procedures and is appropriate for a selected group of patients, especially in interstitial lung disease. However, prospective studies are urgently needed.
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Affiliation(s)
- Matthias Grott
- grid.5253.10000 0001 0328 4908Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany ,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Martin Eichhorn
- grid.5253.10000 0001 0328 4908Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany ,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Florian Eichhorn
- grid.5253.10000 0001 0328 4908Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany ,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Werner Schmidt
- grid.5253.10000 0001 0328 4908Department of Anaesthesiology and Intensive Care Medicine, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany
| | - Michael Kreuter
- Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Center for Interstitial and Rare Lung Diseases, Pneumology Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany
| | - Hauke Winter
- grid.5253.10000 0001 0328 4908Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany ,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
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Sponholz C, Winkens M, Fuchs F, Moschovas A, Steinert M. [Videoassisted Thoracoscopy with Preserved Spontaneous Breathing - an Anaesthesiological Perspective]. Zentralbl Chir 2020; 146:S10-S18. [PMID: 33176388 DOI: 10.1055/a-1263-1504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Video-assisted thoracoscopic procedures with preserved spontaneous breathing (NI-VATS = conscious video-assisted thoracic surgery) have enjoyed a revival in recent years. However, there have been few reports on proper patient selection, as well as surgical or anaesthesiologic management for these procedures in Germany. Therefore, we present our experience with NI-VATS procedures in the form of a case study and discuss the results with a current survey and the current literature. METHOD Retrospective evaluation of all NI-VATS procedures at our local institution. RESULTS From June 2018 to January 2020 n = 17 (9 male and 8 female) patients underwent NI-VATS at our institution. Median age of patients was 68 [61 - 79] years. Fourteen patients suffered from progressive cancer as the underlying disease, leading to thoracic surgery. All patients had a number of comorbidities and were classified according to the ASA categories III (n = 9) or IV (n = 8). Surgical procedures were of short duration (in median 18 [15 - 27] min) and included 82% pleural procedures (pleurectomy, decortication or insertion of pleural drainage). All patients tolerated the surgical procedures under local anaesthesia and conscious sedation very well. Eleven patients could therefore be transferred to the normal ward after surgery, while the remaining patients underwent prolonged and intensified postoperative monitoring. Five of the 17 patients died within the hospital, in median 8 [3.0 - 33.5] days after surgery, in context of the underlying disease. None of the deaths could be associated with the surgical procedures. DISCUSSION In a well selected patient cohort and with our local experience, NI-VATS is a safe and practicable alternative to standard thoracotomy in general anaesthesia and one-lung ventilation. In our local institution, multimorbid patients with interventions of short duration and reasonable extent underwent successful NI-VATS and emerged as good candidates for this procedure. Careful patient selection and knowledge of the procedure and its side effects present important milestones for successful NI-VATS.
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Affiliation(s)
- Christoph Sponholz
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Deutschland
| | - Michael Winkens
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Deutschland
| | - Frank Fuchs
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Deutschland
| | | | - Matthias Steinert
- Klinik für Herz- und Thoraxchirurgie, Universitätsklinikum Jena, Deutschland
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