Combined non-intubated anaesthesia and paravertebral nerve block in comparison with intubated anaesthesia in children undergoing video-assisted thoracic surgery

Non-intubated tracheal resection and reconstruction for a tracheal tumor in an 8-year-old child

INTRODUCTION

It has been reported that non-intubated anesthesia can be used successfully in adult trachea reconstruction. Herein, our center reported a case of a child undergoing non-intubated trachea reconstruction for benign tracheal tumors.

CASE DESCRIPTION

In January 2023, it was decided to attempt tracheal resection and reconstruction (TRR) in an 8-year-old child with an inflammatory myofibroblastic tumor under non-intubated spontaneous breathing. After anesthesia induction, the laryngeal mask airway (LMA) was inserted. Thereafter, a bilateral superficial cervical plexus block was performed with 15 mL of 0.25% ropivacaine injected into each side. The patient was induced to resume spontaneous breathing by artificially assisted ventilation with an oxygen flow of 2 to 5 L/min and FiO2=1. After tracheotomy, the oxygen flow was increased to 15 L/min to improve the local oxygen flow to maintain the pulse oxygen saturation (SpO2) above 90% under spontaneous breathing. The patient had stable spontaneous breathing after tracheal anastomosis. The anastomosis was perfect without leakage. The LMA was removed and oxygen was given by the nasal catheter under light sedation at post anesthesia care unit (PACU).

CONCLUSION

Tracheal reconstruction under spontaneous breathing may be an alternative anesthesia method for upper tracheal surgery in children.

Effect of thoracic paravertebral nerve block on delirium in patients after video-assisted thoracoscopic surgery: a systematic review and meta-analysis of randomized controlled trials

Background

Nerve blocks are widely used in various surgeries to alleviate postoperative pain and promote recovery. However, the impact of nerve block on delirium remains contentious. This study aims to systematically evaluate the influence of Thoracic Paravertebral Nerve Block (TPVB) on the incidence of delirium in patients post Video-Assisted Thoracoscopic Surgery (VATS).

Methods

We conducted a systematic search of PubMed, Embase, Web of Science, Cochrane Library, and Scopus databases in June 2023. The search strategy combined free-text and Medical Subject Headings (MeSH) terms, including perioperative cognitive dysfunction, delirium, postoperative cognitive dysfunction, paravertebral nerve block, thoracic surgery, lung surgery, pulmonary surgery, and esophageal/esophagus surgery. We utilized a random effects model for the analysis and synthesis of effect sizes.

Results

We included a total of 9 RCTs involving 1,123 participants in our study. In VATS, TPVB significantly reduced the incidence of delirium on postoperative day three (log(OR): -0.62, 95% CI [-1.05, -0.18], p = 0.01, I2 = 0.00%) and postoperative day seven (log(OR): -0.94, 95% CI [-1.39, -0.49], p < 0.001, I2 = 0.00%). Additionally, our study indicates the effectiveness of TPVB in postoperative pain relief (g: -0.82, 95% CI [-1.15, -0.49], p < 0.001, I2 = 72.60%).

Conclusion

The comprehensive results suggest that in patients undergoing VATS, TPVB significantly reduces the incidence of delirium and notably diminishes pain scores.

Systematic review registration

CRD42023435528. https://www.crd.york.ac.uk/PROSPERO.

Influence of Regional Nerve Block in Addition to General Anesthesia on Postoperative Delirium, Pain, and In-hospital Stay in Patients Undergoing Cardiothoracic Surgery: A Meta-analysis

ABSTRACT

This study aims to investigate whether venous injection of sedative agent or regional nerve block in alliance with major anesthesia could decrease the risk of postoperative delirium occurrence in patients receiving cardiothoracic surgery. Electronic academic databases were retrieved for related publications, and statistical software was used for data pooling and analysis. Forest plot was used to show the pooled sensitivity, specificity, and diagnostic odds ratio. Combined receiver operating characteristic curve was used to show the area under the curve of complex data. Seven studies were included for analysis. The risk of occurrence of delirium still showed no difference (risk rate = 0.93, 95% CI, 0.85-1.03) between the intervention group and placebo group. Postoperative pain feeling was more alleviated in patients with prophylactic application of regional nerve block. In addition, prophylactic application of regional nerve block could decrease the risk of postoperative in-hospital stay (risk rate = 0.28, 95% CI, 0.02-0.54). Our study demonstrated that, in elderly patients or pediatric patients undergoing cardiac surgery, prophylactic application of regional nerve block failed to decrease the incidence of postoperative delirium. However, the option of regional nerve block could decrease the duration of in-hospitalization stay and alleviate the acute pain during the postoperative period after open-heart surgery.

Chronic postoperative pain after non-intubated uniportal VATS lobectomy

Introduction

Patients undergoing thoracic surgery are at increased risk of developing, long-lasting pain. Beyond the non-surgical factors, the type of operation, including the number of incisions, and the anesthetic assessment seemed to be important factors, although some studies are controversial. The aim of our study was to examine the presence of chronic postoperative pain after non-intubated uniportal VATS lobectomy. We examined the difference between the intubated, relaxed and non-intubated spontaneous ventilation surgical approaches in patients who underwent video-assisted thoracoscopic (VATS) uniportal lobectomy.

Methods

Demographic and postoperative data were retrospectively collected and analyzed, focusing on the use of pain medications, in 67 patients of the 140 patients selected by propensity score matching who underwent intubated (iVATS) or non-intubated (NITS) uniportal VATS lobectomy. This study focused on the use of analgesic medications 3, 6, and 12 months after surgery.

Results

Thirty-five intubated and 32 non-intubated patients were compared. Although the analgesic consumption was nearly 2% higher among the iVATS patients during the follow-up period, there were no statistically significant differences at 3 months (15.6 vs. 17.1%) (p = 0.868), at 6 months (9.4 vs. 12.4%) (p = 0.785), and at 12 months (3.3 vs. 5.9%) (p = 0.633) between the NITS and iVATS groups, respectively. More female than male patients reported chronic pain, but the difference was not statistically significant (p = 0.616). Diabetes mellitus was a statistically significant cofactor associated with chronic pain (p = 0.03), while cardiac disease (p = 0.6), perioperative morbidity (p = 0.228), prolonged air leak (p = 0.057), and repeat drainage (p = 0.626) were not.

Conclusion

Our study suggests that after non-intubation VATS lobectomies, the postoperative pain was less at 3, 6, and 12 months in NITS patients compared to iVATS patients. The 2% difference was not significant, so it may not be appropriate to claim the advantages of NITS in terms of postoperative pain.

Application of laryngeal mask airway anesthesia with preserved spontaneous breathing in children undergoing video-assisted thoracic surgery

Purpose

To investigate the feasibility and safety of non-intubated general anesthesia with spontaneous breathing combined with paravertebral nerve blocks (PVNB) in young children undergoing video-assisted thoracic surgery (VATS) and to determine its significance for rapid recovery after pediatric thoracic surgery.

Methods

The data of 46 children aged 6-36 months with an American Society of Anesthesiologists status of I-II who underwent elective VATS under general anesthesia were retrospectively analyzed. Of these patients, 25 underwent non-intubated general anesthesia with spontaneous breathing combined with PVNB (non-intubation group), and 21 received conventional intubated general anesthesia combined with local infiltration anesthesia (intubation group). The following perioperative parameters were compared between the two groups: heart rate (HR), mean arterial pressure, saturation of pulse oximetry (SpO₂), partial pressure end-tidal carbon dioxide, time from the completion of the operation to extubation or removing laryngeal masks, time to first feeding after the operation, length of postoperative in-hospital stay, incidence of postoperative complications, and hospitalization expenses.

Results

The operations were completed successfully in both groups. When the non-intubation group was compared with the intubation group, the minimal SpO₂ level during the surgery was higher (93% vs. 88%, P < 0.001), which might indicate better oxygenation. There was no significant difference of the duration of surgery and intraoperative blood loss between two groups. Compared to the intubation group, the duration of anesthesia (P = 0.027), time from the completion of the operation to extubation (P < 0.001), time to the first feeding after surgery (P < 0.001), and length of postoperative in-hospital stay (P < 0.001) were significantly reduced in the non-intubation group. The incidence of postoperative complications was not significantly different.

Conclusions

Non-intubated general anesthesia with spontaneous breathing combined with PVNB is safe and feasible in young children undergoing VATS and can promote rapid recovery in young children undergoing thoracoscopic surgery.

Ultrasound-guided single thoracic paravertebral nerve block and erector spinae plane block for perioperative analgesia in thoracoscopic pulmonary lobectomy: a randomized controlled trial

OBJECTIVE

To explore the effect of a single preoperative ultrasound-guided thoracic paravertebral nerve block (TPVB) and erector spinae plane block (ESPB) for perioperative analgesia in thoracoscopic pulmonary lobectomy.

METHODS

Seventy-two patients aged 40-70 years who underwent thoracoscopic pulmonary lobectomy under general anesthesia were enrolled and randomly divided into the control group (Group C), the TPVB group (Group T) and the ESPB group (Group E). The primary observation indicators included the visual analogue scale (VAS) at 1, 6, 12, 24, and 48 h postoperatively at rest and with a cough. The secondary observation indicators included the intraoperative sufentanil consumption, anesthesia awakening time and extubation time, the sufentanil consumption in the analgesic pump, and flurbiprofen ester consumption for remedial analgesia within 48 h after surgery and the incidence of postoperative adverse events.

RESULTS

The intraoperative sufentanil consumption, anesthesia awakening time, and extubation time were lower in groups T and E than those in group C (p < 0.05). Patients in group T had lower VAS scores at rest and with a cough at 1, 6, and 12 h postoperatively than in group C at the same time points (p < 0.05). The VAS scores at rest at 1 and 6 h postoperatively and coughing status at 1, 6, and 12 h postoperatively were lower in group E than in group C at the same time points (p < 0.05).

CONCLUSION

The ultrasound-guided preoperative single TPVB and ESPB for thoracoscopic pulmonary lobectomy could both reduce the postoperative pain VAS score and reduce the dose of perioperative sufentanil and postoperative remedial analgesics.

Thoracic surgery in the non-intubated spontaneously breathing patient

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.

To tube or not to tube: a skeptic's guide to nonintubated thoracic surgery

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the rationale and evidence for nonintubated thoracic surgery and guide clinicians, considering the implementation of nonintubated thoracic surgery, to find an anesthetic approach suitable for their department.

RECENT FINDINGS

Based on physiologic considerations alone, nonintubated thoracic surgery would be expected to be an advantageous concept in thoracic anesthesia, especially in patients at high risk for pulmonary complications. Currently existing evidence, however, does not support these claims. Although the feasibility and safety have been repeatedly demonstrated, high-quality evidence showing a significant benefit regarding clinically relevant patient-centered outcomes is not available.Anesthetic approaches to nonintubated thoracic surgery differ significantly; however, they usually concentrate on six main aspects: maintenance of airway patency, respiratory support, analgesia, patient comfort, cough suppression, and conversion techniques. Given the lack of high-quality studies comparing different techniques, evidence-based guidance of clinical decision-making is currently not possible. Until further evidence is available, anesthetic management will depend mostly on local availability and expertise.

SUMMARY

In select patients and with experienced teams, nonintubated thoracic surgery can be a suitable alternative to intubated thoracic surgery. Until more evidence is available, however, a general change in anesthetic management in thoracic surgery is not justified.