Anesthesia and analgesia: how does the role of anesthetists changes in the ERAS program for VATS lobectomy

Abstract

Enhanced recovery after surgery (ERAS) programs are developed to prevent factors that delay postoperative recovery as well as issues that cause complications. The development of video-assist thoracoscopic surgery (VATS) techniques favors the fast recovery after thoracic procedures. ERAS strategies are based on multidisciplinary approach in which the anesthetist plays an important role from the preoperative to the postoperative phase with several goals. After preoperative evaluation and medical optimization, the anesthetist must ensure a tailored anesthetic plan aiming to a fast recovery and adequate pain relief to reduce the response to the surgical stress. The present narrative review presents the major parts of the ERAS anesthetic approach to VATS lobectomy like short-acting drugs, protective one-lung ventilation (OLV), fluid administration and opioid-sparing multimodal analgesia.

Keywords: Anesthesia and analgesia; pain management; pain postoperative; thoracic surgery; video assisted.

Figure 1

Essential elements of multimodal analgesia after VATS lobectomy. Loco-regional analgesia should be always included in the anesthetic plan. TPVB is the first choice technique but TEA should be considered in case of high risk of conversion to thoracotomy. ICNB or SAPB are usable as secondary alternatives to TPVB. Regional techniques must be supplemented with NSAID, paracetamol and, if necessary, with opioids. NSAIDs, paracetamol and weak opioids must be administered on a regular schedule. The use of PCA delivery system is recommended for strong opioids administration to individualize the dosage. TPVB, thoracic paravertebral block; ICNB, intercostal nerve block; SAPB, serratus anterior plane block; NSAID, nonsteroidal anti-inflammatory drug; PCA, patient controlled analgesia; TEA, thoracic epidural analgesia.