Anesthetic management for enhanced recovery after thoracic surgery

INTRODUCTION — Enhanced recovery after surgery (ERAS) refers to multimodal multidisciplinary standardization of perioperative care to minimize responses to surgical stress and postoperative pain, expedite recovery, decrease hospital length of stay, reduce complications, and improve outcomes following elective procedures. This topic discusses elements of medical and anesthetic management specific for enhanced recovery after thoracic surgery (ERATS).

Separate topics address ERAS for cardiac surgery and major noncardiac procedures:

●(See "Anesthetic management for enhanced recovery after cardiac surgery (ERACS)".)

●(See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)

●(See "Enhanced recovery after colorectal surgery".)

●(See "Enhanced recovery after gynecologic surgery: Components and implementation".)

SCOPE AND GOALS OF ERATS PROGRAMS — Key recommendations for medical, anesthetic, and surgical management in enhanced recovery after thoracic surgery (ERATS) programs address the entire pathway from preoperative consultation to hospital discharge [1]. Specific goals include reducing opioid use, length of stay in the intensive care unit (ICU) and hospital, morbidity (particularly pulmonary and cardiac morbidity), and costs. Studies of implementation of ERATS protocols for lung resection include [1-8]:

●A 2017 meta-analysis of seven randomized trials included 486 patients undergoing lung resection [7]. ERATS patients had lower overall morbidity (risk ratio [RR] 0.64, 95% CI 0.51-0.80), particularly rates of pulmonary (RR 0.43, 95% CI 0.31-0.60) and surgical complications (RR 0.46, 95% CI 0.25-0.83) compared with control group patients. Cardiovascular complications and in-hospital mortality were similar in the groups. Five of the seven trials reported shortened ICU and hospital length of stay in patients enrolled in an ERATS protocol, although significant heterogeneity was noted among studies [7].

●A 2021 prospective study compared 169 patients undergoing pulmonary resection before implementation of an ERATS protocol with 126 patients after implementation [2]. After implementation of their ERATS protocol, the investigators noted increased use of minimally invasive surgery (62.7 versus 39.6 percent), reduced ICU utilization (21.4 versus 70.4 percent), improved early removal of chest tubes (54.8 versus 24.3 percent) and urinary catheters (65.1 versus 20.1 percent) by postoperative day one, and improved success with ambulation at least three times on postoperative day one (54.8 versus 46.8 percent). Decreased opioid use (101 versus 82 daily oral morphine equivalents, 95% CI 1-36), and direct costs of hospitalization were noted [2]. Furthermore, an overall decrease in the incidence of morbid events was noted (32 to 20 percent, 95% CI 1.6-22.5 percent). These included delirium, atrial fibrillation, myocardial infarction, atelectasis, pneumothorax, pleural effusion, respiratory failure, air leak, renal failure, venous thromboembolism, blood transfusion, pneumonia, surgical site infection, urinary tract infection, and sepsis. Readmission was similar before and after implementation of the ERATS protocol, even though discharge had been expedited resulting in a shorter length of stay in the hospital (4.4 versus 3.2 days, 95% CI 0.3-2.0 days) [2].

●A 2018 review of 2886 lung resections noted that the implementing a full ERATS protocol after open thoracotomy was associated with decreased pulmonary and cardiac complications, as well as decreased hospital length of stay (pre-ERATS, n = 1615; transitional period, n = 929; full ERATS protocol, n = 342) [3]. However, there was little change in these outcomes after minimally invasive video-assisted thoracic surgery procedures. ERATS did not affect hospital readmission after either surgical procedure type [3].

●A 2018 study comparing outcomes in minimally invasive video-assisted thoracic surgery lung resections before (n = 162) and after (n = 81) implementation of an ERATS protocols noted shortened hospital length of stay, decreased opioid usage, minimized fluid overload, and decreased hospital costs in the first year following implementation [4].

●A 2015 retrospective study in open lung resection comparing outcomes before (n = 127 patients) and after (n = 107 patients) implementation of an ERATS protocol noted decreased overall incidence of complications from 64 to 37 percent, in particular urinary tract infections (3 versus 15 percent]) [6]. Hospital length of day also decreased after implementation of the protocol from a median of 7 days (interquartile range [IQR] 6 to 10 days) to a median of 6 days (IQR 5 to 7 days) in ERATS patients. The incidence of hospital readmission was similar between groups [6].

However, results demonstrating improvements after implementation of ERATS protocols are not consistent [9]. As with other types of major surgery, positive effects of ERATS protocols for patients undergoing pulmonary resection are greatest when high compliance with all elements of the pathway is achieved rather than implementing one or two elements in isolation [1,3,5,8].

PREOPERATIVE STRATEGIES

Anemia management — Anemia should be always be identified in the preoperative period in time to correct reversible causes (eg, iron deficiency) prior to elective thoracic surgery (algorithm 1) [1]. Notably, anemia is associated with adverse outcomes in patients undergoing lung resection for cancer, even after perioperative correction with blood transfusion [10,11]. (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia'.)

Smoking cessation — Smoking cessation is important to minimize postoperative complications after thoracic surgery, particularly before pulmonary resection for lung cancer because of the need for one lung ventilation and the loss of lung tissue. Smoking cessation may also decrease long-term mortality [12]. (See "Strategies to reduce postoperative pulmonary complications in adults", section on 'Smoking cessation'.)

Many of these patients have a smoking history (and may be active smokers). Ideally, smoking should stop at least four weeks before thoracic surgery [1,13]. Strategies are discussed in another topic. (See "Smoking or vaping: Perioperative management", section on 'Helping perioperative patients quit smoking or vaping'.)

Prehabilitation in selected patients — Prehabilitation in selected patients with poor nutrition and poor pulmonary function can optimize functional status, enhance recovery, and improve postoperative outcomes. Details are discussed in a separate topic. (See "Overview of prehabilitation for surgical patients", section on 'Nutritional supplementation' and "Overview of prehabilitation for surgical patients", section on 'Physical exercise programs'.)

Patient education — Patient and family education during the preoperative anesthetic consultation emphasizes expectations for early extubation, postoperative pain relief, and expedited recovery and discharge from the hospital. (See "Anesthetic management for enhanced recovery after cardiac surgery (ERACS)", section on 'Preanesthetic consultation' and "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)", section on 'Preanesthesia consultation'.)

DAY OF SURGERY STRATEGIES

Limit fasting — Clear fluids should be allowed up until two hours before and solids until six hours before induction of anesthesia, similar to enhanced recovery after surgery (ERAS) protocols for other types of surgery. Oral carbohydrate loading reduces postoperative insulin resistance and should be used routinely. (See "Enhanced recovery after colorectal surgery", section on 'Fasting guidelines'.)

Avoid benzodiazepine premedication — We avoid or minimize preoperative benzodiazepine anxiolytics including midazolam [6,14]. As discussed in separate topics, perioperative benzodiazepine administration may lead to oversedation, upper airway obstruction, and postoperative cognitive dysfunction and delirium. (See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)", section on 'Medications administered in the preoperative period' and "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with higher risk'.)

INTRAOPERATIVE STRATEGIES

Use of minimally invasive surgical procedures — When feasible, a minimally invasive technique such as video-assisted thoracoscopic surgery rather than open thoracotomy is employed to decrease surgical trauma and postoperative pain in patients participating in enhanced recovery after thoracic surgery (ERATS) protocols [1]. (See "Overview of minimally invasive thoracic surgery" and "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection".)

Use of short-acting anesthetic agents — Short-acting intravenous (IV) and/or inhalation anesthetic agents as well as short-acting muscle relaxants are selected to facilitate early emergence and extubation. (See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)", section on 'Maintenance of anesthesia' and "Clinical use of neuromuscular blocking agents in anesthesia".)

Multimodal pain management — Moderate-to-severe pain is common after thoracotomy due to the surgical incision, muscle retraction, rib spreading, and opening of the pleural space, which can result in injury to sternocostal and costovertebral joints and intercostal nerves [15]. We agree with the Society of Cardiovascular Anesthesiologists (SCA) recommendations to use customized multimodal opioid-sparing strategies to effectively control postoperative pain, which promotes recovery by allowing early mobilization and reducing risk for pulmonary complications, and potentially prevents development of persistent postoperative pain [15]. Strategies to limit use of opioids include combinations of neuraxial analgesia and regional nerve blocks, as well as administration of nonopioid analgesics [1,15-17]. These strategies are similar to those for enhanced recovery after other types of major surgery. (See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)", section on 'Management of pain'.)

Notably, thoracic surgery is associated with greater postoperative pain than most other major surgical procedures. Although the pathogenesis of pain after thoracic pain is complex, factors increasing postsurgical pain perception include stimulation of several nociceptive signals due to skin incision, muscle division, rib fracturing or spreading, rib disarticulation, costochondral joint disarticulation, bronchial resection, and pleural incision [18]. These multiple nociceptive signals amplify pain transmission and cause central sensitization.

Adequate pain management is necessary to avoid complications such as ineffective cough leading to poor clearing of secretions, development of hypoxemia and hypercarbia, and pain-induced sympathetic stimulation leading to arrhythmias and myocardial ischemia. Furthermore, meta-analyses suggest that one-half to one-third of patients experience pain at three and six months after thoracotomy [19,20]. Some develop a chronic postthoracotomy pain syndrome, often with a primary neuropathic component that becomes unresponsive to opioid medication [17,20].

Regional anesthetic techniques — We use regional anesthetic techniques for ERATS protocols. The most common techniques are thoracic epidural analgesia, paravertebral block, fascial plane blocks (eg, erector spinae block, serratus anterior plane block), or intercostal nerve blocks [1,15]. These are described in separate topics:

●Thoracic epidural analgesia (see "Anesthesia for open pulmonary resection", section on 'Thoracic epidural analgesia')

●Paravertebral block (see "Thoracic paravertebral block procedure guide" and "Anesthesia for open pulmonary resection", section on 'Paravertebral block')

●Thoracic nerve block techniques

•Erector spinae block (see "Erector spinae plane block procedure guide")

•Serratus anterior plane block (see "Thoracic nerve block techniques", section on 'Serratus plane block')

●Intercostal nerve blocks (see "Thoracic nerve block techniques", section on 'Intercostal nerve block')

Nonopioid analgesics — Minimizing opioids is an important component of multimodal analgesic strategies [1,15]. Systemically administered nonopioid analgesics typically used in ERATS protocols include (see "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)", section on 'Management of pain' and "Postoperative care after cardiac surgery", section on 'Analgesia'):

●Acetaminophen – Oral or IV acetaminophen is a common component of pain management after thoracic surgery, particularly in combination with nonsteroidal anti-inflammatory drugs (NSAIDs), since acetaminophen reduces opioid consumption and has limited contraindications or adverse side effects [1,15,21,22]. Typically, we administer 1000 mg po before surgery, plus 1000 mg IV in the operating room if the duration of surgery is longer than six hours.

●NSAIDs – NSAIDs can improve postthoracotomy pain and limit opioid consumption [1,15,22-24]. A limited dose of an NSAID may be administered for a limited duration in patients who are not at risk for significant bleeding or acute kidney injury, usually in combination with acetaminophen. We typically administer preoperative oral celecoxib 200 mg po or IV ketorolac 15 mg at the end of surgery.

●Dexmedetomidine – Dexmedetomidine is an alpha-2 agonist with sedative and anesthetic-sparing properties that is associated with improved postoperative pain scores, and with reduced opioid requirements and respiratory complications after cardiothoracic surgery [1,15,25].

Ketamine is an N-methyl-D-aspartate (NMDA) receptor antagonist that is of uncertain benefit but is used in subanesthetic doses in some ERATS protocols to reduce morphine consumption and improve early postoperative lung function, particularly in patients with opioid tolerance [1,15,26]. Other agents of uncertain benefit that are used in some centers include magnesium and lidocaine [15].

Opioid analgesics — Limited use of opioids may be necessary to provide effective analgesia, prevent splinting, and enable passive expiration in the immediate postoperative period [15]. We typically administer doses of fentanyl during the intraoperative period. If necessary, we administer oral oxycodone in the early postoperative period (usually in combination with acetaminophen and an NSAID). However, opioid use is limited due to risk of respiratory depression after thoracic surgery, particularly in older patients or those with pre-existing pulmonary conditions such as chronic obstructive pulmonary disease. (See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)", section on 'Opioids'.)

Another concern is persistent postoperative opioid and chronic opioid dependence after a painful thoracic surgical procedure. Persistent opioid use is associated with poor compliance with postoperative treatment, increased postoperative morbidity including cardiovascular risk, and decreased overall survival (particularly cancer-specific survival) [27].

Lung protective ventilation — Risks associated with one lung ventilation include hypoxemia and ventilator-associated lung injury due to volutrauma and oxidative stress in the ventilated lung and atelectasis in the nonventilated lung [28]. Lung-protective ventilation strategies are employed to minimize iatrogenic lung injury to minimize iatrogenic lung injury during periods of ventilation of one or both lungs [1,29,30]. Details are available in separate topics. (See "One lung ventilation: General principles", section on 'Lung-protective ventilation strategies' and "Mechanical ventilation during anesthesia in adults", section on 'Lung protective ventilation during anesthesia'.)

Maintenance of normovolemia — A "moderate," goal-directed fluid management strategy (rather than a restrictive or liberal fluid management strategy) is employed to maintain normovolemia (ie, euvolemia). A balanced crystalloid solution is selected, and we typically use dynamic parameters to determine fluid responsiveness. Accumulating evidence suggests that carefully titrated goal-directed fluid therapy may decrease postoperative complications and length of stay [1,31]. Although very restrictive limitation of crystalloid solutions may facilitate early extubation and reduce pulmonary complications, concern for hypovolemia with impaired tissue perfusion and acute kidney injury has led to development of moderate goal-directed strategies to maintain euvolemia as a component of ERATS protocols [1]. However, we avoid excessive fluid administration (ie, >3 L during the 24-hour perioperative period) because patients undergoing thoracic surgery are at increased risk for interstitial and alveolar edema due to existing pulmonary disease, prior chemoradiation, duration of one lung ventilation, direct lung manipulation, and ischemia-reperfusion injury. Excessive fluid administration is associated with worsening of acute lung injury and delayed recovery [32-41]. (See "Intraoperative fluid management", section on 'Goal-directed fluid therapy' and "Intraoperative fluid management", section on 'Dynamic parameters to assess volume responsiveness' and "Anesthesia for open pulmonary resection", section on 'Fluid and hemodynamic management'.)

Maintenance of normothermia — We fastidiously maintain temperature near normothermia (≥35.5°C) throughout the perioperative period [1]. (See "Perioperative temperature management".)

Postoperative nausea and vomiting prophylaxis — In additional to use of opioid-sparing anesthetic techniques (see 'Multimodal pain management' above), we routinely administer a 5-hydroxytryptamine type 3 (5-HT3) antagonist such as IV ondansetron 4 mg and a glucocorticoid such as dexamethasone as part of multimodal postoperative nausea and vomiting prophylaxis [1]. For patients with history of postoperative nausea and vomiting or strong risk factors, we use a total IV anesthesia and avoid inhalation agents during surgery. (See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)", section on 'Antiemetic prophylaxis' and "Postoperative nausea and vomiting", section on 'Prevention'.)

Early extubation — Most patients are extubated in the operating room at end of the thoracic surgical procedure as described in separate topics. (See "Anesthesia for open pulmonary resection", section on 'Emergence and postoperative airway management' and "Anesthesia for esophagectomy and other esophageal surgery", section on 'Emergence and extubation'.)

Selected patients may need a period of postoperative controlled mechanical ventilation, particularly those with poor preoperative pulmonary function or those who required significant intraoperative pulmonary resection or administration of large volumes of fluid or blood.

POSTOPERATIVE STRATEGIES

Early postoperative mobilization — As with enhanced recovery after other major surgical procedures, early postoperative mobilization is encouraged to reduce the risk of postoperative pneumonia and venous thromboembolism. For thoracic surgical patients, early removal of the chest tube and urinary catheter is particularly important to facilitate early mobility [1]. (See "Enhanced recovery after colorectal surgery", section on 'Early mobilization' and "Postoperative care after cardiac surgery", section on 'Mobility'.)

Early enteral hydration and nutrition — As with other major surgical procedures, early resumption of a diet and oral hydration within a few hours after surgery is optimal [1]. (See "Enhanced recovery after colorectal surgery", section on 'Diet'.)

Venous thromboembolism prophylaxis — Prophylactic measures to reduce the incidence of venous thromboembolism are discussed separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

Atrial fibrillation prevention — Postoperative atrial fibrillation (AF) occurs in 12 to 44 percent of patients after thoracic surgery, and is associated with increased risk of pulmonary complications, hospital length of stay, and mortality [1,42]. Professional society guidelines for prophylaxis and treatment of AF include continuing chronically administered beta-blockers, ensuring adequate magnesium levels with magnesium supplementation when appropriate, and considering administration of prophylactic medications for high-risk patients who are not taking beta-blockers (eg, preoperative diltiazem or postoperative amiodarone) [1,42]. However, a randomized trial in 154 patients undergoing major thoracic surgery found a similar incidence of AF after postoperative administration of amiodarone compared with placebo [43].

Further discussion of AF prophylaxis after pulmonary resection is available in a separate topic. (See "Overview of pulmonary resection", section on 'Preventive measures'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Enhanced recovery after surgery".)

SUMMARY AND RECOMMENDATIONS

●Scope and goals of ERATS programs – Key recommendations for medical, anesthetic, and surgical management in enhanced recovery after thoracic surgery (ERATS) programs address the entire pathway from preoperative consultation to hospital discharge. Specific goals include reducing opioid use, length of stay in the intensive care unit (ICU) and hospital, morbidity (particularly pulmonary and cardiac morbidity), and costs. Positive effects are greatest when high compliance with all elements of the pathway is achieved. (See 'Scope and goals of ERATS programs' above.)

●Preoperative strategies – Preoperative elements include identification and correction of anemia (algorithm 1), smoking cessation at least four weeks before surgery, education regarding expectations, and, in selected patients, prehabilitation (eg, nutrition, exercise, and/or respiratory muscle training). (See 'Preoperative strategies' above.)

●Day of surgery strategies – Fasting is limited (ie, allow clear fluids up until two hours before and solids until six hours before surgery). Benzodiazepines including midazolam are avoided. (See 'Day of surgery strategies' above.)

●Intraoperative anesthetic strategies

•Short-acting anesthetics and neuromuscular blocking agents – Short-acting intravenous (IV) and/or inhalation anesthetic agents and neuromuscular blocking agents are selected to facilitate early emergence and extubation. (See 'Use of short-acting anesthetic agents' above.)

•Multimodal pain management – Regional anesthetic techniques (eg, epidural, paravertebral, or serratus anterior plane blocks) and nonopioid analgesics (eg, acetaminophen, nonsteroidal antiinflammatory agents [NSAIDs]) are employed to minimize postoperative opioid use. (See 'Multimodal pain management' above.)

•Lung-protective ventilation – We employ lung-protective ventilation strategies during ventilation of one or both lungs. (See "One lung ventilation: General principles", section on 'Lung-protective ventilation strategies' and "Mechanical ventilation during anesthesia in adults", section on 'Lung protective ventilation during anesthesia'.)

•Maintain normovolemia – We employ a "moderate," goal-directed fluid management strategy to maintain normovolemia. A balanced crystalloid solution is selected, and we typically use dynamic parameters to determine fluid responsiveness. (See 'Maintenance of normovolemia' above.)

•Maintain normothermia – We maintain normothermia (ie, temperature ≥35.5°C) throughout the perioperative period. (See 'Maintenance of normothermia' above.)

•Postoperative nausea and vomiting prophylaxis – We use multimodal antiemetic prophylaxis including a 5-hydroxytryptamine type 3 (5-HT3) antagonist such as IV ondansetron combined with a glucocorticoid (eg, dexamethasone, methylprednisolone). (See 'Postoperative nausea and vomiting prophylaxis' above.)

•Early extubation – Most patients are extubated in the operating room at the end of the procedure. (See 'Early extubation' above.)

●Postoperative strategies – Postoperative strategies include early postoperative mobilization, enteral hydration and nutrition, and venous thromboembolism prophylaxis. Prevention of atrial fibrillation (AF) includes continuing chronically administered beta-blockers and ensuring adequate magnesium levels. (See 'Postoperative strategies' above.)