Table 1 List of recommendations for intraoperative and postoperative care
Recommendation | Level of evidencea | Strength of recommendationa |
|---|---|---|
Intraoperative care | ||
The use of videolaryngoscopy for tracheal intubation with a double-lumen tube might improve visualization of the glottis and the success rate at the first attempt, reducing difficulty and positioning time. Videolaryngoscopy can be used in cases of unexpected difficult intubation. | Poor | C |
We recommend the use of a double-lumen tube to manage one-lung ventilation. A single lumen tube with a bronchial blocker, rather than a double-lumen tube, is recommended for patients with difficult airways. | Good | A |
We recommend the use of a flexible bronchoscope to control the position of the lung isolation device. Flexible bronchoscopy must always be available, even if not used routinely. Thoracic anesthesiologists must have adequate bronchoscopy skills to manage DLT and bronchial blockers for one-lung ventilation. | Good | A |
We recommend monitoring arterial blood pressure with invasive (intra-arterial) techniques, rather than the non-invasive oscillometric cuff technique, in patients undergoing major thoracic surgery, or when sudden changes in hemodynamics, hemoglobin and blood gas concentrations (oxygen and carbon dioxide) are expected. | Good | A |
We suggest considering the use of a central venous catheter on a case-by-case basis in patients undergoing thoracic surgery. Peripheral catheters are safe for short-term and low-dose treatment with inotropic vasoactive drugs. | Fair | C |
In patients undergoing thoracic surgery who are considered at higher risk of postoperative complications, we suggest the use of hemodynamic monitoring with cardiac output estimation systems. | Poor | C |
We do not recommend the use of dynamic preload indices during open-chest thoracic surgery, because these parameters might not be reliable. | Good | D |
We suggest that patients undergoing thoracic surgery under general anesthesia are monitored with processed electroencephalography (pEEG) in order to titrate anesthetic administration. | Fair | B |
We recommend that intraoperative temperature be monitored using an appropriate system in all patients undergoing thoracic surgery lasting more than 30 minutes. A core temperature of at least 36 °C should be maintained. | Good | A |
We recommend monitoring neuromuscular blockade in all patients receiving neuromuscular blocking agents during general anesthesia for thoracic surgery. | Good | A |
In low risk patients (simple procedures, younger patients and without cardiac or renal comorbidities), the use of a bladder catheter is not recommended. | Fair | D |
We recommend using balanced crystalloid solutions, rather than normal saline (NaCl 0.9%), as standard fluid of choice. | Good | A |
We do not recommend the use of hydroxyethyl starch as routine fluid therapy in patients undergoing thoracic surgery. | Good | D |
We recommend a near-zero, rather than restricted or permissive, fluid balance to patients undergoing thoracic surgery. In high-risk patients a goal-directed approach to fluid therapy should be applied. | Fair | A |
We suggest using serum hemoglobin concentration in the evaluation of volume status in non-bleeding patients undergoing thoracic surgery. | Poor | C |
We recommend a protective ventilation approach during one-lung ventilation, based on the combination of low tidal volumes (≤ 6 mL/kg ideal body weight) with alveolar recruitment maneuvers, adequately titrated positive end-expiratory pressure (PEEP) and the lowest fraction of inspired oxygen (FiO2) to maintain satisfactory arterial oxygen saturation. | Fair | A |
Volatile anesthesia cannot be recommended over intravenous propofol administration in order to reduce postoperative complications, although there is evidence of a lower degree of both systemic and local inflammation when volatile anesthetics are used. | Good | I |
We recommend the use of a steroid neuromuscular blocking agent because of the availability of sugammadex, a reversal agent that, unlike acetylcholinesterase inhibitors, can be used even in cases of deep residual block, and reduces both extubation time and adverse events (bradycardia, postoperative nausea and vomiting and postoperative residual paralysis). | Fair | A |
We recommend evaluation of the risk of postoperative nausea and vomiting, and the use of appropriate prophylaxis according to the level of risk, in all patients undergoing lung surgery. | Good | A |
We recommend avoiding the routine placement of a nasogastric tube, and early removal in patients in whom a nasogastric tube is used. | Fair | A |
We recommend the early removal of urinary catheters to promote mobilization in patients undergoing lung surgery, including those receiving thoracic epidural catheters. | Fair | A |
Postoperative care | ||
We recommend the use of pre-emptive locoregional analgesia as part of a multimodal analgesic approach for thoracic surgery. Systemic opioids, nonsteroidal anti-inflammatory drugs, and paracetamol have shown no evidence of benefit when used as pre-emptive analgesics. | Fair | A |
Currently, there are no elements to suggest the routine perioperative use of gabapentinoids in patients undergoing thoracic surgery, but their use can be effective in a comprehensive multimodal analgesia protocol. | Poor | I |
We suggest intraoperative intravenous administration of ketamine to reduce postoperative pain after thoracic surgery. There is no evidence about the best dose and timing of administration of ketamine. | Fair | B |
We suggest intraoperative intravenous administration of magnesium sulfate to reduce postoperative pain after thoracic surgery. | Fair | B |
There is no evidence to suggest the routine use of α2-agonists as part of a multimodal analgesia regimen to reduce postoperative pain after thoracic surgery. There is no consensus on the best timing and schedule for administration of these drugs. | Fair | I |
We suggest considering the use of intravenous steroids as part of a multimodal approach to reduce peripheral sensibilization of inflammatory-induced pain in patients undergoing thoracic surgery. Adverse effects of single doses of steroids are of trivial clinical impact. | Fair | C |
We recommend the use of intravenous nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce peripheral sensitization to inflammation-induced pain in patients undergoing thoracic surgery. Combined use of NSAIDs and paracetamol may give a further analgesic advantage. | Good | A |
We recommend the use of locoregional anesthesia for intraoperative and postoperative pain management. | Poor | A |
We recommend the use of thoracic epidural analgesia in high-risk patients or in major surgical procedures where the parietal pleura (eg chest wall resection) is violated (i.e. thoracotomy, thoracosternotomy, chest wall resection). | Fair | A |
We recommend thoracic paravertebral block for VATS, as part of a multimodal approach. | Good | A |
We recommend paravertebral block in preference to thoracic epidural analgesia in patients with known or suspected coagulopathy. | Fair | A |
We suggest that intercostal nerve blockade should be considered only as a second choice for analgesia after thoracic surgical procedures. | Good | C |
We suggest erector spinae plane block as part of a multimodal analgesia for thoracic surgery, especially for VATS. | Poor | B |
We suggest the use of fascial pain blocks as part of multimodal analgesia for thoracic surgery, particularly for VATS. | Fair | B |
We suggest considering the use of adjuvants (i.e. opioids, clonidine, dexmedetomidineb, dexamethasone, magnesium) when loco-regional anesthesia is performed, because the use of adjuvants can potentiate and prolong the effect of local anesthetics. | Poor | C |
We suggest considering the use of a single large-bore chest tube instead of a double tube after thoracic surgery. Insertion of more than one chest tube may be considered in selected cases (e.g., bi-lobectomy or bleeding patients). | Poor | C |
We suggest considering the use of digital chest drainage systems to promote early mobilization of the patient. | Fair | B |
The routine use of drainage with suction is not recommended in the absence of complications, provided there is full re-expansion of the residual parenchyma after lung resection. | Good | D |
We suggest removing chest tubes in lung resection patients when liquid output is ≤ 5 cm3/kg/24 h of serous fluid. | Poor | B |
We do not recommend systematic ICU admission after thoracic surgery. | Poor | D |
We recommend that, in adult patients undergoing thoracic surgery, oral intake, including clear liquids, can be initiated 4-6 hours after surgery, in the absence of nausea and vomiting. Oral intake should, however, be adapted to individual tolerance. | Fair | A |
We recommend early mobilization of patients within the first 24 h after both minor and major thoracic surgery. | Fair | A |
We recommend a physiotherapy program after thoracic surgery. | Fair | A |
We suggest considering daily chest radiographs only in selected cases under specific clinical indications. | Good | C |
We do not recommend the routine use of either continuous positive airway pressure (CPAP) or non invasive ventilation (NIV) to prevent postoperative pulmonary complications, prolonged length of stay, and mortality (both in ICU and in hospital) in patients undergoing major thoracic surgery. CPAP or NIV could be considered case by case in selected high risk patients. | Poor | D |
We suggest the use of NIV or CPAP to treat acute respiratory failure complicating thoracic surgery. | Poor | B |
We suggest considering the use of high-flow nasal cannula oxygen therapy (HFNC) as an alternative or integrative support to CPAP or NIV to prevent or treat acute respiratory failure complicating thoracic surgery. | Poor | C |
For prophylaxis and management of atrial fibrillation after thoracic surgery, we recommend reference to the Society of Thoracic Surgery (STS) 2011 Guidelines. | Good | A |