This research presents a step-by-step protocol detailing the execution of non-intubated video assisted thoracoscopic surgery. The protocol of N-I-V-A-T-S is based on multimodal analgesia, including ultrasound guided thoracic paravertebral blockade, a thoracoscopic vagal block, and proloinfiltration anesthesia. Multimodal analgesia effectively relieves intraoperative pain and inhibits the cough reflex.
This protocol provides a sevoflurane inhalation anesthesia regiment to reduce the cough reflex during thoracoscopic surgery. Minimize the over sedation while providing a safe and a pain-free operating environment for patients. We maintain the patient spontaneous breathing and minimize mediastinal oscillations during the procedure while taking into account the associated technical challenges.
Begin by adjusting the temperature of the operating room to between 24 to 26 degrees Celsius. Insert a 20 gauge top-winged infusion needle into the elbow vein of the non-surgical hand of the patient. Now monitor the electrocardiography, blood pressure, pulse, oxygen saturation, and respiratory rate of the patient.
Apply a Bispectral Index Quatro Sensor to the patient's forehead. To induce anesthesia by continuous oxygen administration, insert a laryngeal mask airway. Maintain the sevoflurane concentration at 1.5 to 2%and an oxygen flow rate of 0.5 to one liter per minute.
Monitor the inhaled oxygen concentration, the end tidal carbon dioxide, the body temperature, and the level of consciousness. Place the patient in a lateral decubitus position and place the ultrasound probe directly above the spinous processors of the third and seventh thoracic vertebrae. Obtain a cross-sectional image of the spinous processes.
Move the ultrasound probe laterally to show the transverse process in its entirety. Move it outward to visualize the transverse process, transverse rib joints and the ribs. Keep moving the probe cardinally until the transverse process, pleura, and the thoracic paravertebral space are detected in the image.
On the ultrasound guidance, insert a block needle with the in plain approach from the lateral to the medial side. Next, carefully increase the aspiration before the injection to ensure no blood reflux is seen. After injecting 0.5 milliliters of ropivacaine, visualize the anterior displacement of the pleura and the widening of the thoracic paravertebral space.
Maintain a bispectral index value of 40 to 60. Using an infusion pump, continuously perfuse norepinephrine. Perform arterial blood gas analysis 15 minutes before the end of the surgery.
Inject one milligram per kilogram of flurbiprofen 30 minutes before the end of the surgery. The pulmonary complication rate was observed to be significantly lower in the non-intubated video assisted thoracic surgery, or NIVTAS group related to the general anesthesia, or GA group. Six patients in the GA group developed postoperative pneumothorax.
Three patients in the GA group developed plural effusion compared to one in the NIVATS group, which was not statistically significant. Seven patients in the GA group developed pneumonia compared to none in the NIVATS group, and the difference between the two groups was statistically significant. Additionally, three GA patients developed pulmonary atelectasis and two developed pulmonary embolisms.
Neither group developed acute respiratory distress syndrome. The NIVATS group showed reduced intraoperative blood loss at 20 milliliters, shorter mean surgery duration, and post-anesthesia care unit stay time. Furthermore, the chest drain was removed from the NIVATS group on day two and the GA group on day three, which was significant.
Significant differences were observed in the amount of postoperative chest drainage between the NIVTAS and the GA group. Three patients in the GA group had prolonged ICU stays and four had postoperative chest tightness with shortness of breath. Relative to the GA group, the NIVTAS group had significantly shorter hospital stay lengths at five days.
