Video-assisted thoracoscopic surgery - Revision history

Chris.Rishel: Text replacement - "|Respiratory" to "|Pulmonary"

2022-02-22T05:45:54Z

Text replacement - "|Respiratory" to "|Pulmonary"

← Older revision		Revision as of 22:45, 21 February 2022
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	\|Evidence of ventricular or valvular dysfunction, coronary disease, pulmonary hypertension		\|Evidence of ventricular or valvular dysfunction, coronary disease, pulmonary hypertension
	\|-		\|-
	\|~~Respiratory~~		\|Pulmonary
	\|History of COPD, asthma, pleural effusion, pulmonary fibrosis, sarcoidosis, other pulmonary pathology		\|History of COPD, asthma, pleural effusion, pulmonary fibrosis, sarcoidosis, other pulmonary pathology
	\|-		\|-

Karen.Sibert at 17:48, 15 November 2021

2021-11-15T17:48:07Z

← Older revision		Revision as of 10:48, 15 November 2021
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	* Injury to airway from traumatic DLT insertion		* Injury to airway from traumatic DLT insertion
	* Arrhythmia, especially atrial fibrillation		* Arrhythmia, especially atrial fibrillation
	* ~~Anastamotic~~ leak after esophagectomy; mediastinitis		* Anastomotic leak after esophagectomy; mediastinitis
	* Hypotension as a result of inadequate volume replacement and/or epidural analgesia		* Hypotension as a result of inadequate volume replacement and/or epidural analgesia
	* Persistent air leak; bronchopleural fistula		* Persistent air leak; bronchopleural fistula

Karen.Sibert at 06:17, 15 November 2021

2021-11-15T06:17:53Z

← Older revision		Revision as of 23:17, 14 November 2021
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	#* The tracheal lumen is the one occluded during lung isolation, so it is easy to look down the tracheal lumen with a bronchoscope to check the position of the blue (bronchial) cuff without interrupting ventilation.		#* The tracheal lumen is the one occluded during lung isolation, so it is easy to look down the tracheal lumen with a bronchoscope to check the position of the blue (bronchial) cuff without interrupting ventilation.
	#* With left lung surgery and a left DLT, the tracheal orifice (which is now in the dependent or posterior position after the patient is positioned R lateral decubitus) may be pushed against the tracheal wall and occluded, impairing airflow to the R lung.		#* With left lung surgery and a left DLT, the tracheal orifice (which is now in the dependent or posterior position after the patient is positioned R lateral decubitus) may be pushed against the tracheal wall and occluded, impairing airflow to the R lung.
	#* With left lung surgery and a left DLT, pressure on the operated lung may dislodge the bronchial cuff and push the tube out into the trachea, with a loss of lung isolation.		#* With left lung surgery and a left DLT, the surgeon's pressure on the operated lung or manipulation of the lung may dislodge the bronchial cuff and push the tube out into the trachea, with a loss of lung isolation.
	#* The occurrence of complications or ventilation problems has not been shown to differ with R vs. L DLTs.<ref>{{Cite journal\|last=Ehrenfeld\|first=Jesse M.\|last2=Walsh\|first2=John L.\|last3=Sandberg\|first3=Warren S.\|date=June 1, 2008\|title=Right- and Left-Sided Mallinckrodt Double-Lumen Tubes Have Identical Clinical Performance\|url=https://journals.lww.com/00000539-200806000-00038\|journal=Anesthesia & Analgesia\|language=en\|volume=106\|issue=6\|pages=1847–1852\|doi=10.1213/ane.0b013e31816f24d5\|issn=0003-2999\|via=}}</ref><ref>{{Cite journal\|last=Ehrenfeld\|first=Jesse M.\|last2=Mulvoy\|first2=William\|last3=Sandberg\|first3=Warren S.\|date=August 1, 2010\|title=Performance Comparison of Right- and Left-Sided Double-Lumen Tubes Among Infrequent Users\|url=https://linkinghub.elsevier.com/retrieve/pii/S1053077009003401\|journal=Journal of Cardiothoracic and Vascular Anesthesia\|language=en\|volume=24\|issue=4\|pages=598–601\|doi=10.1053/j.jvca.2009.09.007\|via=}}</ref>		#* The occurrence of complications or ventilation problems has not been shown to differ with R vs. L DLTs.<ref>{{Cite journal\|last=Ehrenfeld\|first=Jesse M.\|last2=Walsh\|first2=John L.\|last3=Sandberg\|first3=Warren S.\|date=June 1, 2008\|title=Right- and Left-Sided Mallinckrodt Double-Lumen Tubes Have Identical Clinical Performance\|url=https://journals.lww.com/00000539-200806000-00038\|journal=Anesthesia & Analgesia\|language=en\|volume=106\|issue=6\|pages=1847–1852\|doi=10.1213/ane.0b013e31816f24d5\|issn=0003-2999\|via=}}</ref><ref>{{Cite journal\|last=Ehrenfeld\|first=Jesse M.\|last2=Mulvoy\|first2=William\|last3=Sandberg\|first3=Warren S.\|date=August 1, 2010\|title=Performance Comparison of Right- and Left-Sided Double-Lumen Tubes Among Infrequent Users\|url=https://linkinghub.elsevier.com/retrieve/pii/S1053077009003401\|journal=Journal of Cardiothoracic and Vascular Anesthesia\|language=en\|volume=24\|issue=4\|pages=598–601\|doi=10.1053/j.jvca.2009.09.007\|via=}}</ref>
	#* This [https://www.youtube.com/watch?v=I_gZ5UfrFsw video] offers a more comprehensive review of R DLT insertion, indications, advantages and disadvantages.<ref>{{Citation\|last=UCLA Anesthesiology\|first=K. S. Sibert, MD\|title=Why bother to use a RIGHT double lumen tube\|url=https://www.youtube.com/watch?v=I_gZ5UfrFsw\|volume=\|pages=\|language=en\|access-date=2021-11-13}}. </ref>		#* This [https://www.youtube.com/watch?v=I_gZ5UfrFsw video] offers a more comprehensive review of R DLT insertion, indications, advantages and disadvantages.<ref>{{Citation\|last=UCLA Anesthesiology\|first=K. S. Sibert, MD\|title=Why bother to use a RIGHT double lumen tube\|url=https://www.youtube.com/watch?v=I_gZ5UfrFsw\|volume=\|pages=\|language=en\|access-date=2021-11-13}}. </ref>

Karen.Sibert at 06:16, 15 November 2021

2021-11-15T06:16:26Z

← Older revision		Revision as of 23:16, 14 November 2021
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	#* If the tracheal cuff of the R DLT tears on the patient’s molars during intubation, the bronchial cuff will still guarantee lung isolation.		#* If the tracheal cuff of the R DLT tears on the patient’s molars during intubation, the bronchial cuff will still guarantee lung isolation.
	#* The tracheal lumen is the one occluded during lung isolation, so it is easy to look down the tracheal lumen with a bronchoscope to check the position of the blue (bronchial) cuff without interrupting ventilation.		#* The tracheal lumen is the one occluded during lung isolation, so it is easy to look down the tracheal lumen with a bronchoscope to check the position of the blue (bronchial) cuff without interrupting ventilation.
	#* With left lung surgery and a left DLT, the tracheal orifice (which is now in the dependent or posterior position after the patient is positioned R lateral decubitus) may be pushed against the tracheal wall and occluded.		#* With left lung surgery and a left DLT, the tracheal orifice (which is now in the dependent or posterior position after the patient is positioned R lateral decubitus) may be pushed against the tracheal wall and occluded, impairing airflow to the R lung.
	#* With left lung surgery and a left DLT, pressure on the operated lung may dislodge the bronchial cuff and push it out into the trachea, ~~impairing~~ lung isolation.		#* With left lung surgery and a left DLT, pressure on the operated lung may dislodge the bronchial cuff and push the tube out into the trachea, with a loss of lung isolation.
	#* The occurrence of complications or ventilation problems has not been shown to differ with R vs. L DLTs.<ref>{{Cite journal\|last=Ehrenfeld\|first=Jesse M.\|last2=Walsh\|first2=John L.\|last3=Sandberg\|first3=Warren S.\|date=June 1, 2008\|title=Right- and Left-Sided Mallinckrodt Double-Lumen Tubes Have Identical Clinical Performance\|url=https://journals.lww.com/00000539-200806000-00038\|journal=Anesthesia & Analgesia\|language=en\|volume=106\|issue=6\|pages=1847–1852\|doi=10.1213/ane.0b013e31816f24d5\|issn=0003-2999\|via=}}</ref><ref>{{Cite journal\|last=Ehrenfeld\|first=Jesse M.\|last2=Mulvoy\|first2=William\|last3=Sandberg\|first3=Warren S.\|date=August 1, 2010\|title=Performance Comparison of Right- and Left-Sided Double-Lumen Tubes Among Infrequent Users\|url=https://linkinghub.elsevier.com/retrieve/pii/S1053077009003401\|journal=Journal of Cardiothoracic and Vascular Anesthesia\|language=en\|volume=24\|issue=4\|pages=598–601\|doi=10.1053/j.jvca.2009.09.007\|via=}}</ref>		#* The occurrence of complications or ventilation problems has not been shown to differ with R vs. L DLTs.<ref>{{Cite journal\|last=Ehrenfeld\|first=Jesse M.\|last2=Walsh\|first2=John L.\|last3=Sandberg\|first3=Warren S.\|date=June 1, 2008\|title=Right- and Left-Sided Mallinckrodt Double-Lumen Tubes Have Identical Clinical Performance\|url=https://journals.lww.com/00000539-200806000-00038\|journal=Anesthesia & Analgesia\|language=en\|volume=106\|issue=6\|pages=1847–1852\|doi=10.1213/ane.0b013e31816f24d5\|issn=0003-2999\|via=}}</ref><ref>{{Cite journal\|last=Ehrenfeld\|first=Jesse M.\|last2=Mulvoy\|first2=William\|last3=Sandberg\|first3=Warren S.\|date=August 1, 2010\|title=Performance Comparison of Right- and Left-Sided Double-Lumen Tubes Among Infrequent Users\|url=https://linkinghub.elsevier.com/retrieve/pii/S1053077009003401\|journal=Journal of Cardiothoracic and Vascular Anesthesia\|language=en\|volume=24\|issue=4\|pages=598–601\|doi=10.1053/j.jvca.2009.09.007\|via=}}</ref>
	#* This [https://www.youtube.com/watch?v=I_gZ5UfrFsw video] offers a more comprehensive review of R DLT insertion, indications, advantages and disadvantages.<ref>{{Citation\|last=UCLA Anesthesiology\|first=K. S. Sibert, MD\|title=Why bother to use a RIGHT double lumen tube\|url=https://www.youtube.com/watch?v=I_gZ5UfrFsw\|volume=\|pages=\|language=en\|access-date=2021-11-13}}. </ref>		#* This [https://www.youtube.com/watch?v=I_gZ5UfrFsw video] offers a more comprehensive review of R DLT insertion, indications, advantages and disadvantages.<ref>{{Citation\|last=UCLA Anesthesiology\|first=K. S. Sibert, MD\|title=Why bother to use a RIGHT double lumen tube\|url=https://www.youtube.com/watch?v=I_gZ5UfrFsw\|volume=\|pages=\|language=en\|access-date=2021-11-13}}. </ref>

Karen.Sibert: Added to maintenance section

2021-11-15T06:09:01Z

Added to maintenance section

← Older revision		Revision as of 23:09, 14 November 2021
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	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
	Before beginning one-lung ventilation, the lungs are usually ventilated with 100% FiO2 in order to denitrogenate the lung that will be collapsed. Tidal volume to the ventilated lung should be reduced to approximately 5 ml/kg of ideal body weight, and adjusted to maintain peak airway pressure of less than 25-30 cmH20. A somewhat higher tidal volume may be possible during L-sided procedures, as the R lung has more than 50% of total lung capacity. PEEP may be added at a typical range of 5-8 cmH20 for the ventilated lung, with caution that excessive PEEP may reduce blood pressure and compress alveolar capillaries.		Before beginning one-lung ventilation, the lungs are usually ventilated with 100% FiO2 in order to denitrogenate the lung that will be collapsed. Tidal volume to the ventilated lung should be reduced to approximately 5 ml/kg of ideal body weight, and adjusted to maintain peak airway pressure of less than 25-30 cmH20. A somewhat higher tidal volume may be possible during L-sided procedures, as the R lung has more than 50% of total lung capacity. PEEP may be added at a typical range of 5-8 cmH20 for the ventilated lung, with caution that excessive PEEP may reduce blood pressure and compress alveolar capillaries.

			During robotic-assisted VATS cases, it is common to see an initial drop in blood pressure during the initial insufflation of CO2 into the thorax. This sudden hypotension may be severe, and must be managed with pressors (ephedrine, phenylephrine, norepinephrine) as appropriate depending on the patient's heart rate and other preexisting medical problems. The continuous insufflation of CO2 during robotic-assisted cases invariably leads to a higher baseline end-tidal CO2 than is seen with conventional VATS. Generally, this is well tolerated, and it is not necessary to try to correct it by hyperventilating the ventilated lung.

	The choice of ventilatory mode is at the discretion of the anesthesiologist. Some experienced anesthesiologists prefer pressure-controlled ventilation, and others prefer volume control.		The choice of ventilatory mode is at the discretion of the anesthesiologist. Some experienced anesthesiologists prefer pressure-controlled ventilation, and others prefer volume control.
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	Arrhythmias are not uncommon during VATS, but typically are self-limited if they are due to direct irritation of the heart by surgical instrumentation. If sustained arrhythmia requires treatment, it is important to bear in mind the association of amiodarone with acute pulmonary injury.<ref>{{Cite journal\|last=Brinker\|first=Allen\|last2=Johnston\|first2=Michael\|date=April 1, 2004\|title=Acute pulmonary injury in association with amiodarone\|url=https://pubmed.ncbi.nlm.nih.gov/15078784\|journal=Chest\|volume=125\|issue=4\|pages=1591–1592\|issn=0012-3692\|pmid=15078784\|via=}}</ref> Many thoracic surgeons will include metoprolol or diltiazem in postoperative orders for prevention of atrial fibrillation.		Arrhythmias are not uncommon during VATS, but typically are self-limited if they are due to direct irritation of the heart by surgical instrumentation. If sustained arrhythmia requires treatment, it is important to bear in mind the association of amiodarone with acute pulmonary injury.<ref>{{Cite journal\|last=Brinker\|first=Allen\|last2=Johnston\|first2=Michael\|date=April 1, 2004\|title=Acute pulmonary injury in association with amiodarone\|url=https://pubmed.ncbi.nlm.nih.gov/15078784\|journal=Chest\|volume=125\|issue=4\|pages=1591–1592\|issn=0012-3692\|pmid=15078784\|via=}}</ref> Many thoracic surgeons will include metoprolol or diltiazem in postoperative orders for prevention of atrial fibrillation.

	Restriction of IV crystalloid remains a cornerstone of intraoperative management. As previously noted, acute lung injury (ALI) is a feared complication of lung resection, and carries a high mortality rate if it progresses to full ARDS. ALI is defined as acute hypoxemia accompanied by radiographic pulmonary infiltrates without a clearly identifiable cause, occurring in the first 72 hours post surgery. In 1984, Zeldin and colleagues identified three major causative factors in the development of "post-pneumonectomy pulmonary edema", which we would now recognize as ALI or ARDS: right-sided pneumonectomy, large perioperative fluid load, and high urine output.<ref>{{Cite journal\|last=Zeldin\|first=Robert A.\|last2=Normandin\|first2=Denyse\|last3=Landtwing\|first3=Donna\|last4=Peters\|first4=Richard M.\|date=March 1, 1984\|title=Postpneumonectomy pulmonary edema\|url=http://dx.doi.org/10.1016/s0022-5223(19)37385-4\|journal=The Journal of Thoracic and Cardiovascular Surgery\|volume=87\|issue=3\|pages=359–365\|doi=10.1016/s0022-5223(19)37385-4\|issn=0022-5223\|via=}}</ref> <sup> </sup>At Memorial Sloan-Kettering, a retrospective review of more than 2000 lung resection cases revealed an overall ALI incidence of 2.5%. Mortality was 50% in the post-pneumonectomy patients, and 42% in the post-lobectomy patients. Review of causative factors once again showed perioperative fluid load (more than 3 liters in the first 24 hours) to be a significant risk factor, along with poor preexisting pulmonary function (decreased DLCO and FEV<sub>1</sub>).<ref>{{Cite journal\|last=Alam\|first=Naveed\|last2=Park\|first2=Bernard J.\|last3=Wilton\|first3=Andrew\|last4=Seshan\|first4=Venkatraman E.\|last5=Bains\|first5=Manjit S.\|last6=Downey\|first6=Robert J.\|last7=Flores\|first7=Raja M.\|last8=Rizk\|first8=Nabil\|last9=Rusch\|first9=Valerie W.\|last10=Amar\|first10=David\|date=October 1, 2007\|title=Incidence and Risk Factors for Lung Injury After Lung Cancer Resection\|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497507011472\|journal=The Annals of Thoracic Surgery\|language=en\|volume=84\|issue=4\|pages=1085–1091\|doi=10.1016/j.athoracsur.2007.05.053\|via=}}</ref> Other risk factors include neoadjuvant chemotherapy, and/or radiation therapy.		Restriction of IV crystalloid remains a cornerstone of intraoperative management. As previously noted, acute lung injury (ALI) is a feared complication of lung resection, and carries a high mortality rate if it progresses to full ARDS. ALI is defined as acute hypoxemia accompanied by radiographic pulmonary infiltrates without a clearly identifiable cause, occurring in the first 72 hours post surgery. In 1984, Zeldin and colleagues identified three major causative factors in the development of "post-pneumonectomy pulmonary edema", which we would now recognize as ALI or ARDS: right-sided pneumonectomy, large perioperative fluid load, and high urine output.<ref>{{Cite journal\|last=Zeldin\|first=Robert A.\|last2=Normandin\|first2=Denyse\|last3=Landtwing\|first3=Donna\|last4=Peters\|first4=Richard M.\|date=March 1, 1984\|title=Postpneumonectomy pulmonary edema\|url=http://dx.doi.org/10.1016/s0022-5223(19)37385-4\|journal=The Journal of Thoracic and Cardiovascular Surgery\|volume=87\|issue=3\|pages=359–365\|doi=10.1016/s0022-5223(19)37385-4\|issn=0022-5223\|via=}}</ref> <sup> </sup>At Memorial Sloan-Kettering, a retrospective review of more than 2000 lung resection cases revealed an overall ALI incidence of 2.5%. Mortality was 50% in the post-pneumonectomy patients, and 42% in the post-lobectomy patients. Review of causative factors once again showed perioperative fluid load (more than 3 liters in the first 24 hours) to be a significant risk factor, along with poor preexisting pulmonary function (decreased DLCO and FEV<sub>1</sub>).<ref>{{Cite journal\|last=Alam\|first=Naveed\|last2=Park\|first2=Bernard J.\|last3=Wilton\|first3=Andrew\|last4=Seshan\|first4=Venkatraman E.\|last5=Bains\|first5=Manjit S.\|last6=Downey\|first6=Robert J.\|last7=Flores\|first7=Raja M.\|last8=Rizk\|first8=Nabil\|last9=Rusch\|first9=Valerie W.\|last10=Amar\|first10=David\|date=October 1, 2007\|title=Incidence and Risk Factors for Lung Injury After Lung Cancer Resection\|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497507011472\|journal=The Annals of Thoracic Surgery\|language=en\|volume=84\|issue=4\|pages=1085–1091\|doi=10.1016/j.athoracsur.2007.05.053\|via=}}</ref> Other risk factors include neoadjuvant chemotherapy and/or radiation therapy.

	No subsequent study has disproved the value of being conservative with fluid administration, especially crystalloid, during lung resection. Blood transfusion may be required in some cases, but carries the additional risk of transfusion-related acute lung injury (TRALI).		No subsequent study has disproved the value of being conservative with fluid administration, especially crystalloid, during lung resection. Blood transfusion may be required in some cases, but carries the additional risk of transfusion-related acute lung injury (TRALI).

Karen.Sibert at 21:32, 14 November 2021

2021-11-14T21:32:47Z

← Older revision		Revision as of 14:32, 14 November 2021
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	=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===

	# Double-lumen endotracheal tube (DLT) or endobronchial blocker<ref>{{Cite web\|title=Best of ATS Video Lecture Series\|url=https://www.thoracic.org/professionals/clinical-resources/video-lecture-series/bronchoscopy/endobronchial-blocker-placement.php\|access-date=2021-11-13\|website=www.thoracic.org}}</ref> as appropriate		# Double-lumen endotracheal tube (DLT) or endobronchial blocker<ref>{{Cite web\|title=Best of ATS Video Lecture Series: Endobronchial Blocker Placement\|url=https://www.thoracic.org/professionals/clinical-resources/video-lecture-series/bronchoscopy/endobronchial-blocker-placement.php\|access-date=2021-11-13\|website=www.thoracic.org\|date=\|last=\|first=\|archive-url=\|archive-date=\|url-status=live}}</ref> as appropriate
	# Fiberoptic bronchoscope		# Fiberoptic bronchoscope
	# Video laryngoscope to facilitate DLT insertion		# Video laryngoscope to facilitate DLT insertion

Karen.Sibert: Added a reference on analgesia

2021-11-14T21:31:04Z

Added a reference on analgesia

Karen.Sibert at 00:21, 14 November 2021

2021-11-14T00:21:58Z

← Older revision		Revision as of 17:21, 13 November 2021
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	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
	Before beginning one-lung ventilation, the ~~patient is~~ usually ventilated with 100% FiO2 in order to denitrogenate the lung that will be collapsed. Tidal volume to the ventilated lung should be reduced to approximately 5 ml/kg of ideal body weight, and adjusted to maintain peak airway pressure of less than 25-30 cmH20. A somewhat higher tidal volume may be possible during L-sided procedures, as the R lung has more than 50% of total lung capacity. PEEP may be added at a typical range of 5-8 cmH20 for the ventilated lung, with caution that excessive PEEP may reduce blood pressure and compress alveolar capillaries.		Before beginning one-lung ventilation, the lungs are usually ventilated with 100% FiO2 in order to denitrogenate the lung that will be collapsed. Tidal volume to the ventilated lung should be reduced to approximately 5 ml/kg of ideal body weight, and adjusted to maintain peak airway pressure of less than 25-30 cmH20. A somewhat higher tidal volume may be possible during L-sided procedures, as the R lung has more than 50% of total lung capacity. PEEP may be added at a typical range of 5-8 cmH20 for the ventilated lung, with caution that excessive PEEP may reduce blood pressure and compress alveolar capillaries.

	The choice of ventilatory mode is at the discretion of the anesthesiologist. Some experienced anesthesiologists prefer pressure-controlled ventilation, and others prefer volume control.		The choice of ventilatory mode is at the discretion of the anesthesiologist. Some experienced anesthesiologists prefer pressure-controlled ventilation, and others prefer volume control.

Karen.Sibert at 22:28, 13 November 2021

2021-11-13T22:28:59Z

Karen.Sibert: Added to postop section

2021-11-13T21:32:24Z

Added to postop section

← Older revision		Revision as of 14:32, 13 November 2021
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	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
			Effective pain management utilizes a multimodal approach, including non-narcotic analgesics and regional techniques, to avoid respiratory depression and encourage early mobilization.

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
			The potential complications and postoperative sequelae of VATS are variable depending on the exact surgical procedure:

	~~== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table~~ to ~~very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +~~, ~~–, additional symbols such~~ as ↑ and ~~↓ are available using the "Ω" tool in the editor). --> ==~~		* Acute lung injury
			* Injury to airway from traumatic DLT insertion
	~~{\| class="wikitable wikitable-horizontal-scroll"~~		* Arrhythmia, especially atrial fibrillation
	\|+		* Anastamotic leak after esophagectomy; mediastinitis
	!		* Hypotension as a result of inadequate volume replacement and/or epidural analgesia
	~~!Variant 1~~		* Persistent air leak; bronchopleural fistula
	~~!Variant 2~~		* Positioning injury
	\|-		* Respiratory depression/failure
	~~\|Unique considerations~~		* Post-surgical bleeding
	\|		* Acute kidney injury
	\|
	\|-
	~~\|Position~~
	\|
	\|
	\|-
	~~\|Surgical time~~
	\|
	\|
	\|-
	~~\|EBL~~
	\|
	\|
	\|-
	~~\|Postoperative disposition~~
	\|
	\|
	\|-
	~~\|Pain management~~
	\|
	\|
	\|-
	~~\|Potential complications~~
	\|
	\|
	\|}

	== References ==		== References ==

	[[Category:Surgical procedures]]		[[Category:Surgical procedures]]

← Older revision		Revision as of 14:31, 14 November 2021
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	Nearly any patient may be a candidate regardless of extremes of age or pulmonary disease.		Nearly any patient may be a candidate regardless of extremes of age or pulmonary disease.

	Procedures usually requiring open thoracotomy include pneumonectomy, intrathoracic tracheal resection, and chest wall resection.		Procedures usually requiring open thoracotomy as opposed to VATS include pneumonectomy, intrathoracic tracheal resection, and chest wall resection.

	The advantages of VATS include decreased hospital length of stay, decreased morbidity, and less postoperative pain.		The advantages of VATS include decreased hospital length of stay, decreased morbidity, and less postoperative pain.
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	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
	\|Evidence of ventricular or valvular dysfunction, pulmonary hypertension		\|Evidence of ventricular or valvular dysfunction, coronary disease, pulmonary hypertension
	\|-		\|-
	\|Respiratory		\|Respiratory
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	=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===		=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
	Thoracic epidural analgesia may be considered especially if bilateral VATS is undertaken or if the surgeon thinks there is a high likelihood that conversion to open thoracotomy may be necessary.		Thoracic epidural analgesia may be considered especially if bilateral VATS is undertaken or if the surgeon thinks there is a high likelihood that conversion to open thoracotomy may be necessary<ref>{{Cite journal\|last=Liang\|first=Xiao-Long\|last2=An\|first2=Ran\|last3=Chen\|first3=Qi\|last4=Liu\|first4=Hong-Liang\|date=March 26, 2021\|title=The Analgesic Effects of Thoracic Paravertebral Block versus Thoracic Epidural Anesthesia After Thoracoscopic Surgery: A Meta-Analysis\|url=https://www.dovepress.com/the-analgesic-effects-of-thoracic-paravertebral-block-versus-thoracic--peer-reviewed-article-JPR\|journal=Journal of Pain Research\|language=en\|volume=Volume 14\|pages=815–825\|doi=10.2147/JPR.S299595\|issn=1178-7090\|pmc=\|pmid=33814927\|via=}}</ref>.

	The epidural catheter should be inserted at a high enough level that the patient will not have any lumbar motor block and can safely ambulate. Insertion prior to surgery offers the advantage of beginning continuous epidural infusion before the patient emerges from anesthesia. Some anesthesiologists prefer to utilize the epidural infusion along with general anesthesia for the entire case. Others prefer to activate the epidural catheter only near the end of surgery once blood loss is over in order to avoid intraoperative hypotension. There is no conclusive evidence that either approach is superior.		The epidural catheter should be inserted at a high enough level that the patient will not have any lumbar motor block and can safely ambulate. Insertion prior to surgery offers the advantage of beginning continuous epidural infusion before the patient emerges from anesthesia. Some anesthesiologists prefer to utilize the epidural infusion along with general anesthesia for the entire case. Others prefer to activate the epidural catheter only near the end of surgery once blood loss is over in order to avoid intraoperative hypotension. There is no conclusive evidence that either approach is superior.
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	# During any resection of the left lung, several factors argue in favor of placing a R DLT as opposed to a L DLT or L bronchial blocker:		# During any resection of the left lung, several factors argue in favor of placing a R DLT as opposed to a L DLT or L bronchial blocker:
	#* There is no risk of stapling the tube or the endobronchial blocker to the bronchus during lobectomy or pneumonectomy, which can lead to serious or fatal complications.		#* There is no risk of stapling the tube or the endobronchial blocker to the bronchus during lobectomy or pneumonectomy, which can lead to serious or fatal complications.
	#* If the tracheal cuff of the DLT tears on the patient’s molars during intubation, the bronchial cuff will still guarantee lung isolation.		#* If the tracheal cuff of the R DLT tears on the patient’s molars during intubation, the bronchial cuff will still guarantee lung isolation.
	#* The tracheal lumen is the one occluded during lung isolation, so it is easy to look down the tracheal lumen with a bronchoscope to check the position of the blue (bronchial) cuff without interrupting ventilation.		#* The tracheal lumen is the one occluded during lung isolation, so it is easy to look down the tracheal lumen with a bronchoscope to check the position of the blue (bronchial) cuff without interrupting ventilation.
	#* With left lung surgery and a left DLT, the tracheal orifice (which is now in the dependent or posterior position after the patient is positioned R lateral decubitus) may be pushed against the tracheal wall and occluded.		#* With left lung surgery and a left DLT, the tracheal orifice (which is now in the dependent or posterior position after the patient is positioned R lateral decubitus) may be pushed against the tracheal wall and occluded.
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	Arrhythmias are not uncommon during VATS, but typically are self-limited if they are due to direct irritation of the heart by surgical instrumentation. If sustained arrhythmia requires treatment, it is important to bear in mind the association of amiodarone with acute pulmonary injury.<ref>{{Cite journal\|last=Brinker\|first=Allen\|last2=Johnston\|first2=Michael\|date=April 1, 2004\|title=Acute pulmonary injury in association with amiodarone\|url=https://pubmed.ncbi.nlm.nih.gov/15078784\|journal=Chest\|volume=125\|issue=4\|pages=1591–1592\|issn=0012-3692\|pmid=15078784\|via=}}</ref> Many thoracic surgeons will include metoprolol or diltiazem in postoperative orders for prevention of atrial fibrillation.		Arrhythmias are not uncommon during VATS, but typically are self-limited if they are due to direct irritation of the heart by surgical instrumentation. If sustained arrhythmia requires treatment, it is important to bear in mind the association of amiodarone with acute pulmonary injury.<ref>{{Cite journal\|last=Brinker\|first=Allen\|last2=Johnston\|first2=Michael\|date=April 1, 2004\|title=Acute pulmonary injury in association with amiodarone\|url=https://pubmed.ncbi.nlm.nih.gov/15078784\|journal=Chest\|volume=125\|issue=4\|pages=1591–1592\|issn=0012-3692\|pmid=15078784\|via=}}</ref> Many thoracic surgeons will include metoprolol or diltiazem in postoperative orders for prevention of atrial fibrillation.

	As previously noted, acute lung injury (ALI) ~~remains~~ a feared complication of lung resection, and carries a high mortality rate if it progresses to full ARDS. ALI is defined as acute hypoxemia accompanied by radiographic pulmonary infiltrates without a clearly identifiable cause, occurring in the first 72 hours post surgery. In 1984, Zeldin and colleagues identified three major causative factors in the development of post-pneumonectomy pulmonary edema: right-sided pneumonectomy, large perioperative fluid load, and high urine output.<ref>{{Cite journal\|last=Zeldin\|first=Robert A.\|last2=Normandin\|first2=Denyse\|last3=Landtwing\|first3=Donna\|last4=Peters\|first4=Richard M.\|date=March 1, 1984\|title=Postpneumonectomy pulmonary edema\|url=http://dx.doi.org/10.1016/s0022-5223(19)37385-4\|journal=The Journal of Thoracic and Cardiovascular Surgery\|volume=87\|issue=3\|pages=359–365\|doi=10.1016/s0022-5223(19)37385-4\|issn=0022-5223\|via=}}</ref> <sup> </sup>At Memorial Sloan-Kettering, a retrospective review of more than 2000 lung resection cases revealed an overall ALI incidence of 2.5%. Mortality was 50% in the post-pneumonectomy patients, and 42% in the post-lobectomy patients. ~~Review~~ of causative factors once again showed perioperative fluid load (more than 3 liters in the first 24 hours) to be a significant risk factor, along with poor preexisting pulmonary function (decreased DLCO and FEV<sub>1</sub>).<ref>{{Cite journal\|last=Alam\|first=Naveed\|last2=Park\|first2=Bernard J.\|last3=Wilton\|first3=Andrew\|last4=Seshan\|first4=Venkatraman E.\|last5=Bains\|first5=Manjit S.\|last6=Downey\|first6=Robert J.\|last7=Flores\|first7=Raja M.\|last8=Rizk\|first8=Nabil\|last9=Rusch\|first9=Valerie W.\|last10=Amar\|first10=David\|date=October 1, 2007\|title=Incidence and Risk Factors for Lung Injury After Lung Cancer Resection\|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497507011472\|journal=The Annals of Thoracic Surgery\|language=en\|volume=84\|issue=4\|pages=1085–1091\|doi=10.1016/j.athoracsur.2007.05.053\|via=}}</ref> Other risk factors include neoadjuvant chemotherapy, radiation therapy~~, and transfusion~~.		Restriction of IV crystalloid remains a cornerstone of intraoperative management. As previously noted, acute lung injury (ALI) is a feared complication of lung resection, and carries a high mortality rate if it progresses to full ARDS. ALI is defined as acute hypoxemia accompanied by radiographic pulmonary infiltrates without a clearly identifiable cause, occurring in the first 72 hours post surgery. In 1984, Zeldin and colleagues identified three major causative factors in the development of "post-pneumonectomy pulmonary edema", which we would now recognize as ALI or ARDS: right-sided pneumonectomy, large perioperative fluid load, and high urine output.<ref>{{Cite journal\|last=Zeldin\|first=Robert A.\|last2=Normandin\|first2=Denyse\|last3=Landtwing\|first3=Donna\|last4=Peters\|first4=Richard M.\|date=March 1, 1984\|title=Postpneumonectomy pulmonary edema\|url=http://dx.doi.org/10.1016/s0022-5223(19)37385-4\|journal=The Journal of Thoracic and Cardiovascular Surgery\|volume=87\|issue=3\|pages=359–365\|doi=10.1016/s0022-5223(19)37385-4\|issn=0022-5223\|via=}}</ref> <sup> </sup>At Memorial Sloan-Kettering, a retrospective review of more than 2000 lung resection cases revealed an overall ALI incidence of 2.5%. Mortality was 50% in the post-pneumonectomy patients, and 42% in the post-lobectomy patients. Review of causative factors once again showed perioperative fluid load (more than 3 liters in the first 24 hours) to be a significant risk factor, along with poor preexisting pulmonary function (decreased DLCO and FEV<sub>1</sub>).<ref>{{Cite journal\|last=Alam\|first=Naveed\|last2=Park\|first2=Bernard J.\|last3=Wilton\|first3=Andrew\|last4=Seshan\|first4=Venkatraman E.\|last5=Bains\|first5=Manjit S.\|last6=Downey\|first6=Robert J.\|last7=Flores\|first7=Raja M.\|last8=Rizk\|first8=Nabil\|last9=Rusch\|first9=Valerie W.\|last10=Amar\|first10=David\|date=October 1, 2007\|title=Incidence and Risk Factors for Lung Injury After Lung Cancer Resection\|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497507011472\|journal=The Annals of Thoracic Surgery\|language=en\|volume=84\|issue=4\|pages=1085–1091\|doi=10.1016/j.athoracsur.2007.05.053\|via=}}</ref> Other risk factors include neoadjuvant chemotherapy, and/or radiation therapy.

	No subsequent study has disproved the value of being conservative with fluid administration, especially crystalloid, during lung resection. Blood transfusion may be required in some cases, but carries the additional risk of transfusion-related acute lung injury (TRALI).		No subsequent study has disproved the value of being conservative with fluid administration, especially crystalloid, during lung resection. Blood transfusion may be required in some cases, but carries the additional risk of transfusion-related acute lung injury (TRALI).
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	Emergence from general anesthesia for VATS requires the usual precautions: complete reversal of muscle relaxants, adequate control of pain, and demonstration of satisfactory respiratory mechanics prior to extubation. In some cases where pulmonary function is poor and there are copious secretions in the large airways, it may be beneficial to change the DLT to a single-lumen ETT to allow bronchoscopy, bronchial lavage, and thorough suctioning before emergence.		Emergence from general anesthesia for VATS requires the usual precautions: complete reversal of muscle relaxants, adequate control of pain, and demonstration of satisfactory respiratory mechanics prior to extubation. In some cases where pulmonary function is poor and there are copious secretions in the large airways, it may be beneficial to change the DLT to a single-lumen ETT to allow bronchoscopy, bronchial lavage, and thorough suctioning before emergence.

	It is always preferable to extubate the trachea in any case of lung resection, as postoperative mechanical ventilation increases the risk of ~~rupturing~~ the fresh bronchial ~~stump~~ and creating a bronchopleural fistula. Deep vs. awake extubation is at the discretion of the anesthesiologist. Some anesthesiologists prefer to extubate with the patient in the lateral position to preserve the advantages of increased ventilation and perfusion to the nonoperative (dependent) lung.		It is always preferable to extubate the trachea in any case of lung resection, as postoperative mechanical ventilation increases the risk of developing a leak in the fresh bronchial staple line and creating a bronchopleural fistula. Deep vs. awake extubation is at the discretion of the anesthesiologist. Some anesthesiologists prefer to extubate with the patient in the lateral position to preserve the advantages of increased ventilation and perfusion to the nonoperative (dependent) lung.

	== Postoperative management ==		== Postoperative management ==

← Older revision		Revision as of 15:28, 13 November 2021
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	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type = General ~~(rarely, monitored anesthesia care for selected cases)~~		\| anesthesia_type = General
	\| airway = Double-lumen endotracheal tube or ~~bronchial~~ blocker		\| airway = Double-lumen endotracheal tube or endobronchial blocker
	\| lines_access = Adequate peripheral IV access; consider arterial line		\| lines_access = Adequate peripheral IV access; consider arterial line
	\| monitors = Standard; consider arterial monitoring		\| monitors = Standard; consider arterial monitoring
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	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
	Before beginning one-lung ventilation, the patient is usually ventilated with 100% FiO2 in order to denitrogenate the lung that will be collapsed. Tidal volume to the ventilated lung should be reduced to approximately 5 ml/kg of ideal body weight, and adjusted to maintain peak airway pressure of less than 25-30 cmH20. A somewhat higher tidal volume may be possible during L-sided procedures, as the R lung has more than 50% of total lung capacity. PEEP may be added at a typical range of 5-8 cmH20 for the ventilated lung, with caution that excessive PEEP may reduce blood pressure and compress alveolar capillaries.		Before beginning one-lung ventilation, the patient is usually ventilated with 100% FiO2 in order to denitrogenate the lung that will be collapsed. Tidal volume to the ventilated lung should be reduced to approximately 5 ml/kg of ideal body weight, and adjusted to maintain peak airway pressure of less than 25-30 cmH20. A somewhat higher tidal volume may be possible during L-sided procedures, as the R lung has more than 50% of total lung capacity. PEEP may be added at a typical range of 5-8 cmH20 for the ventilated lung, with caution that excessive PEEP may reduce blood pressure and compress alveolar capillaries.

	The choice of ventilatory mode is at the discretion of the anesthesiologist. Some experienced anesthesiologists prefer pressure-controlled ventilation, and others prefer volume control.		The choice of ventilatory mode is at the discretion of the anesthesiologist. Some experienced anesthesiologists prefer pressure-controlled ventilation, and others prefer volume control.

	After the onset of one-lung ventilation, it is normal to see a decrease in SaO2 over the first 20-30 minutes.<ref>{{Cite journal\|last=Karzai\|first=Waheedullah\|last2=Schwarzkopf\|first2=Konrad\|date=2009-06-01\|title=Hypoxemia during One-lung Ventilation: Prediction, Prevention, and Treatment\|url=https://doi.org/10.1097/ALN.0b013e31819fb15d\|journal=Anesthesiology\|volume=110\|issue=6\|pages=1402–1411\|doi=10.1097/ALN.0b013e31819fb15d\|issn=0003-3022}}</ref> The process of hypoxic pulmonary vasoconstriction (HPV) is not instantaneous.<ref>{{Cite journal\|last=Lumb\|first=Andrew B.\|last2=Slinger\|first2=Peter\|date=2015-04-01\|title=Hypoxic Pulmonary Vasoconstriction: Physiology and Anesthetic Implications\|url=https://doi.org/10.1097/ALN.0000000000000569\|journal=Anesthesiology\|volume=122\|issue=4\|pages=932–946\|doi=10.1097/ALN.0000000000000569\|issn=0003-3022}}</ref> If the SaO2 declines to an unacceptable level, additional PEEP may be added to the ventilated lung or CPAP applied to the operative lung. However, it should be noted that adding CPAP to the operative lung may obscure the surgeon's view to an unacceptable degree, and this technique should be used for the minimal time necessary. As HPV takes effect, the SaO2 often improves without intervention. During lung resection, surgical clamping of the lobar or pulmonary artery results in prompt improvement of V/Q mismatch and SaO2 rises accordingly.		After the onset of one-lung ventilation, it is normal to see a decrease in SaO2 over the first 20-30 minutes.<ref>{{Cite journal\|last=Karzai\|first=Waheedullah\|last2=Schwarzkopf\|first2=Konrad\|date=2009-06-01\|title=Hypoxemia during One-lung Ventilation: Prediction, Prevention, and Treatment\|url=https://doi.org/10.1097/ALN.0b013e31819fb15d\|journal=Anesthesiology\|volume=110\|issue=6\|pages=1402–1411\|doi=10.1097/ALN.0b013e31819fb15d\|issn=0003-3022}}</ref> The process of hypoxic pulmonary vasoconstriction (HPV) is not instantaneous.<ref>{{Cite journal\|last=Lumb\|first=Andrew B.\|last2=Slinger\|first2=Peter\|date=2015-04-01\|title=Hypoxic Pulmonary Vasoconstriction: Physiology and Anesthetic Implications\|url=https://doi.org/10.1097/ALN.0000000000000569\|journal=Anesthesiology\|volume=122\|issue=4\|pages=932–946\|doi=10.1097/ALN.0000000000000569\|issn=0003-3022}}</ref> If the SaO2 declines to an unacceptable level, additional PEEP may be added to the ventilated lung or CPAP applied to the operative lung. However, it should be noted that adding CPAP to the operative lung may obscure the surgeon's view to an unacceptable degree, and this technique should be used for the minimal time necessary. As HPV takes effect, the SaO2 often improves without intervention. During lung resection, surgical clamping of the lobar or pulmonary artery results in prompt improvement of V/Q mismatch and SaO2 rises accordingly.

			Air may be added to the fresh gas inflow at the anesthesiologist's discretion after SaO2 has stabilized. If the patient has risk factors for acute lung injury such as previous chemotherapy with bleomycin, the FiO2 should be decreased as promptly as possible. With a properly positioned DLT, FiO2 as low as 35-40% may be tolerated with acceptable SaO2 around 90%.

	The choice of maintenance technique for general anesthesia favors inhalation anesthesia over total intravenous anesthesia (TIVA). In addition to the beneficial bronchodilating effects of volatile anesthetics, both desflurane and sevoflurane have been found to suppress the alveolar proinflammatory effects of one-lung ventilation compared with TIVA.<ref>{{Cite journal\|last=Schilling\|first=T.\|last2=Kozian\|first2=A.\|last3=Kretzschmar\|first3=M.\|last4=Huth\|first4=C.\|last5=Welte\|first5=T.\|last6=Bühling\|first6=F.\|last7=Hedenstierna\|first7=G.\|last8=Hachenberg\|first8=T.\|date=September 1, 2007\|title=Effects of propofol and desflurane anaesthesia on the alveolar inflammatory response to one-lung ventilation\|url=http://dx.doi.org/10.1093/bja/aem184\|journal=British Journal of Anaesthesia\|volume=99\|issue=3\|pages=368–375\|doi=10.1093/bja/aem184\|issn=0007-0912\|via=}}</ref><ref>{{Cite journal\|last=Schilling\|first=Thomas\|last2=Kozian\|first2=Alf\|last3=Senturk\|first3=Mert\|last4=Huth\|first4=Christof\|last5=Reinhold\|first5=Annegret\|last6=Hedenstierna\|first6=Göran\|last7=Hachenberg\|first7=Thomas\|date=2011-07-01\|title=Effects of Volatile and Intravenous Anesthesia on the Alveolar and Systemic Inflammatory Response in Thoracic Surgical Patients\|url=https://pubs.asahq.org/anesthesiology/article/115/1/65/12793/Effects-of-Volatile-and-Intravenous-Anesthesia-on\|journal=Anesthesiology\|language=en\|volume=115\|issue=1\|pages=65–74\|doi=10.1097/ALN.0b013e318214b9de\|issn=0003-3022}}</ref><ref>{{Cite journal\|last=Lohser\|first=Jens\|last2=Slinger\|first2=Peter\|date=August 1, 2015\|title=Lung Injury After One-Lung Ventilation: A Review of the Pathophysiologic Mechanisms Affecting the Ventilated and the Collapsed Lung\|url=https://journals.lww.com/00000539-201508000-00008\|journal=Anesthesia & Analgesia\|language=en\|volume=121\|issue=2\|pages=302–318\|doi=10.1213/ANE.0000000000000808\|issn=0003-2999\|via=}}</ref>		The choice of maintenance technique for general anesthesia favors inhalation anesthesia over total intravenous anesthesia (TIVA). In addition to the beneficial bronchodilating effects of volatile anesthetics, both desflurane and sevoflurane have been found to suppress the alveolar proinflammatory effects of one-lung ventilation compared with TIVA.<ref>{{Cite journal\|last=Schilling\|first=T.\|last2=Kozian\|first2=A.\|last3=Kretzschmar\|first3=M.\|last4=Huth\|first4=C.\|last5=Welte\|first5=T.\|last6=Bühling\|first6=F.\|last7=Hedenstierna\|first7=G.\|last8=Hachenberg\|first8=T.\|date=September 1, 2007\|title=Effects of propofol and desflurane anaesthesia on the alveolar inflammatory response to one-lung ventilation\|url=http://dx.doi.org/10.1093/bja/aem184\|journal=British Journal of Anaesthesia\|volume=99\|issue=3\|pages=368–375\|doi=10.1093/bja/aem184\|issn=0007-0912\|via=}}</ref><ref>{{Cite journal\|last=Schilling\|first=Thomas\|last2=Kozian\|first2=Alf\|last3=Senturk\|first3=Mert\|last4=Huth\|first4=Christof\|last5=Reinhold\|first5=Annegret\|last6=Hedenstierna\|first6=Göran\|last7=Hachenberg\|first7=Thomas\|date=2011-07-01\|title=Effects of Volatile and Intravenous Anesthesia on the Alveolar and Systemic Inflammatory Response in Thoracic Surgical Patients\|url=https://pubs.asahq.org/anesthesiology/article/115/1/65/12793/Effects-of-Volatile-and-Intravenous-Anesthesia-on\|journal=Anesthesiology\|language=en\|volume=115\|issue=1\|pages=65–74\|doi=10.1097/ALN.0b013e318214b9de\|issn=0003-3022}}</ref><ref>{{Cite journal\|last=Lohser\|first=Jens\|last2=Slinger\|first2=Peter\|date=August 1, 2015\|title=Lung Injury After One-Lung Ventilation: A Review of the Pathophysiologic Mechanisms Affecting the Ventilated and the Collapsed Lung\|url=https://journals.lww.com/00000539-201508000-00008\|journal=Anesthesia & Analgesia\|language=en\|volume=121\|issue=2\|pages=302–318\|doi=10.1213/ANE.0000000000000808\|issn=0003-2999\|via=}}</ref>
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	Emergence from general anesthesia for VATS requires the usual precautions: complete reversal of muscle relaxants, adequate control of pain, and demonstration of satisfactory respiratory mechanics prior to extubation. In some cases where pulmonary function is poor and there are copious secretions in the large airways, it may be beneficial to change the DLT to a single-lumen ETT to allow bronchoscopy, bronchial lavage, and thorough suctioning before emergence.		Emergence from general anesthesia for VATS requires the usual precautions: complete reversal of muscle relaxants, adequate control of pain, and demonstration of satisfactory respiratory mechanics prior to extubation. In some cases where pulmonary function is poor and there are copious secretions in the large airways, it may be beneficial to change the DLT to a single-lumen ETT to allow bronchoscopy, bronchial lavage, and thorough suctioning before emergence.

	It is always preferable to extubate the trachea in any case of lung resection, as postoperative mechanical ventilation increases the risk of rupturing the fresh bronchial stump and creating a bronchopleural fistula. Deep vs. awake extubation is at the discretion of the anesthesiologist. Some anesthesiologists prefer to extubate with the patient in the lateral position to preserve the ~~advantges~~ of ventilation and perfusion to the nonoperative (dependent) lung.		It is always preferable to extubate the trachea in any case of lung resection, as postoperative mechanical ventilation increases the risk of rupturing the fresh bronchial stump and creating a bronchopleural fistula. Deep vs. awake extubation is at the discretion of the anesthesiologist. Some anesthesiologists prefer to extubate with the patient in the lateral position to preserve the advantages of increased ventilation and perfusion to the nonoperative (dependent) lung.

	== Postoperative management ==		== Postoperative management ==

	=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===		=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
	Whether the patient needs intensive care in the postoperative period will depend on several factors: the magnitude of the surgical procedure, whether or not ~~extubtion~~ is possible, any continuing need for invasive monitoring, and the patient's underlying risk factors. Some centers send post-VATS patients routinely to a non-ICU ward where the nursing staff is experienced in the care of chest tubes and continuous monitoring of pulse oximetry and capnography ~~are available~~.		Whether the patient needs intensive care in the postoperative period will depend on several factors: the magnitude of the surgical procedure, whether or not extubation is possible, any continuing need for invasive monitoring, and the patient's underlying risk factors. Some centers send post-VATS patients routinely to a non-ICU ward, where the nursing staff is experienced in the care of chest tubes, and continuous monitoring is available with pulse oximetry and capnography.

	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===