Updates in Thoracic Anesthesia

Educational Objectives

The goal of this program is to improve the outcomes of thoracic anesthesia. After hearing and assimilating this program, the clinician will be better able to:

1. Assess evidence regarding the effect of enhanced recovery after surgery in thoracic surgery.
2. Compare epidural and intercostal blocks in thoracic anesthesia.

Summary

Thoracic enhanced recovery after surgery (ERAS): is also known as enhanced recovery after thoracic surgery (ERATS); ERAS and fast track anesthesia are related, but differ significantly; fast track is focuses on recovery quantity (time to extubation, discharge); ERAS emphasizes quality of recovery (time to return to functional baseline), and spans the entire perioperative period; study from Switzerland (Forster et al [2021]) reported a high rate of compliance (≈80%); the study found significantly shorter length of stay and reduction in cardiopulmonary complications by 13% in the ERAS group following video assisted thoracic surgery (lobectomy); there was no change in the admission rate; Khoury et al (2021) in a systematic review and meta-analysis found that ERAS decreased hospital length of stay (3 days), postoperative complications, and readmission rates; Rogers et al (2018) reported improved outcomes with increased compliance; 2 key aspects of ERAS includes protocol compliance and multimodal analgesia for effective pain management

Updates in analgesia: patients with uncontrolled pain may have ineffective cough, which leads to respiratory failure; post-thoracotomy pain syndrome is debilitating and costly; patients undergoing thoracic surgery have 2.5 times increased rate of opioid dependence; Makkad et al (2025) reviewed different elements of analgesia for thoracic surgery

Analgesia receptors: there are several receptors to target for thoracic analgesia; epidural anesthesia — benefits include dense analgesia for large incisions, reduced postoperative cardiac morbidity and mortality, and decreased pneumonia; drawbacks are hypotension, dural puncture, hematoma, and epidural abscess; patients on anticoagulation are ineligible; given the shift towards minimally invasive surgery, anesthesia techniques must evolve; Van Haren et al (2018) reported significant reduction in epidural usage (76%–3%) after implementation of ERAS propensity-matched study (Yamazaki et al [2022]) showed that intercostal blocks yielded lower pain scores compared with epidurals because epidurals were removed on post-operative day 1 leading to rebound pain; van den Broek et al (2025) found that continuous erector spinae plane (ESP) was non-inferior to epidurals; Moorthy et al (2023) found similar pain scores with ESP and paravertebral block, but superior quality of recovery in the ESP group

Practice pearls: choice depends on patient eligibility, institutional resources and provider familiarity

Lung-protective ventilation: the rate of pulmonary complications after thoracic surgery is 15% to 30%; Blank et al (2016) found that lower tidal volumes reduced complications when paired with positive end-expiratory pressure (PEEP) of ≥5 cm water; Colquhoun et al (2021) reported no association between tidal volume and complications

Driving pressure: correlates with outcomes in nonthoracic surgeries (acute respiratory distress syndrome); multicenter trial (Park et al [2023]) investigated driving pressure-guided ventilation in patients undergoing lung resection surgery; driving pressure-guided ventilation did not reduce complications, but improved intraoperative pulmonary mechanics (better compliance, oxygenation, and reduced need for rescue ventilation)

Mechanical energy: incorporating tidal volume, pressures, PEEP, and respiratory rate represents the cumulative mechanical power delivered over time, and may be a more comprehensive metric for assessing ventilation strategies; evidence suggests that mechanical energy increases the risk for postoperative pulmonary complications

Positive end-expiratory pressure: the goal is to provide enough PEEP to prevent atelectasis without causing over distension; individualizing PEEP settings is beneficial; techniques, eg, measuring esophageal pressure to optimize transpulmonary pressure or performing PEEP decrement have been explored; no single method is superior

Practice pearls: use tidal volumes based on ideal body weight (4–6 mL/kg during one-lung ventilation), individualize PEEP, and minimize peak airway pressures

Fluid management: traditionally, surgeons were taught to keep the lungs dry; patients undergoing thoracic surgeries are vulnerable to lung injury because of underlying disease, mechanical ventilation, and surgical stress; overtly restrictive fluid strategies may increase the risk for lung injury

Goals for fluid management: preoperatively, patients must be hydrated and metabolically stable; allowing clear liquids ≤2 hr prior to surgery or “sip till send” strategy may improve patient satisfaction; carbohydrate loading may help with insulin resistance and comfort; postoperatively, patients must resume oral intake as soon as feasible; intraoperatively, ERAS guidelines recommend euvolemia

Goal-directed fluid therapy: in thoracic surgery is complicated with unreliable end points; urine output, and mean arterial pressure are poor predictors; dynamic monitors, eg, pulse pressure variation, stroke volume variation have limited utility because of lateral positioning and one-lung ventilation; Wang et al (2023) confirmed these findings; Licker et al (2021) suggests the administration of 4 to 8 mL/kg per hr of fluid for open procedures, less for minimally invasive surgeries, and resume enteral feeding early in the post-operative period

Readings

Blank RS, Colquhoun DA, Durieux ME, et al. Management of one-lung ventilation: impact of tidal volume on complications after thoracic surgery. Anesthesiology. 2016;124(6):1286-1295. doi:10.1097/ALN.0000000000001100; Colquhoun DA, Leis AM, Shanks AM, et al. A lower tidal volume regimen during one-lung ventilation for lung resection surgery is not associated with reduced postoperative pulmonary complications. Anesthesiology. 2021;134(4):562-576. doi:10.1097/ALN.0000000000003729; Forster C, Doucet V, Perentes JY, et al. Impact of an enhanced recovery after surgery pathway on thoracoscopic lobectomy outcomes in non-small cell lung cancer patients: a propensity score-matched study. Transl Lung Cancer Res. 2021;10(1):93-103. doi:10.21037/tlcr-20-891; Khoury AL, McGinigle KL, Freeman NL, et al. Enhanced recovery after thoracic surgery: systematic review and meta-analysis. JTCVS Open. 2021;7:370-391. Published 2021 Jul 15. doi:10.1016/j.xjon.2021.07.007; Licker M, Hagerman A, Bedat B, et al. Restricted, optimized or liberal fluid strategy in thoracic surgery: a narrative review. Saudi J Anaesth. 2021;15(3):324-334. doi:10.4103/sja.sja_1155_20; Licker M, Hagerman A, Jeleff A, et al. The hypoxic pulmonary vasoconstriction: from physiology to clinical application in thoracic surgery. Saudi J Anaesth. 2021;15(3):250-263. doi:10.4103/sja.sja_1216_20; Makkad B, Heinke TL, Sheriffdeen R, et al. Practice advisory for postoperative pain management of thoracic surgical patients: a report from the Society of Cardiovascular Anesthesiologists. J Cardiothorac Vasc Anesth. 2025;39(5):1306-1324. doi:10.1053/j.jvca.2024.12.004; Moorthy A, Ní Eochagáin A, Dempsey E, et al. Postoperative recovery with continuous erector spinae plane block or video-assisted paravertebral block after minimally invasive thoracic surgery: a prospective, randomised controlled trial. Br J Anaesth. 2023;130(1):e137-e147. doi:10.1016/j.bja.2022.07.051; Park M, Yoon S, Nam JS, et al. Driving pressure-guided ventilation and postoperative pulmonary complications in thoracic surgery: a multicentre randomised clinical trial. Br J Anaesth. 2023;130(1):e106-e118. doi:10.1016/j.bja.2022.06.037; Rogers LJ, Bleetman D, Messenger DE, et al. The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. J Thorac Cardiovasc Surg. 2018;155(4):1843-1852. doi:10.1016/j.jtcvs.2017.10.151; van den Broek RJC, Postema JMC, Koopman JSHA, et al. Continuous erector spinae plane block versus thoracic epidural analgesia in video-assisted thoracoscopic surgery: a prospective randomized open-label non-inferiority trial. Reg Anesth Pain Med. 2025;50(1):11-19. Published 2025 Jan 7. doi:10.1136/rapm-2023-105047; Van Haren RM, Mehran RJ, Mena GE, et al. Enhanced recovery decreases pulmonary and cardiac complications after thoracotomy for lung cancer. Ann Thorac Surg. 2018;106(1):272-279. doi:10.1016/j.athoracsur.2018.01.088; Wang C, Feng Z, Cai J, et al. Accuracy of stroke volume variation and pulse pressure variation in predicting fluid responsiveness undergoing one-lung ventilation during thoracic surgery: a systematic review and meta-analysis. Ann Transl Med. 2023;11(1):19. doi:10.21037/atm-22-6030; Yamazaki S, Koike S, Eguchi T, et al. Preemptive intercostal nerve block as an alternative to epidural analgesia. Ann Thorac Surg. 2022;114(1):257-264. doi:10.1016/j.athoracsur.2021.07.019; Yoon S, Nam JS, Blank RS, et al. Association of mechanical energy and power with postoperative pulmonary complications in lung resection surgery: a post Hoc analysis of randomized clinical trial data. Anesthesiology. 2024;140(5):920-934. doi:10.1097/ALN.0000000000004879.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Teeter was recorded at the Carolina Refresher Course 2025: 36th Annual Update in Anesthesiology, Pain, and Critical Care Medicine, held June 18-21, 2025, on Kiawah Island, SC, and presented by the University of North Carolina at Chapel Hill, School of Medicine. For information on future CME activities from this presenter, please visit https://www.med.unc.edu/. AudioDigest thanks the speakers and the presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

AN674001

Qualifies for:

ABA MOCA, Clinical Pharmacology

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.