Non-intubated Anesthesia With Ultrasound-guided Vagus Nerve And Intercostal Nerves Block In Thoracoscopic Surgery

Background Modern thoracoscopic surgery is rapidly developed with the progress of high-precision electronic camera-imaging system and endoscopic instruments,and more lesion can be resected in thoracoscopy which need thoracotomy previously.Traditional thracoscopy need general anesthesia and lung separation with double-lumen tubes or bronchial occlusive device.However,it increase stress response and postoperative complications with double-lumen tube intubation.Non-intubated thoracoscopic surgery with epidural anesthesia,paravertebral block,intercostal block,or other analgesic techniques,combined target sedation and vagus nerve block under direct vision for inhibition of cough reflex,and preserve spontaneous ventilation can avoid complications with general anesthesia or double-lumen tube intubation.Vagal blockade in endoscopic direct vision need to invove lobes and hilar structures,which may initiate cough reflex,lead to other organ injury,even heart and great vessels.The technique demands skilled surgeons to operate and that limits its widely application.Objectives To investigate the safety and feasibility of ultrasound-guided vagus nerve and intercostal nerves block in non-intubated thoracoscopic surgery.Methods Total 80 patients scheduled for resection for pulmonary bullae or mediastinal tumors,and pulmonary wedge resection in cardiothoracic surgery department of People's Hospital of Puyang City were enrolled,randomly assigned to two groups with random number table.General anesthesia was adopted in control group(Double-lumen Endobronchial TubeGroup,DLT Group),video-assist double-lumen endobronchial tube was intubated after intravenous induction and confirmed lung isolation was successful,and anesthesia maintained with target-controlled infusion of propofol and remifentanil,dependent lung was ventilated during operation.Vagus nerve was blocked in lower cervical segment with ultrasound-guided in observation group(Non-intubated Group,NI Group),inhaled 100% O2 with mask after lateral decubitus position,target infusion sedation with propofol and remifentanil,when bispectral index value was between 40 and 60,intercostal nerves block was performed with ultrasound-guided,patients preserved spontaneous ventilation during operation.Monitored ECG,NIBP,SPO2 and PETCO2 in both groups,measured arterial gas analysis 20 minutes after surgery start.Record the basal heart rate and vagal blocking heart rate in NI group.Record the time of operation room and operation,lung collapse scale 10 and 20 minutes after surgery start,postoperative nausea and vomiting(PONV),postoperative feeding time(POFT),the volume of thoracic drainage,and reexamined the chest X-ray on the 1th day after surgery,survey the satisfaction of anesthesia on the 3th day after operation,Data analysis with statistical method.Results There's no significant difference in operation room time(121.8±17.4min VS 120.2±16.3min,P=0.478),operation time(61.1±15.5min VS57.9±14.0min,P=0.115),and the volume of chest drainage(352.43±140.6ml VS370.9±160.7ml,P=0.371))between the two groups;and there's no significant difference between basal heart rate and vagal blocking heart rate(71.9±7.2bpm VS 72.9±6.0bpm,P=0.513)in NI group;PONV(2/36 VS 10/39,P=0.018),POFT(2.91±0.6h VS 6.96±1.3h,P<0.001),morphine consumption(0/36 VS 6/39,P=0.014),and satisfaction of anesthesia(29/36 VS 21/39,P=0.014)are better in NI group;no cough happenning and lung collapsed can meet the desire of operation in both groups.Conclusions 1.Ultrasound-guided vagal blockade can inhibit the cough reflex effectively in VATS.2.Non-intubated anesthesia can provide favorable condition for VATS,avoid complications with intubation and mechanical ventilation,and reduce stress response;patient's complications were reduced postoperatively and anesthetic satisfaction is better.3.Non-intubated anesthesia in VATS should select indications strictly.