1. Video Assisted Thoracoscopy (VATS) CarePath
Goal
Reduce PACU length of stay and increase patient satisfaction by reducing post-op pain, avoiding postoperative respiratory depression, PONV, sedation and time to void by minimizing opioids and maximizing alternative medications and techniques.
To whom it applies
All patients who are scheduled to undergo a VATS procedure
Meds for holding area
Anesthesia team orders meds the previous evening
What Meds to order
Acetaminophen: mg PO. Consider 500 mg in patients<50 kg.
Contraindications: cirrhosis or severe liver dysfunction, allergy or if taken in the previous 6 hours (e.g. Percocet, Vicodin)
Pregabalin: 75 mg PO
Contraindications: Renal failure on dialysis or known CrCl < 30 mg/dl, allergy
If patient chronically on Gabapentin or Pregabalin, patient can take their am dose instead.
Side effects: sedation, dizziness, blurred vision.
Regional Blocks
Intracostal nerve blocks . Mix 30 ml 0.25% bupivacaine with epi plus 30 ml 0.5% bupivicaine with 1 cc (100 mcg) dexmedetomidine to produce 0.375% solution anesthetic mixture for the intercostal nerve block.
Paravertebral nerve block in select cases. Surgeon will book those cases as block and GA
Anesthetic
General Anesthesia with double lumen tube or bronchial blocker.
Minimize opioid use especially when patient has a complete nerve block .
Antibiotics as per ID recommendations. Antibiotic protocols are available on the intranet as well as in ever OR.
At induction
Dexamethasone 8 mg IV slow. Avoid steroids in patients who have lung cancer.
Small doses of ketamine (0.3 mg/kg) after induction may be helpful to decrease hyperalgesia for patients with incomplete nerve blocks .
Intraop medications
Ondansetron at the end of the case.
Use Hydromorphone (0.1 to 0.2 mg doses) or Fentanyl sparingly (<100 mcg)
Ketorolac 30 mg IV. Contraindicated in renal insufficiency, known platelet disorders, allergy.
PACU analgesia
PO narcotics preferred
Ketorolac 30 mg IV. If not administered before
Hydromorphone (0.1-2 mg) or small doses of Fentanyl (<100 mcg) for breakthrough pain.
Consider reblocking early if pain is severe.
Consider 1 gm PO Acetaminophen
Consider PO Pregabalin 75 mg for supplemental analgesia.
Authors
John Pawlowski M.D,