VATS lobectomy anaesthesia and postoperative analgesia

Model answer

Isolation/OLV (5). Left DLT preferred; fibreoptic confirm before and after the lateral turn; VT 4–6 mL/kg PBW (inside the 4–7 range of the 17-trial meta-analysis, OR 0.50 for pulmonary complications); low peak/plateau pressures with routine PEEP and permissive hypercapnia; hypoxaemia algorithm ready (FiO2 up, scope first, then PEEP/recruitment, CPAP to the operative lung, back to two lungs if failing).

Analgesia (6). PROSPECT basic analgesia (paracetamol plus NSAID/COX-2, continued postop; opioids rescue; dexmedetomidine infusion only when basic plus regional unavailable) with paravertebral or ESP first-choice and SAP second-choice; name the Wu–Yeap disagreement (Wu 176 patients: similar rest/cough scores, less hypotension/retention with PVB; Yeap: epidural superior on movement pain and 24–72 h opioids; single-shot PVB equals catheter).

Anticoagulation/LAST (2). Apixaban timing takes continuous neuraxial or deep paravertebral catheters off the table under the ASRA antithrombotic framework — single-shot plane block plus infiltration instead; fractionate local anaesthetic, dose by lean weight, 20% lipid emulsion ready per the ASRA LAST advisory.

Postop (2). Extubate awake and cough-effective (TOF anchors are recovery teaching, not ventilation-trial numbers); physio; monitor drains and shoulder-tip plan; escalate the block if open conversion.