Purpose of review: To find a reliable answer to the question in the title: Should fluid management in thoracic surgery be goal directed? Recent findings: ’Moderate’ fluid regimen is the current recommendation of fluid management in thoracic anesthesia, however, especially in more risky patients; ’Goal-Directed Therapy’ (GDT) can be a more reliable approach than just ’moderate’. There are numerous studies examining its effects in general anesthesia; albeit mostly retrospective and very heterogenic. There are few studies of GDT in thoracic anesthesia with similar drawbacks. Summary: Although the evidence level is low, GDT is generally associated with fewer postoperative complications. It can be helpful in decision-making for volume-optimization, timing of fluid administration, and indication of vasoactive agents.

Background: The aim of this study was to evaluate the effect of awake video-assisted thoracoscopic surgery on postoperative pulmonary complications among patients with different risk scores using the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT). Methods: Between January 2011 and August 2021, a total of 246 patients (158 males, 88 females; mean age: 59.1±13.6 years; range, 25 to 84 years) who underwent awake video-assisted thoracoscopic surgery were retrospectively analyzed. According to the ARISCAT scores, the patients with low and intermediate scores were included in Group L (n=173), while those with high scores (n=73) were included in Group H. Sedation protocol consisted of the combination of midazolam and fentanyl with propofol infusion, if necessary. Oxygen was delivered via face mask or nasal canula (2 to 5 L/min) maintaining an oxygen saturation of >95%, and analgesia was achieved with intercostal nerve block. Demographics, operative, and postoperative data of the patients, and pulmonary complications were evaluated. Results: Demographics, operative, and postoperative data were similar between the groups. Postoperative pulmonary complications were observed in 20 (27%) patients in Group H and 29 (17%) patients in Group L without statistically significant difference (p=0.056). Surgical approaches consisted of pleural procedures (n=194) and pulmonary resection (n=52). The incidence of pulmonary complications was significantly higher in the pulmonary resection compared to non-pulmonary procedures (p=0.027). Conclusion: Awake video-assisted thoracoscopic surgery seems to be beneficial in reducing the incidence of postoperative pulmonary complications in high-risk patients as assessed with the ARISCAT.

Regional anesthesia is commonly preferred technique for carotid endarterectomy (CEA) as it allows neuromotor evaluation and provides more stable hemodynamics. Cervical plexus blocks (CPBs) including superficial, intermediate and deep, are used alone or in combination in carotid surgery. Ultrasound guidance provides better visualization with increased safety for CPBs. The aim of this study is to compare the anesthetic efficacy of deep and intermediate CPBs by assessing the number of patients requiring additional local anesthetic during CEA. In this randomized, single-blind study, we enrolled 90 patients who underwent CEA. Patients who received either intermediate or deep CPB were divided into two groups: Group of Intermediate (GI) and Group of Deep (GD). The number of patients requiring additional lidocaine infiltration, time spent for block performance, extra number of needle insertions and orientations, assessment of cutaneous sensory loss in four peripheral cervical plexus nerve territories (lesser occipital, supraclavicular, transverse cervical and great auricular), pain scores, amount of additional lidocaine and complications were recorded. Patient and surgeon satisfaction were also evaluated. Nineteen out of 40 patients (47.5%) in GI and 10 out of 41 patients (24.5%) in GD needed additional lidocaine infiltration intraoperatively (p = 0.03). Time spent for intermediate block was 208.5 (50–332) s and for deep was 320 (90–780) s (p < 0.001). The blocks were performed successfully with single needle orientation 85% of GI and in 68% of GD (p = 0.11). The number of extra needle insertions was significantly higher in GD compared to GI (1 [1–4] and 1 [1–2], respectively; p = 0.04). All patients achieved adequate cutaneous sensory loss for surgery. Pain scores and amount of additional lidocaine were comparable. Patient satisfaction was significantly higher in GI than in GD (p = 0.03). In this study we found that significantly fewer patients required additional lidocaine in deep CPB than in intermediate CPB with low initiation LA volumes under USG guidance. The study was registered at ClinicalTrials.gov (registration number NCT05353218) on 24/04/2022.

Objectives: This randomized, single-blind study aimed to compare the effects of ultrasound-guided erector spinae plane block (ESPB), thoracic paravertebral block (TPVB) and intravenous (IV) analgesia on postoperative pain, opioid consumption and quality of recovery in patients undergoing laparoscopic cholecystectomy (LC). Methods: A total of 120 adult patients (ASA I-III) scheduled for elective LC were randomized into three groups: ESPB (GI), TPVB (GII) and IV analgesia (GIII). Bilateral ESPB or TPVB was performed preoperatively; then all patients received standardized general anesthesia and postoperative analgesia including paracetamol, tenoxicam and IV tramadol via patient-controlled analgesia. The primary outcome was 24 h tramadol consumption. Secondary outcomes included pain scores, rescue analgesia requirement, patient satisfaction, postoperative nausea and vomiting, time to first ambulation, length of hospital stay and Quality of Recovery-15 (QoR-15) scores. Results: Twenty-four-hour tramadol consumption was significantly higher in GIII (135.78 ± 22.73 mg) compared with GI (101.05 ± 26.99 mg) and GII (95.67 ± 31.49 mg) (p < 0.001), with no difference between GI and GII. Both static and dynamic pain scores were lower in GI and GII compared with GIII at most time points. Rescue analgesia requirement and patient dissatisfaction were significantly higher in GIII. QoR-15 scores were significantly improved in GI and GII compared with GIII (p < 0.001), while no difference was observed between the regional techniques. Block performance time was shorter with ESPB than TPVB (p < 0.001). No complications were reported. Conclusions: ESPB and TPVB provided effective analgesia and improved recovery after LC compared with IV analgesia alone. Both regional techniques may be considered as components of multimodal analgesia after LC.