From “Awake” to “Monitored Anesthesia Care” Thoracic Surgery. a 15 Years Evolution

Despite general anesthesia still represents the standard to perform thoracic surgery, the interest toward alternative methods is increasing. These has evolved from the employ of just local or regional analgesia technique in completely alert patients (awake thoracic surgery), to more complex protocols entailing conscious sedation and spontaneous ventilation. The main rationale of these methods is to prevent serious complications related to general anesthesia and selective ventlation, such as tracheobronchial injury, acute lung injury, and cardiovascular events. Also, trends toward shorter hospitalization and reduced overall costs have been indicated in preliminary reports. Monitored anesthesia care thoracic surgery can be successfully employed to manage diverse oncologic conditions, such as malignant pleural effusion, peripheral lung nodules, and mediastinal tumors. Main non-oncologic indications include pneumothorax, emphysema, pleural infections, and interstitial lung disease. Furthermore, as the familiarity with this surgical practice has increased, major operations are now being performed this way. Despite the absence of randomized controlled trials, there is preliminary evidence that monitored anesthesia care protocols in thoracic surgery may be beneficial in high-risk patients, with non-inferior efficacy when compared to standard operations under general anesthesia. Monitored anesthesia care thoracic surgery should enter the armamentarium of modern thoracic surgeons, and adequate training should be scheduled in accredited residency programs.