Non-Intubated Thoracotomy Under an Opioid-Sparing Intravenous Sedation and Analgesia Protocol without Central or Peripheral Nerve Blocks: A Case Report with Insights into Shared Decisions

Key Objectives: Non-intubated thoracic surgery has been performed under regional anaesthesia or sedation. Totally intravenous opioid-sparing analgesia and sedation protocols, without the use of any central or peripheral nerve blocks, have not been used so far for open, non-intubated thoracic surgery. We present the case of a patient who underwent non-intubated thoracotomy under intravenous multimodal opioid-sparing analgesia and sedation. Methods: A high-risk patient was referred for non-intubated segmental lung resection. A solely intravenous multimodal opioid-sparing analgesia/sedation strategy was planned, as the patient did not consent to central or peripheral nerve blocks. Results: Intraoperatively severe hypoxaemia occurred without signs of tissue hypoxia, which resolved when the lung was re-expanded. There were no other significant events and the patient was later discharged, pain-free and with high level of satisfaction. Conclusions: The idea of shared decision-making represents a shift from the basic concept of 'informed consent' to a more deliberative interaction. This involves a robust discussion between the doctor and patient about the best way to shape care in accordance with the patient's values and preferences. In this context an intravenous opioid-sparing strategy, which could prevent the adverse effects of perioperative opioids and regional blocks, could be an efficient alternative in non-intubated thoracic surgery. Intraoperative hypoxaemia is not by default associated with tissue hypoxia and does not always require immediate ventilatory intervention.