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Tratamiento del Dolor, Hospital Clínico Universitario, Valencia, Spain" "etiqueta" => "q" "identificador" => "aff0085" ] 17 => array:3 [ "entidad" => "Servicio de Anestesia y Reanimación, Hospital Universitari Arnau de Vilanova, Lleida, Spain" "etiqueta" => "r" "identificador" => "aff0090" ] 18 => array:3 [ "entidad" => "Bloc Quirúrgic i Esterilització, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain" "etiqueta" => "s" "identificador" => "aff0095" ] 19 => array:3 [ "entidad" => "Servicio de Anestesia y Reanimación, Complejo Hospitalario Universitario A Coruña, La Coruña, Spain" "etiqueta" => "t" "identificador" => "aff0100" ] 20 => array:3 [ "entidad" => "Servicio de Anestesia y Reanimación, Clínica Universidad de Navarra, Navarra, Pamplona, Spain" "etiqueta" => "u" "identificador" => "aff0105" ] 21 => array:3 [ "entidad" => "Servicio de Anestesia y Reanimación, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain" "etiqueta" => "v" "identificador" => "aff0110" ] 22 => array:3 [ "entidad" => "Departamento de Farmacología y Toxicología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "w" "identificador" => "aff0115" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones de la Sociedad Española de Cirugía Torácica y de la Sección de Cardiotorácica y Cirugía Vascular de la Sociedad Española de Anestesia, Reanimación y Terapéutica del Dolor, para los pacientes sometidos a cirugía pulmonar incluidos en un programa de recuperación intensificada" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In 1997, Danish surgeon Henrik Kehlet put forward a series of measures to reduce perioperative stress in patients undergoing colorectal surgery, and coined the term “multimodal approach”.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This coincided with the development and spread of minimally invasive surgical techniques, also known as keyhole surgery, that were ideally suited to these protocols. Following advances in the field of anaesthesiology and a deeper understanding of the negative pathophysiological effects of perioperative stress, further measures were added to the multimodal approach. Over time, these protocols have been called variously fast track surgery, multimodal rehabilitation, accelerated recovery after surgery, and enhanced recovery after surgery. In Spain, the term “Intensified Recovery” (IR) has come to the fore in recent years. These programmes have been developed for almost all types of surgery, and although they are widely known and accepted by surgical teams, their application in clinical practice varies.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In thoracic surgery, there is ample evidence in the literature that IR programs reduce postoperative pulmonary complications (PPC), shorten hospital stay and reduce healthcare costs.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–7</span></a> These studies mainly show the effectiveness of applying a series of evidence-based perioperative measures to improve outcomes in thoracic surgery. Individually, each intervention may be more of less beneficial, but when combined they can provide a far greater benefit.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The basic principles known to facilitate postoperative recovery in thoracic surgery include preoperative optimization (including prehabilitation), keyhole surgery, prompt removal of chest drains, early mobilization, and good perioperative pain control. However, there are another "minor" interventions with proven benefit that are not implemented across the board. To address this, in 2018 the European Society of Thoracic Surgeons and the ERAS Society published joint guidelines for the management of patients undergoing thoracic surgery.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of this guideline is to analyse the current scientific evidence for a series of measures to be included in intensified recovery in lung surgery (IRLS) protocols that will improve the outcomes of patients undergoing this type of surgical procedure, and to provide some recommendations to facilitate and standardise their implementation.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material and method</span><p id="par0025" class="elsevierStylePara elsevierViewall">In January 2019, the cardiothoracic anaesthesia division of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy, in conjunction with the Spanish Society of Thoracic Surgery, decided to analyse the measures put forward in the scientific literature to facilitate patient recovery after lung resection surgery. The Spanish Society of Cardiorespiratory Rehabilitation, the Spanish Association of Physiotherapists, and the Spanish Association of Surgical Nurses collaborated on issues specific to these societies.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The PubMed, Cochrane Library, UpToDate, and Embase databases were systematically searched using the following terms: «enhanced recovery after anesthesia», «multimodal approach», «fast-track surgery», «non-cardiac thoracic surgery», «lung resection surgery or cancer lung surgery» and the corresponding terms in Spanish and French. Meta-analyses, systematic reviews, reviews, consensus recommendations from societies other than those involved in these guidelines, randomized controlled trials, nonrandomized controlled trials, observational studies, and case reports were considered eligible. Studies with full access to the content, published up to June 2019, and written in any of the foregoing 3 languages were included. The topics to be analysed in our review were extracted from the studies retrieved. Following this, members of the participating societies were invited to contribute to the project, and the topics selected were distributed among those who accepted the invitation, according to their familiarity with each item.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We used the same terms listed above for the cited references search. When the information retrieved was too scant or of low quality, the search was extended to surgeries other than thoracic surgery, and a note was included to the effect that information used to draft the recommendation had been extrapolated from other surgeries.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Each expert made a series of recommendations on their assigned topics, and these were then discussed and agreed on with the 2 corresponding authors of these guidelines (AC for thoracic surgery and IG for anaesthesia).</p><p id="par0045" class="elsevierStylePara elsevierViewall">The evidence was classified according to the Grading of Recommendations, Assessment, Development and Evaluation ‒GRADE‒<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> system. The grade of recommendation was “strong” when the authors were confident that the desirable effects of a recommendation outweigh the undesirable effects. The quality of evidence for each recommendation was rated as high, moderate, or low, depending on the quality of the studies on which the recommendation was based. “High” quality evidence comes from randomized clinical trials and meta-analyses, “moderate” quality evidence comes from a single clinical trial or from large, non-randomised trials, and “low” quality evidence comes from retrospective studies, cases reports or expert opinions. When the evidence came from studies not performed specifically in the field of thoracic surgery, the evidence was classed as "extrapolated".</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the recommendations on various aspects of perioperative management.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Information and preoperative education</span><p id="par0055" class="elsevierStylePara elsevierViewall">Preoperative education and detailed information about the surgical and anaesthetic procedure provided by the respective specialists may reduce anxiety and fear among patients and family members regarding the upcoming surgical procedure,<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> and is a key element in any IR programme. A few years ago, Devine published a meta-analysis showing the effect of preoperative psychological education and intervention in reducing postoperative pain, improving patient satisfaction with the surgical experience, and accelerating patient recovery.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> More recently, Barlési et al., corroborated these findings in patients scheduled for lung cancer surgery, and reported worse results in patients who received only written educational material about the procedure compared to those who had received standard oral information provided by the thoracic surgeon.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Since then, the introduction of new technologies (Internet and audio-visual media) has improved the quality of patient information. Crabtree et al. analysed the impact of showing a patient scheduled for lung resection a video outlining perioperative expectations and then discussing with them how their postoperative pain would be treated, explaining the strategies used to manage chest drains, the aim of postoperative lung exercises, and giving the patients instructions on post-operative care in their homes after discharge. They that this approach shortened postoperative hospital stay and reduced the readmission rate, albeit insignificantly; however, pain at rest scores at discharge were significantly lower in patients who had been shown the video compared to those who only received standard oral information about the procedure.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Summary</span><p id="par0060" class="elsevierStylePara elsevierViewall">Preoperative information and education are key elements of IR protocols. They encourage the patient to take an active role in their recovery process and increase their adherence to the protocol, resulting in shorter hospital stays and fewer postoperative complications. Using new technologies instead of written texts can improve the quality of the information the patient receives before the intervention</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Recommendations</span><p id="par0065" class="elsevierStylePara elsevierViewall">Providing the patient with adequate information before surgery can improve postoperative results in thoracic surgery. Quality of evidence: low. Grade of recommendation: strong.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Prehabilitation and preoperative physical exercise</span><p id="par0070" class="elsevierStylePara elsevierViewall">Prehabilitation is a series measures implemented before surgery for the purpose of enhancing the functional and physiological capacity of an individual to withstand surgery, and may aid postoperative recovery.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Prehabilitation in thoracic surgery includes optimizing lung function, giving patients advice on bad habits (smoking, drinking alcohol or using drug), nutritional support and pulmonary rehabilitation.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Two meta-analyses and one systematic review agreed that prehabilitation in thoracic surgery is beneficial and can reduce PPCs by up to 67% and shorten hospital stay by up to 5 days.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–18</span></a> Poor preoperative physical condition is associated with an increased risk of postoperative complications after lung resection surgery,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and can even affect survival.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Physical exercise, particularly aerobic resistance training, is the best way to increase maximum oxygen consumption, and should therefore form the basis of prehabilitation programmes.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Liker et al. analysed the impact of 8 sessions of high-intensity interval training, and found that it increased maximum oxygen consumption and 6-minute walk distance, and reduced the incidence of PPC.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The improvement in cardiorespiratory fitness, however, was not sustained in the long term. Recently, Liu et al., in a small randomized controlled trial, found that a prehabilitation programme initiated 15 days before thoracic surgery led to a mean increase of 60 m in the 6-minute walk test; however, they observed no differences in 3-month postoperative morbidity and mortality between groups.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> In terms of training methods, the current trend is to prescribe interval training that combines short periods of high intensity (at 80 %–90 % of peak power) with active rest periods of equal or greater duration (1−5 min), although both interval and continuous training appear to be equally effective in increasing maximal oxygen uptake.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> In most cases, aerobic resistance training is usually accompanied by exercises to increase the strength of the main muscle groups, particularly the legs, since leg muscle strength is strongly correlated with peak cardiorespiratory fitness.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Although the latest evidence appears to confirm that prehabilitation improves postoperative outcomes, these programmes are still rarely used in clinical practice. Waiting time in thoracic surgery, for example, is often less than 4 weeks, and pulmonary rehabilitation programmes usually last 8 weeks or more, and are therefore difficult to fit in before surgery. However, some studies have observed that shorter, high-intensity programmes (lasting between 1 and 4 weeks) are also effective in improving cardiorespiratory fitness and optimizing post-operative recovery,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> although the results may not be sustained in the long term.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> In the case of patients that are not considered suitable for surgery due to their preoperative physical condition, a longer prehabilitation programme could improve their capacity to withstand surgery and, therefore, dramatically improve their long-term outcomes.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In any event, though all patients could benefit from prehabilitation, they are most beneficial in those with worse physical condition.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> There is no consensus on the best approach to patient selection, although aerobic reserve should ideally be assessed by means of simple cardiopulmonary exercise tests that, though not an accurate measure of cardiorespiratory capacity and surgical risk, are appropriate for preliminary screening.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Another factor to take into account is frailty – a physical condition in which the body’s functional reserve is impaired. Although there is evidence to show that frailty can influence surgical outcomes, this condition is not clearly defined, and different criteria have been used in the literature to classify patients as frail or robust. There is currently scant evidence on the usefulness of evaluating frailty as a predictor of complications and/or mortality after lung resection surgery.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Summary</span><p id="par0085" class="elsevierStylePara elsevierViewall">Low preoperative physical capacity is associated with increased risk of postoperative complications. Instructing patients to improve their physical capacity while awaiting surgery will get them involved in the upcoming intervention, and the training they undergo will improve their level of preoperative fitness.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Recommendations</span><p id="par0090" class="elsevierStylePara elsevierViewall">Physical training programs lasting more than 4 weeks improve preoperative physical capacity. Quality of evidence: moderate. Grade of recommendation: strong.</p><p id="par0095" class="elsevierStylePara elsevierViewall">These programs reduce the rate of postoperative complications. Quality of evidence: low. Grade of recommendation: strong.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Incentive spirometry</span><p id="par0100" class="elsevierStylePara elsevierViewall">Prehabilitation programs include incentive spirometry (IS), such as deep inspiration exercises or inspiratory muscle training. It is reasonable to believe that exercising both the respiratory and systemic muscles will improve muscle strength and endurance. In 2013, Agostini et al. published a randomized study on incentive spirometry in which they reported that IS in thoracic surgery patients did not improve recovery of lung function or the incidence of PPCs.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> However, in a sub-study in high-risk patients (age ≥75 years, ASA ≥ III, COPD, smokers, body mass index ≥30) they observed that IS reduced the incidence of PPCs (14% vs. 23%). In a recent meta-analysis, Kendall et al. showed that IS is effective in reducing PPCs and length of hospital stay, and should be started preoperatively and continued postoperatively. They also confirm that the greatest benefits are obtained in older, high-risk patients and those undergoing lung surgery.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Other authors have also observed that perioperative respiratory physiotherapy programmes significantly reduce the incidence of PPC, the length of hospital stay, and healthcare costs associated with complications in patients undergoing pulmonary lobectomy.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32,33</span></a></p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Summary</span><p id="par0105" class="elsevierStylePara elsevierViewall">SI exercises are a standard element in prehabilitation programmes, and can be used in conjunction with other preoperative physical activity aimed at preparing the patient for their upcoming lung resection surgery. Weak respiratory muscles make the patient more susceptible to serious postoperative respiratory complications. Improving the strength of these muscles can be beneficial and will, if nothing else, involve the patient in their postoperative recovery and rehabilitation.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Recommendations</span><p id="par0110" class="elsevierStylePara elsevierViewall">Performing IS during surgery waiting time vs. not performing IS improves respiratory function. Quality of evidence: high. Grade of recommendation: Strong.</p><p id="par0115" class="elsevierStylePara elsevierViewall">These measures reduce the incidence of CPP and may help shorten the length of hospital stay. Quality of evidence: Low. Grade of recommendation: Strong.</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Smoking cessation</span><p id="par0120" class="elsevierStylePara elsevierViewall">Smoking is associated with perioperative adverse effects, such as cardiovascular, respiratory, and surgical wound-related complications.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Quitting smoking before lung resection surgery also reduces the risk of pulmonary complications and hospital mortality.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> The perioperative period is an ideal opportunity for patients to quit smoking for at least 4 weeks prior to surgery, and can mitigate the negative effects of smoking.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> This benefit may be even greater with longer abstinence periods (6–8 weeks).<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Some recent international consensus statements on perioperative smoking cessation recommend advising patients to stop smoking as far in advance of surgery as possible and administering high-intensity smoking cessation interventions that combine personal advice, pharmacological support and follow-up. Evidence has shown that these interventions are more effective in reducing the incidence of complications and increasing postoperative abstinence rates.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Philips et al. recently reported that more than half of all smokers scheduled for lung resection surgery remained smoke-free when given intensive treatment with face-to-face interviews, replacement therapy of their choice (nicotine preparations, bupropion, varenicline, or nothing), and a warning that surgery could be delayed if they were unable to quit smoking for more than 2 weeks before the operation.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Thomsen et al. published a meta-analysis showing that the combination of preoperative counselling and nicotine replacement therapy increases short-term cessation and reduced the incidence of postoperative morbidity.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Promising randomized clinical trials in smoking cessation have been conducted with varenicline combined with behavioural interventions.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40,41</span></a> There is insufficient evidence to recommend the administration of bupropion or to determine the safety and efficacy of electronic cigarettes for smoking cessation in the perioperative period. According to reports, government funding of pre-operative smoking cessation programmes is cost-effective.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Summary</span><p id="par0130" class="elsevierStylePara elsevierViewall">Quitting smoking before surgery reduces postoperative morbidity and mortality. Patients should be advised to stop smoking as far in advance of surgery as possible, and should be offered programmes that combine personal counselling, pharmacological support and follow-up.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Recommendations</span><p id="par0135" class="elsevierStylePara elsevierViewall">Patients should be advised to quit smoking from the moment they are scheduled for surgery. Quality of evidence: moderate. Grade of recommendation: strong.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Patients should be offered high-intensity smoking cessation programmes from the moment they are scheduled for surgery. Quality of evidence: moderate. Grade of recommendation: strong.</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Alcohol consumption</span><p id="par0145" class="elsevierStylePara elsevierViewall">Patients who report habitual preoperative alcohol consumption of more than 2–3 drinks per day, i.e. 36−60 g alcohol, may be at greater risk of postoperative complications than those who do not consume alcohol or do so more moderately.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> Alcohol abuse is associated with an increased risk and severity of infections and respiratory complications in lung resection surgery.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> Even in the absence of overt liver damage, alcohol causes adverse immunological, haematological, and psychological effects in the postoperative period. These patients may also present postoperative alcohol withdrawal syndrome that would limit their capacity to collaborate with an ERAS programme. Therefore, when taking the medical history it is essential to ask specifically about alcohol consumption habits (amount and frequency). In exceptional cases where the clinician mistrusts the patient’s answers, laboratory tests to detect the presence of alcohol may be requested. Intensive alcohol detoxification programmes include information and recommendations for alcohol cessation, treatment of withdrawal, relapse prevention with pharmacological support, and specialist follow-up. In a 2018 meta-analysis, Egholm et al. observed that alcohol cessation interventions applied before surgery increased the percentage of patients with total alcohol abstinence at the end of the programme, and reduced the risk of postoperative complications.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> This was followed by another meta-analysis published 1 year later that reviewed these therapies, and showed that behavioural interventions are effective in reducing the amount of alcohol consumption, but not in achieving complete abstinence.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Summary</span><p id="par0150" class="elsevierStylePara elsevierViewall">Patients do not usually volunteer information on their alcohol consumption habits, so these should be targeted when taking the clinical history. There are no clear limits to adjust the intensity of alcohol consumption, but patients should be advised to abstain prior to surgery. Alcoholism is associated with an increased risk and severity of infections and respiratory complications in lung resection surgery.</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Recommendations</span><p id="par0155" class="elsevierStylePara elsevierViewall">We recommend asking all patients about their alcohol consumption habits before surgery. Quality of evidence: moderate. Grade of recommendation: strong.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Alcohol consumption should be avoided for at least 4 weeks prior to surgery. Quality of evidence: moderate. Grade of recommendation: strong.</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Preoperative optimization of haemoglobin</span><p id="par0165" class="elsevierStylePara elsevierViewall">About a quarter of all patients undergoing surgery for lung cancer present anaemia.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> This disease is associated with a 2 to 3-fold increase in postoperative infectious and respiratory complications,<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> and may also affect medium to long-term survival.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> In their meta-analysis, Huang et al. found that low haemoglobin levels in patients with lung cancer was significantly correlated with poor survival (HR 1.51, 95% CI 1.42–1.61), and that the lower the haemoglobin level, the shorter the overall survival (HR 1.11, 95% CI 1.06–1.16).<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> Another recent meta-analysis showed that patients with lung cancer and anaemia had a 1.6-fold greater risk of death compared to those without these diseases,<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> and although blood transfusion can correct anaemia, transfusion in thoracic surgery increases the risk of postoperative complications,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> tumour recurrence, and death.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">We recommend that the preoperative anaemia workup should include not only haemoglobin values, but also ferritin, transferrin saturation index, inflammatory markers (C-reactive protein) and renal function.</p><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Iron</span><p id="par0175" class="elsevierStylePara elsevierViewall">The most common cause of preoperative anaemia is iron deficiency, so iron supplementation is one of the cornerstones of therapy. If surgery is scheduled less than 6 weeks after diagnosis, as is often the case in lung cancer surgery, patients can receive intravenous iron preparations that will increase haemoglobin levels within 2–3 weeks.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> No studies have specifically analysed the benefit of preoperative intravenous iron in thoracic surgery. Two recent studies on this issue found that while preoperative administration is useful for increasing preoperative haemoglobin levels, its effect on reducing perioperative transfusions is less clear.<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54–56</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Erythropoietin</span><p id="par0180" class="elsevierStylePara elsevierViewall">Erythropoiesis-stimulating agents, such as erythropoietin or darbepoetin, are effective in the preoperative treatment of anaemia. However, erythropoietin has been associated with increased mortality, thromboembolic and cardiovascular events, and poorer response to antitumor treatment in patients with lung cancer.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> Currently, erythropoiesis-stimulating agents are reserved for palliative use in lung cancer patients for the purpose of improving anaemia-related symptoms, but are not used in patients undergoing potentially curative lung cancer interventions.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Summary</span><p id="par0185" class="elsevierStylePara elsevierViewall">Patients scheduled for lung tumour resection often present preoperative anaemia. This can be corrected, at least partially, in the 2–4 weeks prior to the intervention. The most widely accepted treatment is intravenous iron. Erythropoietin and derivatives, though effective in correcting anaemia, are associated with thromboembolic and cardiovascular effects, and should be avoided in these patients.</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Recommendations</span><p id="par0190" class="elsevierStylePara elsevierViewall">We recommend measuring haemoglobin levels from the moment the patient is scheduled for surgery. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0195" class="elsevierStylePara elsevierViewall">We do not recommend giving blood transfusion to correct preoperative anaemia. Quality of evidence: low. Grade of recommendation: strong.</p><p id="par0200" class="elsevierStylePara elsevierViewall">In patients with anaemia, clinicians should investigate the cause and consider administering intravenous iron and/or folic acid prior to surgery. Quality of evidence: low. Grade of recommendation: strong.</p><p id="par0205" class="elsevierStylePara elsevierViewall">We do not recommend administering erythropoietin (or similar) to correct anaemia in cancer patients undergoing thoracic surgery. Quality of evidence: low. Grade of recommendation: strong.</p></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Fasting and preoperative use of carbohydrate drinks</span><p id="par0210" class="elsevierStylePara elsevierViewall">Pulmonary aspiration of gastric or oropharyngeal content during anaesthesia is a rare complication, but one that is associated with high morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> To mitigate this risk, the standard approach has been to recommend total fasting the night before surgery, a measure that has led to exaggerated and unnecessary preoperative fasting periods. Fasting, coupled with surgical stress, not only undermines the patient's well-being, but also worsens their catabolic state, causes insulin resistance, and may delay recovery. All these factors are detrimental to the perioperative course of patients undergoing elective surgery.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Administration of carbohydrate drinks up to 2 h before surgery attenuates the detrimental effects of fasting without increasing the risk of pulmonary aspiration.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> The transfer of this knowledge to routine clinical practice varies among hospitals. In this respect, the implementation of IR programs marks a complete break with conventional practice in many hospitals. Bilku et al. performed a meta-analysis of the effect of carbohydrate drinks in surgery, and showed that they significantly improved both insulin resistance and enhanced patient well-being by diminishing the sensation of hunger, thirst, malaise, anxiety and nausea (p < 0.05).<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> A retrospective study in thoracic surgery patients reported that those who receiving carbohydrate loading up to 2 h before surgery had lower opioid and antiemetic requirements on the first postoperative day compared to the historical group that received standard preoperative preparation.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Evidence on carbohydrate loading in type 2 diabetic patients with poor glycaemic control is inconsistent, since most studies analysing the effects of these drinks do not include diabetic patients due to gastroparesis and the subsequent, albeit it theoretical, increase in the risk of aspiration and the danger of perioperative hyperglycaemia. The Joint British Diabetes Society advises against using this type of drink in insulin-dependent diabetic patients.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> Nevertheless, 2 small studies have shown that administration of carbohydrate drinks in patients with diabetes is safe insofar as it does not delay gastric emptying,<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> and does not alter preoperative blood glucose levels.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a></p><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Summary</span><p id="par0225" class="elsevierStylePara elsevierViewall">Exaggerated, unjustified preoperative fasting is detrimental to the catabolic stress response produced by surgery. Patients should fast from solids for 6 h prior to surgery; however, administration of clear liquids and carbohydrate drinks up to 2 h before surgery could attenuate insulin resistance and improve the patient’s metabolic status and perioperative well-being.</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Recommendations</span><p id="par0230" class="elsevierStylePara elsevierViewall">We recommend administering carbohydrate drinks up to 2 h before surgery. Quality of evidence: low (evidence extrapolated from other surgeries). Grade of recommendation: strong.</p></span></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Preoperative anxiolysis</span><p id="par0235" class="elsevierStylePara elsevierViewall">Preoperative anxiolytics (particularly benzodiazepines) were initially administered to reduce psychological stress before the intervention. A recent survey of Dutch hospitals found that anxiolytics were still used in more than half of all cases.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> However, evidence dating back more than 20 years has shown that these agents are not particularly effective in achieving anxiolysis and can, in fact, worsen the postoperative course (they cause deep sedation that delays rehabilitation, reduces lung function, and can cause postoperative delirium).<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">67–69</span></a> Lung cancer patients are usually elderly and/or have some degree of lung function impairment, so pharmacological anxiolysis is not routinely recommended. Alternative strategies have been developed to reduce perioperative anxiety, including psychological techniques to help patients deal with their disease. Carbohydrate loading 2 h before anaesthesia induction also reduces patient anxiety.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a></p><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Summary</span><p id="par0240" class="elsevierStylePara elsevierViewall">Administering anxiolytics before an intervention is not without risks. These drugs can alter the normal postoperative course, particularly the patient’s cognitive status.</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Recommendations</span><p id="par0245" class="elsevierStylePara elsevierViewall">Benzodiazepines should not be used before surgery to reduce patient anxiety. Quality of evidence: moderate. Grade of recommendation: strong.</p></span></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Preoperative nutrition</span><p id="par0250" class="elsevierStylePara elsevierViewall">Preoperative malnutrition is associated with higher morbidity and mortality, prolonged hospital stay and more readmissions, and significantly increases healthcare costs in thoracic surgery patients.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> The incidence of preoperative malnutrition can be as high as 65%,<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> but it is one of the few postoperative morbidity and mortality factors that can be modified in thoracic surgery patients.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29,73–76</span></a> Despite this, preoperative malnutrition is seldom investigated or treated.</p><p id="par0255" class="elsevierStylePara elsevierViewall">According to the European Society for Clinical Nutrition and Metabolism, nutritional screening tools should include 3 items: current body mass index, recent involuntary weight loss, and documented recent food intake.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> Patients that test positive on screening tests must undergo a more comprehensive assessment by a nutritionist, and should receive nutritional support before surgery. This therapy should ideally be administered for 7–14 days, but there is evidence that even 5–7 days of nutritional support can reduce postoperative morbidity by 50% in malnourished patients.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> In a study in thoracic surgery, Kaya et al. randomised lung cancer surgery patients to receive an immune modulating nutritional regimen for 10 days preoperatively or a normal diet. The intervention group showed a lower rate of postoperative complications and shorter chest tube drainage time. In this study, however, malnourished patients and those with metabolic problems were excluded.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a></p><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Summary</span><p id="par0260" class="elsevierStylePara elsevierViewall">Preoperative malnutrition has a negative impact on postoperative prognosis. Clinicians must evaluate the nutritional status of patients before surgery and administer nutritional support when needed. These measures can improve postoperative outcomes.</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Recommendations</span><p id="par0265" class="elsevierStylePara elsevierViewall">All patients must undergo preoperative nutritional screening. Grade of recommendation: strong. Quality of evidence: moderate.</p><p id="par0270" class="elsevierStylePara elsevierViewall">Prior to surgery, malnourished patients or patients with high nutritional risk should receive oral or enteral nutritional supplementation. Grade of recommendation: strong. Quality of evidence: moderate.</p><p id="par0275" class="elsevierStylePara elsevierViewall">We recommend administering immune modulating formulas to malnourished patients undergoing major cancer surgery. Quality of evidence: low (evidence extrapolated from other surgeries). Grade of recommendation: weak.</p></span></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Thromboprophylaxis in thoracic surgery</span><p id="par0280" class="elsevierStylePara elsevierViewall">Thromboembolic (TE) phenomena, such as deep vein thrombosis or pulmonary embolism, are associated with higher postoperative morbidity and mortality,<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">80–82</span></a> particularly after lung cancer resection in high-risk patients (advanced age, obesity, pneumonectomy, incomplete resection, immobility, previous chemotherapy, high Caprini score). According to estimates, between 7% and 14% of patients suffer from deep vein thrombosis after lung cancer surgery.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a> Agzarian et al. in a study involving CT with pulmonary angiography and ultrasound of the lower limbs, reported 12.1% cases of TE, of which 80% were pulmonary thromboembolisms (mostly asymptomatic), despite the perioperative use of low molecular weight heparin (LMWH).<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> Despite insufficient evidence, the need for routine pre-, intra- and postoperative prophylaxis to reduce the incidence of TE phenomena in major thoracic surgery is generally accepted.<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">83,85,86</span></a> The Society for Translational Medicine recommends: (a) early ambulation or mechanical prophylaxis in patients at low-risk for TE: (b) LMWH or unfractionated heparin or mechanical prophylaxis in moderate-risk TE patients. In surgery with a high risk of bleeding, pharmacological thromboprophylaxis when the risk of bleeding decreases, and (c) unfractionated heparin or LMWH combined with mechanical prophylaxis in patient at high risk for TE. If there is a risk of bleeding, start heparin when the risk decreases.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">It is generally agreed that LMWH should be started before surgery, but opinions vary on how long it should be continued postoperatively. Evidence on the duration of postoperative thromboembolic prophylaxis comes from studies performed in pelvic and abdominal surgery (the ENOXACAN and CANBESURE studies) that compared LMWH for 4 vs. 1 week after surgery. Incidence of deep vein thrombosis was lower in patients receiving 4 weeks of prophylaxis, but the incidence of pulmonary thromboembolism or mortality did not differ between groups.<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">87,88</span></a> In non-oncological lung resection procedures or in lung surgery lasting less than 2 h in patients with no other risk factors, prophylaxis should continue for 1 week, while in other cases it should be maintained for up to 1 month after surgery.<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">83,89</span></a></p><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Summary</span><p id="par0290" class="elsevierStylePara elsevierViewall">Lung cancer surgery should be considered a high thrombotic risk procedure, given the high incidence of postoperative thromboembolic complications and the negative impact these have on prognosis.</p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Recommendations</span><p id="par0295" class="elsevierStylePara elsevierViewall">In patients undergoing lung cancer surgery, mechanical and pharmacological measures should be used to prevent thromboembolism. Quality of evidence: moderate (evidence extrapolated from other surgeries). Grade of recommendation: strong.</p><p id="par0300" class="elsevierStylePara elsevierViewall">Prophylactic treatment with LMWH should be continued for 1 month (instead of 1 week) in high-risk patients. Quality of evidence: moderate (evidence extrapolated from other surgeries). Grade of recommendation: weak.</p></span></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Antibiotic prophylaxis</span><p id="par0305" class="elsevierStylePara elsevierViewall">Thoracic surgeries are classified as clean-contaminated procedures, primarily because potential airway contamination usually plays a major role in the risk of infection. Postoperative infection in these surgeries mainly involves infection of the chest wall and surgical wound, empyema and pneumonia. Incidence of infection ranges from 2% to 24%.<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">90</span></a> The use of antibiotic prophylaxis reduces the risk of surgical wound infection by about half, but does not reduce the risk of pneumonia or empyema.<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">91</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">Surgical wound infection is associated with prolonged hospital stay, use of special postoperative care units, hospital readmission, and mortality.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> In clean-contaminated surgeries, other measures in addition to antibiotics have proven useful in reducing the incidence of this postoperative complication: showering with neutral soap the night before and/or the day of surgery; trimming instead of shaving hair that needs to be removed from the incision site; swabbing the surgical incision site with alcoholic antiseptics (alcoholic chlorhexidine) immediately before the incision; following good surgical practices; and preferably using single-use containers.<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">93–95</span></a> A single dose of the antibiotic should be administered 30−60 min before the surgical incision to ensure high plasma levels of the drug at the time of the incision. When blood loss exceeds 1,500 ml or in procedures lasting over 4 h, clinicians should consider repeating the dose, taking into account the half-life of the drug. However, repeated doses in the postoperative period are ineffective for prophylaxis and may increase the risk of resistance.</p><p id="par0315" class="elsevierStylePara elsevierViewall">The most widely recommended antibiotics for prophylaxis are first-generation cephalosporins (i.v. cefazolin 1−2 g), although amoxicillin-clavulanic acid (i.v. 2 g) can also be used. However, the microbial flora and level of risk of antibiotic resistant pathogens in each centre must be taken into account. Other options are available for patients with penicillin allergy, such as quinolones (levofloxacin 500 mg or clindamycin 600 mg plus gentamicin 240 mg in a single dose), which could be a valid alternative due to their spectrum and lung penetration. In patients with confirmed methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>, vancomycin (1 g) or linezolid (600 mg) may replace cephalosporins for antimicrobial prophylaxis. Linezolid is preferable to vancomycin, as it has shown good lung penetration and plasma concentrations remain above minimum inhibitory concentrations for susceptible pathogens during most of the dosing interval.</p><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Summary</span><p id="par0320" class="elsevierStylePara elsevierViewall">Administering intravenous antibiotics to achieve peak levels at the time of incision in thoracic surgery patients reduces the incidence of postoperative surgical wound infection.</p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Recommendations</span><p id="par0325" class="elsevierStylePara elsevierViewall">In patients that are tolerant of penicillin, administer 2 g cefazolin 30−60 min before surgical incision. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0330" class="elsevierStylePara elsevierViewall">Repeat the dose of prophylactic antibiotic if surgery lasts more than 4 h and/or intraoperative blood loss >1,500 ml. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0335" class="elsevierStylePara elsevierViewall">Alcoholic chlorhexidine is the antiseptic of choice in surgical preparation. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0340" class="elsevierStylePara elsevierViewall">Trim hair instead of shaving if it needs to be removed before the incision. Quality of evidence: high. Grade of recommendation: strong.</p></span></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Prevention of intraoperative hypothermia</span><p id="par0345" class="elsevierStylePara elsevierViewall">Hypothermia, defined as a body temperature less than 36 °C, is common during anaesthesia (general or regional), and is due to a combination of anaesthesia-induced inhibition of the thermoregulatory response, low operating room temperatures, and patient nudity. Despite the measures available in operating rooms to prevent and treat hypothermia, an incidence of between 35% and 50% has been reported.<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">96,97</span></a> Perioperative hypothermia has been associated with higher postoperative morbidity and mortality (cardiac events, greater blood loss, risk of infection, prolonged hospital stay and in postoperative care units).<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a> Hypothermia is also very unpleasant for patients.</p><p id="par0350" class="elsevierStylePara elsevierViewall">Lung resection patients are at high risk for intraoperative hypothermia due to the need to expose a large proportion of the pleural surface during surgery. In a retrospective study, Cywinski et al. analysed 2,000 patients that had undergone open lung surgery, and found the median body temperature to be 36 °C (IQR 35.5–36.5 °C), meaning that half of them were hypothermic.<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a> Another retrospective study in thoracic surgery patients found evidence of hypothermia in 64%, with or without epidural anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">100</span></a> The European Society of Cardiology recommends measuring temperature in the nasopharynx.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0355" class="elsevierStylePara elsevierViewall">The NICE guidelines recommend measuring temperature 1 h before transferring the patient to the operating room. If it is below 36 °C, active warming should be started preoperatively on the ward and continued until anaesthesia induction.<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">101</span></a> Anaesthesia should not be induced until the temperature has reached 36 °C. Thereafter, temperature should be monitored intraoperatively at least every 30 min, and the patient should be adequately covered during surgery, except for the surgical site.</p><p id="par0360" class="elsevierStylePara elsevierViewall">Forced-air warming devices are superior to resistive heating devices in preventing hypothermia, and are recommended during surgery. A combination of active warming methods is beneficial in preventing hypothermia, provided these include a forced air device. Warming intravenous fluids or irrigation fluids above body temperature prevents heat loss and hypothermia.<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">102</span></a></p><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Summary</span><p id="par0365" class="elsevierStylePara elsevierViewall">Perioperative hypothermia (defined as <36 °C) can have detrimental effects in the postoperative period, but is relatively easy to prevent. Thoracic surgery patients are particularly susceptible to hypothermia, and require careful temperature monitoring. Various effective methods are available to prevent or treat hypothermia.</p></span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Recommendations</span><p id="par0370" class="elsevierStylePara elsevierViewall">We recommend performing continuous temperature monitoring during thoracic surgery. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0375" class="elsevierStylePara elsevierViewall">We recommend the routine use of active heating devices. Quality of evidence: high. Grade of recommendation: strong.</p></span></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Perioperative glycaemic control</span><p id="par0380" class="elsevierStylePara elsevierViewall">Surgery and general anaesthesia elicit a physiological neuroendocrine stress response that includes insulin resistance, impaired peripheral glucose uptake, impaired insulin secretion, increased lipolysis, and protein catabolism, leading to hyperglycaemia and even ketosis in some cases. Perioperative hyperglycaemia is attenuated by the lack of caloric intake during and immediately after surgery, making it difficult to predict the final glycaemic balance. The prevalence of hyperglycaemia in non-cardiac surgery is 20%–40% in the surgical population. In both the diabetic and non-diabetic population, the presence of hyperglycaemia (defined as blood glucose >180−200 mg/dl) in the perioperative period is an independent predictor of poor prognosis (delayed healing, increased risk of infection, prolonged hospital stay, and higher mortality).<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">103–105</span></a> The risk of postoperative complications will depend on preoperative glycaemic control measures and the severity of in-hospital hyperglycaemia (pre and post-surgery).<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">103</span></a> Perioperative glycaemic control starts in the preoperative period, and includes giving diabetic patients advise on hypoglycaemic drugs and insulin administration. Blood glucose should be measured in all patients at the time of hospital admission.<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">106</span></a></p><p id="par0385" class="elsevierStylePara elsevierViewall">In diabetic patients, glycated haemoglobin levels must be determined, if they have not been measured in the preceding 4–6 weeks, and blood glucose must be measured. Glycosylated haemoglobin levels will reflect long-term blood glucose, and are an important indicator of the efficacy of current glycaemic management, particularly in patients requiring insulin. Elevated glycated haemoglobin levels are associated with a higher rate of postoperative adverse events, including infections, myocardial infarction, and mortality.<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">107,108</span></a></p><p id="par0390" class="elsevierStylePara elsevierViewall">Although opinions differ on the optimal (safest) perioperative blood glucose level, there is little evidence to support the use of a specific target. According to the WHO, the target glucose range in the perioperative period should be 110−180 mg/dl,<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">109</span></a> while the American Diabetes Association prefers a range of between 80 and 180 mg/dl.<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">106</span></a> Several measures can be used to maintain perioperative glucose levels in the desired range, but the optimal management strategy is still undecided.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">63,110</span></a> In the perioperative setting, hypoglycaemia can be detected by monitoring blood glucose levels - usually every 1 or 2 h during surgery (in patients treated with insulin or oral antidiabetics, in surgeries lasting more than 2 h, and in surgeries associated with high estimated blood glucose levels).<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">111</span></a> Finger stick blood glucose testing is unreliable in critically ill patients and those receiving vasopressor or hypotensive therapy. In these cases, laboratory tests of venous or arterial blood should be used.<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">112</span></a> Most expert-formulated protocols for insulin administration recommend monitoring perioperative glucose levels to avoid hypoglycaemia and hyperglycaemia, prevent ketoacidosis, and maintain fluid and electrolyte balance.</p><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Summary</span><p id="par0395" class="elsevierStylePara elsevierViewall">Perioperative glycaemic control starts in the preoperative period. Diabetic and non-diabetic patients may show high perioperative blood glucose levels that are associated with increased morbidity. There is no clearly defined blood glucose level, but a commonly accepted target is between 140 and 200 mg/dl in diabetic and non-diabetic patients throughout the perioperative period.</p></span><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">Recommendations</span><p id="par0400" class="elsevierStylePara elsevierViewall">Maintain perioperative blood glucose levels between 140 and 200 mg/dl in diabetic and non-diabetic patients throughout the perioperative period. Quality of evidence: moderate. Grade of recommendation: strong.</p><p id="par0405" class="elsevierStylePara elsevierViewall">Monitor blood glucose levels every hour during surgery (patients on insulin or oral antidiabetics). Quality of evidence: moderate. Grade of recommendation: strong.</p><p id="par0410" class="elsevierStylePara elsevierViewall">Treat blood glucose above 200 mg/dl with insulin and close monitoring of blood glucose. Quality of evidence: high. Grade of recommendation: strong.</p></span></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Intraoperative fluid management</span><p id="par0415" class="elsevierStylePara elsevierViewall">Since the 1980s, when Zeldin published his findings on the relationship between fluid administration and postoperative lung damage in pneumonectomy, fluid management has become one of the cornerstones of pulmonary surgery.<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">113</span></a> This relationship has also been reported in subsequent retrospective studies,<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">114,115</span></a> but it has yet to be evaluated in a prospective, randomized control trial. The systemic and pulmonary inflammatory response triggered by surgery, lung manipulation or atelectasis is believed to increase the lung’s susceptibility to a new insult (mediastinal lymphatic damage, oxygen toxicity, ventilator-induced damage of the dependent lung, ischaemia-reperfusion injury in the non-dependent lung). In this context, excessive administration of fluids can lead to pulmonary oedema and a clinical picture similar to that of adult respiratory distress syndrome. At other extreme, restrictive fluid management during pneumonectomy could theoretically cause kidney injury, although retrospective studies focussing specifically on this phenomenon have not observed this association in thoracic surgery.<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">116–118</span></a> Most experts recommend finding a neutral balance to avoid these extremes.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,119,120</span></a> The goal-directed parameters traditionally used to guide fluid therapy (systolic volume variation or pulse pressure variation) are of limited value in thoracic surgery (open chest, low tidal volume ventilation [LTV] during one-lung ventilation [OLV], and hypoxic pulmonary vasoconstriction).<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">121</span></a> In a recent retrospective study in patients undergoing minimally invasive thoracic surgery, Wu et al. observed worse postoperative outcomes in patients receiving either restrictive or liberal fluid management compared with those receiving intermediate fluid therapy.<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">122</span></a> In their observational study, Assaad et al. showed that a neutral balance strategy was not associated with an increase in extravascular lung water.<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">123</span></a> Because IR protocols include shorter fasting time, good preoperative hydration with carbohydrate drinks, and rapid postoperative reintroduction of oral fluid intake, the period during which the patient is hydrated exclusively intravenously can be shortened, thus reducing the risk of organ damage related to fluid replacement.</p><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">Summary</span><p id="par0420" class="elsevierStylePara elsevierViewall">Perioperative fluid management is one of the keys to improving postoperative prognosis in thoracic surgery patients. However, the volume and/or type of fluids to be administered and the optimal method of measuring blood volume in these situations have yet to be fully clarified, although a reasonable option is to maintain a neutral fluid balance.</p></span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">Recommendations</span><p id="par0425" class="elsevierStylePara elsevierViewall">Administer fluids to achieve a neutral fluid balance on the day of the intervention. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0430" class="elsevierStylePara elsevierViewall">Resume oral hydration early in the postoperative period. Quality of evidence: high. Grade of recommendation: strong.</p></span></span><span id="sec0240" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0260">Maintenance of hypnosis (inhalational/intravenous agents)</span><p id="par0435" class="elsevierStylePara elsevierViewall">The therapeutic arsenal currently available for the maintenance of hypnosis includes both intravenous (propofol) and inhalational (sevoflurane or desflurane) agents. These drugs have a good safety profile, and their pharmacokinetic characteristics facilitate early extubation. Halogenated agents were replaced by intravenous agents to maintain hypnosis during OLV following reports that the former inhibit hypoxic pulmonary vasoconstriction. However, latest-generation inhalational anaesthetics (sevoflurane or desflurane) do not cause clinically relevant differences in oxygenation when compared to total intravenous anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">124</span></a></p><p id="par0440" class="elsevierStylePara elsevierViewall">With regard to perioperative lung damage, determination of inflammatory cytokine levels in bronchoalveolar lavage fluid from patients receiving inhalational anaesthetics vs. propofol has shown that the latter attenuate the pulmonary inflammatory response in OLV thoracic surgery by reducing alveolar concentrations of inflammatory cytokines.<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">125</span></a> In terms of the clinical impact of this finding, 2 recent studies in thoracic surgery patients reported contradictory results. In one study, de la Gala et al. found a lower systemic and pulmonary response, a lower incidence of PPC, and lower 1-year mortality in patients receiving sevoflurane.<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">126</span></a> This contrasts with the results of a similar study comparing desflurane with propofol, in which the authors found no differences in postoperative complications between both groups of patients. The inflammatory response was not analysed in this study.<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">127</span></a></p><p id="par0445" class="elsevierStylePara elsevierViewall">Propofol, and more especially inhalational anaesthetics, have proven bronchodilator effects, and the latter are even recommended to treat asthma attacks. Because of their greater bronchodilator effect, lower airway pressures can be achieved during OLV with halogenated agents. Sevoflurane has a dose-dependent effect, while the bronchodilator effects of desflurane do not increase with increasing alveolar concentrations.</p><p id="par0450" class="elsevierStylePara elsevierViewall">However, total intravenous anaesthesia with propofol has some benefits compared to inhalational anaesthesia, including: a lower incidence of postoperative nausea and vomiting (PONV),<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">128</span></a> no environmental contamination if the bronchus is exposed during the intervention, and tolerance of slightly higher FiO<span class="elsevierStyleInf">2</span> than that permitted with inhalational anaesthesia. Zhang et al., in a randomised study of 350 cancer surgery patients (aged between 65 and 90 years), found a lower incidence of postoperative cognitive dysfunction in the group that received propofol vs. sevoflurane.<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">129</span></a> The results of 2 randomised studies comparing propofol and sevoflurane in thoracic surgery, however, were inconsistent: in one, the authors found that propofol improves cognitive function, while in the other no difference between the 2 anaesthetic agents were observed.<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">130,131</span></a></p><p id="par0455" class="elsevierStylePara elsevierViewall">Many thoracic surgery patients undergo surgery to remove tumours, so the potential clinical impact of the immunomodulatory action of hypnotic drugs is of particular concern among clinicians treating these patients. Propofol attenuates the endocrine-metabolic response and confers immune benefits by not suppressing or altering the level of function of natural killer cells. Inhalational anaesthetics, however, appear to promote immunosuppression by reducing natural killer cell activity and increasing expression of tumour cell hypoxia-inducible factor 1α.<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">132</span></a> These experimental findings, however, have yet to be confirmed in clinical practice, and there is no evidence of the advantages of total intravenous anaesthesia over inhalational anaesthesia in terms of recurrence-free survival and overall survival in cancer patients undergoing thoracic surgery.<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">133</span></a></p><span id="sec0245" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0265">Summary</span><p id="par0460" class="elsevierStylePara elsevierViewall">Intravenous and inhalation anaesthesia have shown both advantages and disadvantages, depending on the outcome variable analysed. Inhalational anaesthesia should be used when the goal is to attenuate the pulmonary inflammatory response after OLV.</p></span><span id="sec0250" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0270">Recommendations</span><p id="par0465" class="elsevierStylePara elsevierViewall">Inhalational anaesthesia vs. intravenous anaesthesia (propofol) attenuates the pulmonary inflammatory response in thoracic surgery under OLV. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0470" class="elsevierStylePara elsevierViewall">Inhalational anaesthesia vs. propofol is associated with lower airway resistance. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0475" class="elsevierStylePara elsevierViewall">Propofol reduces the incidence of PONV compared to inhalational anaesthesia. Quality of evidence: low (evidence extrapolated from other surgeries). Grade of recommendation: strong.</p><p id="par0480" class="elsevierStylePara elsevierViewall">Propofol is associated with better preservation of postoperative cognitive status. Quality of evidence: low. Grade of recommendation: moderate.</p><p id="par0485" class="elsevierStylePara elsevierViewall">The choice of intraoperative hypnotic affects prognosis in cancer patients undergoing thoracic surgery. Quality of evidence: low. Grade of recommendation: weak.</p></span></span><span id="sec0255" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0275">Maintenance of arterial oxygen saturation during one-lung ventilation</span><p id="par0490" class="elsevierStylePara elsevierViewall">OLV makes it easier for the surgeon to manage the pulmonary structures during thoracic surgery. This, however, can lead to hypoxaemia (SpO<span class="elsevierStyleInf">2</span> < 90% or PaO<span class="elsevierStyleInf">2</span> < 60 mmHg with a FiO<span class="elsevierStyleInf">2</span> of 1). If hypoxaemia is detected, the first step must be to perform fibreoptic bronchoscopy to verify correct placement of the device used to isolate the lung.<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">134</span></a> If no mechanical causes are detected and hypoxaemia persists, bipulmonary ventilation should be restarted and another strategy considered. Delivering continuous positive airway pressure (CPAP) to the collapsed lung improves arterial oxygen saturation and reduces shunt<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">135</span></a>; however, it can partially obstruct the surgical field, so it must be agreed with the surgeon based on the patient's status. Some authors have proposed delivering selective CPAP to a particular pulmonary lobe using fibreoptic bronchoscopy or a bronchial blocker.<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">136</span></a> Two recent randomized controlled studies found that delivering oxygen through a suction tube placed in the non-dependent lung (apnoeic oxygenation) improved arterial oxygen saturation without obstructing the surgical field.<a class="elsevierStyleCrossRefs" href="#bib0685"><span class="elsevierStyleSup">137,138</span></a></p><p id="par0495" class="elsevierStylePara elsevierViewall">Alveolar recruitment manoeuvres performed before or during OLV improve arterial oxygen saturation and reduce shunt and dead space.<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">139,140</span></a> These manoeuvres allow clinicians to calculate the PEEP level that will maximise lung compliance or driving pressure.<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">141</span></a></p><p id="par0500" class="elsevierStylePara elsevierViewall">Some authors have suggested using pressure-controlled instead of volume-controlled ventilation to improve arterial oxygenation, based on early promising results by Tugrul et al. in patients undergoing OLV.<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">142</span></a> Following this, Kim et al. confirmed these results in a meta-analysis, but the wide range of pressures and tidal volumes (Vt) used in the studies prevented the authors from drawing definitive conclusions.<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">143</span></a></p><span id="sec0260" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0280">Summary</span><p id="par0505" class="elsevierStylePara elsevierViewall">Although the incidence of hypoxaemia during OLV has decreased following the systematic use of fibreoptic bronchoscopy, it is essential to prepare a protocol to deal with this complication (alveolar recruitment manoeuvres, CPAP, apnoeic oxygenation).</p></span><span id="sec0265" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0285">Recommendations</span><p id="par0510" class="elsevierStylePara elsevierViewall">Use fibreoptic bronchoscopy to confirm correct placement of the pulmonary isolation device. Quality of evidence: low. Grade of recommendation: strong.</p><p id="par0515" class="elsevierStylePara elsevierViewall">Delivering oxygen to the dependent lung during OLV, with or without positive pressure (CPAP or apnoeic oxygenation) improves arterial oxygen saturation. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0520" class="elsevierStylePara elsevierViewall">Pressure-controlled ventilation provides better oxygenation than volume-controlled ventilation during OLV. Quality of evidence: low. Grade of recommendation: weak.</p></span><span id="sec0270" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0290">Dependent lung ventilation during one-lung ventilation</span><p id="par0525" class="elsevierStylePara elsevierViewall">One of the causes of PPCs after thoracic surgery is the ventilation strategy used during OLV. However, lung damage is not limited to the ventilated lung (volutrauma, atelectotrauma, biotrauma) - surgical manipulation or ischaemia-reperfusion injury can also cause postoperative injury in the collapsed lung.<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">144</span></a></p><p id="par0530" class="elsevierStylePara elsevierViewall">Following studies in patients with adult respiratory distress syndrome (ARDS), attention has mainly been focused on management of the ventilated lung in conditions that resemble ARDS. Accordingly, various protective measures have been proposed, including the use of a lung protective ventilation strategy during OLV based on low tidal volume (LVt) (<6 ml/kg ideal weight), recruitment manoeuvres, and optimal PEEP. Although there is no clear evidence that this strategy reduces the incidence of PPC or mortality,<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">145,146</span></a> it is widely used. In a recent randomized controlled study, Park et al. observed that individualising PEEP to obtain the lowest possible driving pressure gave better postoperative outcomes than a strategy in which the same Vt and recruitment manoeuvres, but a fixed PEEP, was used.<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">147</span></a></p><p id="par0535" class="elsevierStylePara elsevierViewall">Various good quality, though usually small, studies aimed at detecting differences in postoperative prognostic variables have compared the use of LVt vs high Vt during OLV.<a class="elsevierStyleCrossRefs" href="#bib0740"><span class="elsevierStyleSup">148–155</span></a> Studies analysing the expression of inflammatory biomarkers have consistently shown that lung protective ventilation attenuates the pulmonary inflammatory response.<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">156–158</span></a> However, this does not always lead to a clear improvement in clinical prognosis. Two meta-analyses have been published on this topic, also with different results. While Liu et al. in 2018 observed fewer pulmonary complications in patients receiving LVt,<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">156</span></a> El Tahan et al., in 2017, found no difference between low and high tidal volumes. In this meta-analysis, the authors showed that LVt was associated with higher PaCO<span class="elsevierStyleInf">2</span> and lower airway pressures. They also observed that arterial oxygen saturation at 60 min of starting OLV was lower, while arterial oxygen saturation at the end of surgery was higher.<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">159</span></a> In the postoperative period, the use of LVt was associated with a decrease in postoperative pulmonary infiltrates, although the incidence of PPC and length of hospital stay were similar in both groups. No definitive conclusions regarding the effects of protective ventilation can be drawn from these studies, since they use different Vt pressures, and other important protective ventilation factors (PEEP, alveolar recruitment manoeuvres) were not adequately monitored.</p></span><span id="sec0275" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0295">Summary</span><p id="par0540" class="elsevierStylePara elsevierViewall">One of the causes of postoperative lung damage in thoracic surgery under OLV is inappropriate management of the collapsed lung. Studies in patients with adult respiratory distress syndrome have led to the development of a series of measures aimed at attenuating the atelectotrauma, volutrauma and biotrauma associated with OLV. These measures are called collectively lung protective ventilation.</p></span><span id="sec0280" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0300">Recommendations</span><p id="par0545" class="elsevierStylePara elsevierViewall">We recommend using a lung protective ventilation strategy during OLV, based on LVt, low airway pressures, low driving pressure, recruitment manoeuvres, and optimal PEEP. Quality of evidence: moderate. Grade of recommendation: strong.</p></span></span><span id="sec0285" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0305">Neuromuscular blockade</span><p id="par0550" class="elsevierStylePara elsevierViewall">Incomplete recovery from neuromuscular blockade or residual neuromuscular blockade (rNMB) increases morbidity, prolongs postoperative recovery, and is associated with hypoxia, respiratory failure, and PPCs.<a class="elsevierStyleCrossRefs" href="#bib0800"><span class="elsevierStyleSup">160,161</span></a> According to guidelines on standards of monitoring, a peripheral nerve stimulator must be used to monitor depth of blockade and to guide the administration of reversal agents, even before intubation, whenever neuromuscular blocking drugs are administered. These measures will minimize the incidence of PPCs.<a class="elsevierStyleCrossRefs" href="#bib0785"><span class="elsevierStyleSup">157,162</span></a> Initially, a train-of-4 ratio of at least 0.7 was recommended before extubation. Now, following the emergence of new information on the pathophysiological consequences and incidence of residual blockade, any train-of-4 ratio below 0.9 should be considered rNMB.</p><p id="par0555" class="elsevierStylePara elsevierViewall">Recommendations on extubation advise using neuromuscular blockade reversal agents whenever necessary.</p><p id="par0560" class="elsevierStylePara elsevierViewall">The acetylcholinesterase inhibitor neostigmine has muscarinic effects, a slow and unpredictable onset of action, and cannot reverse the deepest level of neuromuscular blockade due to its ceiling effect.<a class="elsevierStyleCrossRef" href="#bib0815"><span class="elsevierStyleSup">163</span></a></p><p id="par0565" class="elsevierStylePara elsevierViewall">Sugammadex reduces unbound plasma concentrations of aminosteroid muscle relaxants by encapsulating their molecules. It is the fastest and safest of all aminosteroid neuromuscular relaxant reversal agents, and studies have shown that it is associated with a lower incidence of respiratory events than neostigmine.<a class="elsevierStyleCrossRefs" href="#bib0790"><span class="elsevierStyleSup">158,164</span></a> Any degree of neuromuscular blockade must be reversed.<a class="elsevierStyleCrossRef" href="#bib0815"><span class="elsevierStyleSup">163</span></a></p><span id="sec0290" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0310">Summary</span><p id="par0570" class="elsevierStylePara elsevierViewall">There is very little information on the management of rNMB and blockade reversal in thoracic surgery. However, given the large number of studies in recent years warning of the association between rNMB and critical events in the immediate postoperative period and/or PPCs during hospital stay, NMB must be fully reversed at the end of surgery. This is of particular interest in patients presenting a clear decrease in postoperative lung function, such as those undergoing lung resection surgery.</p></span><span id="sec0295" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0315">Recommendations</span><p id="par0575" class="elsevierStylePara elsevierViewall">Always use quantitative monitoring methods to ensure the absence of rNMB before extubating patients that have received neuromuscular blockade. Quality of evidence: high (evidence extrapolated from other surgeries). Grade of recommendation: strong.</p></span></span><span id="sec0300" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0320">Perioperative analgesia in thoracic surgery</span><p id="par0580" class="elsevierStylePara elsevierViewall">Lung resection (particularly open) is among the most painful surgeries. Analgesia plays a key role in the rapid, optimal functional recovery of these patients, and is one of the key elements in IR programs.<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">165</span></a> Inadequate analgesia can lead to respiratory failure due to difficulty mobilizing secretions (ineffective cough), which in turn leads to atelectasis or pneumonia.<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">166</span></a> Poorly controlled pain is also associated with the appearance of hypertension, cardiac arrhythmias,<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">167</span></a> and chronic post-thoracotomy pain.<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">168</span></a> Multimodal opioid-sparing analgesia is considered the cornerstone of analgesic management in patients undergoing lung resection surgery,<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">169</span></a> Most clinicians prefer to take advantage of the synergy created by combining the different mechanisms of action of regional and systemic techniques to achieve balanced analgesia that reduces the risk of adverse effects. Some authors have reported that opioid-free anaesthesia protocols used in combination with regional techniques can reduce postoperative analgesic needs in patients undergoing lung resection surgery.<a class="elsevierStyleCrossRefs" href="#bib0850"><span class="elsevierStyleSup">170,171</span></a></p><span id="sec0305" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0325">Perioperative regional analgesia</span><p id="par0585" class="elsevierStylePara elsevierViewall">Regional anaesthesia using locally administered anaesthetics gives good pain control by inhibiting the transmission of nociceptive stimuli. These techniques provide good dynamic analgesia that facilitates coughing and early mobilization, greatly reduce the demand for systemic analgesics, attenuate the inflammatory response to surgical stress, and prevent central sensitization phenomena.<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">172</span></a></p><p id="par0590" class="elsevierStylePara elsevierViewall">Thoracic epidural analgesia (TEA) has long been considered the gold standard for pain management in thoracic surgery patients. Thoracic paravertebral block (TPVB), however, has now displaced TEA as the anaesthetic technique of choice in thoracic surgery<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">169,173</span></a> because of its excellent safety profile and unilateral blockade. Both technique are similar in terms of analgesic effectiveness, 30-day mortality rate, and mean hospital stay, but TPVB is associated with a lower incidence of complications such as hypotension, respiratory complications, urinary retention, and intra- or postoperative hypotension.<a class="elsevierStyleCrossRefs" href="#bib0870"><span class="elsevierStyleSup">174,175</span></a></p><p id="par0595" class="elsevierStylePara elsevierViewall">These results, however, cannot be generalized to less invasive surgical techniques, such as video-assisted thoracoscopy (VATS). Although TPVB has been shown to be effective in VATS,<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">176</span></a> other less invasive analgesic techniques, such as intercostal nerve blocks, the serratus plane block, fascial plane blocks of the chest wall, the erector spinae block, and subpleural infusions of local anaesthetics could be just as beneficial.<a class="elsevierStyleCrossRefs" href="#bib0885"><span class="elsevierStyleSup">177–179</span></a></p><p id="par0600" class="elsevierStylePara elsevierViewall">The recent appearance of liposomal bupivacaine, which has a longer duration of action than other local anaesthetics (72−96 h), may change the role of fascial plane chest wall and intercostal neve blocks.<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">180</span></a> Mehran et al., in a retrospective analysis of 1,737 patients undergoing lung resection surgery, found that intercostal nerve block with liposomal bupivacaine was as effective as epidural analgesia, and did not increase the incidence of adverse effects.<a class="elsevierStyleCrossRef" href="#bib0905"><span class="elsevierStyleSup">181</span></a> Likewise, Dominguez et al. found that intercostal nerve block with this anaesthetic shortened hospital stay by 1 day compared to standard bupivacaine in patients undergoing VATS, although it did not improve immediate postoperative pain scores at 24 h or opioid consumption.<a class="elsevierStyleCrossRef" href="#bib0910"><span class="elsevierStyleSup">182</span></a> More good quality studies are needed to assess the analgesic effectiveness of this approach compared to other regional techniques.</p></span><span id="sec0310" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0330">Perioperative systemic analgesia</span><p id="par0605" class="elsevierStylePara elsevierViewall">Regional techniques used during the intraoperative period must be maintained for the first 2–3 postoperative days and combined with other systemic drugs. This will facilitate the progressive withdrawal of regional analgesia, and allow the patient to be discharged on oral analgesics alone. The drugs most commonly used for this purpose are:</p><p id="par0610" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Non-steroidal anti-inflammatory drugs and paracetamol.</span> Paracetamol and NSAIDs reduce opioid requirements by 30 %–35 % due to their potential synergistic effect, and are the most widely recommended adjuvant drugs in patients undergoing lung resection surgery.<a class="elsevierStyleCrossRef" href="#bib0915"><span class="elsevierStyleSup">183</span></a> In patients at risk of kidney failure, it is advisable to down-dose NSAIDs and up-dose paracetamol.<a class="elsevierStyleCrossRef" href="#bib0920"><span class="elsevierStyleSup">184</span></a></p><p id="par0615" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ketamine</span>. Studies have reported that ketamine enhances the management of acute post-thoracotomy pain by reducing opioid requirements and the incidence PONV, thereby facilitating postoperative respiratory physiotherapy,<a class="elsevierStyleCrossRefs" href="#bib0925"><span class="elsevierStyleSup">185,186</span></a> although these benefits have not been corroborated by other authors.<a class="elsevierStyleCrossRef" href="#bib0935"><span class="elsevierStyleSup">187</span></a> The effect of ketamine on the central nervous system (disorientation and psychiatric disorders) may be of particular relevance in IR programmes, so its use is reserved for patients with chronic pain prior to surgery and/or chronic high consumption of opioids.</p><p id="par0620" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Alpha-2 adrenergic agonists.</span> Dexmedetomidine as an adjunct to regional analgesia in post-thoracotomy pain management may reduce postoperative opioid requirements and has a good safety profile.<a class="elsevierStyleCrossRef" href="#bib0940"><span class="elsevierStyleSup">188</span></a> However, its haemodynamic effects (bradycardia and hypotension) and postoperative sedation have restricted it use in clinical practice.</p><p id="par0625" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Glucocorticoids.</span> These drugs have beneficial antiemetic, anti-inflammatory and analgesic effects. In the surgical setting, a single 4−8 mg i.v. dose of dexamethasone enhances pain management and reduces opioid consumption without increasing the risk of postoperative infections, although it does appear to be associated with an increase in blood glucose levels.<a class="elsevierStyleCrossRef" href="#bib0945"><span class="elsevierStyleSup">189</span></a> There is little information on the use of these drugs in thoracic surgery. Bjerregaard et al., in a randomized VATS study, observed that a dose of methylprednisolone before surgery only reduced postoperative pain on the day of surgery.<a class="elsevierStyleCrossRef" href="#bib0950"><span class="elsevierStyleSup">190</span></a></p><p id="par0630" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Lidocaine.</span> The perioperative use of this short-acting local anaesthetic has been associated with improved prognosis, particularly in patients undergoing abdominal surgery. There is little information on its use in thoracic surgery. Cui and Li described lower pain score and less demand for opioids in the first 6 postoperative hours when i.v. lidocaine was used intraoperatively.<a class="elsevierStyleCrossRef" href="#bib0955"><span class="elsevierStyleSup">191</span></a> Other authors have observed that intraoperative i.v. lidocaine attenuated the systemic and pulmonary inflammatory response in animals undergoing lobectomy.<a class="elsevierStyleCrossRef" href="#bib0960"><span class="elsevierStyleSup">192</span></a> Its perioperative use in thoracic surgery is increasing, and it is now one of the mainstays of most opioid-free anaesthesia protocols.</p><p id="par0635" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Gabapentinoids (gabapentin and pregabalin).</span> These drugs reduce opioid consumption and acute and chronic postoperative pain when used as adjuncts in multimodal analgesia regimens. Outcomes in thoracic surgery appear to be similar to those observed in other surgeries. According to a recent meta-analysis of thoracic patients, gabapentinoids reduced acute pain scores and opioid consumption in the first postoperative days, and reduced pain scores in the first and third month of follow-up.<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">193</span></a> This study also reports a higher incidence of dizziness and drowsiness associated with these drugs, a factor that may affect early rehabilitation in IR protocols.</p><p id="par0640" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Opioids.</span> These drugs used to be the cornerstone of post-thoracotomy pain treatment, but are now seldom used in thoracic surgery because of their side effects (respiratory depression, PONV, and drowsiness-sedation).<a class="elsevierStyleCrossRef" href="#bib0970"><span class="elsevierStyleSup">194</span></a> Nevertheless, they may be indicated in postoperative pain refractory to other analgesic techniques.</p></span><span id="sec0315" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0335">Summary</span><p id="par0645" class="elsevierStylePara elsevierViewall">Regional analgesia in the perioperative period of lung resection surgery determines to a large extent the evolution and prognosis of the patient. The use of TPVB or TEA with continuous infusion of local anaesthetics from the start of surgery is the technique of choice in open surgery. In minimally invasive procedures, the use of other, safer, peripheral regional nerve blocks performed under ultrasound guidance or direct vision will probably suffice. The use of multimodal, opioid-sparing analgesia reduces postoperative complications and improves pain control.</p></span><span id="sec0320" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0340">Recommendations</span><p id="par0650" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Regional analgesia in thoracotomy</span>. Intraoperative regional anaesthesia reduces perioperative opioid consumption. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0655" class="elsevierStylePara elsevierViewall">Epidural and paravertebral nerve block are the analgesic techniques of choice in open thoracotomy. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0660" class="elsevierStylePara elsevierViewall">Thoracic paravertebral block and TEA provides similar relief of acute post-thoracotomy pain, but TPVB has a better safety profile. Quality of evidence: high. Grade of recommendation: strong.</p><span id="sec0325" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0345">Regional analgesia in VATS. Regional anaesthesia reduces perioperative opioid consumption. Quality of evidence: high. Grade of recommendation: strong.</span><p id="par0665" class="elsevierStylePara elsevierViewall">The use of other peripheral chest wall nerve blocks performed under ultrasound guidance or direct vision provide good perioperative pain control. Quality of evidence: moderate. Grade of recommendation: weak.</p><p id="par0670" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Systemic analgesia</span>. Paracetamol combined with NSAIDs is useful in the management of post-thoracotomy pain. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0675" class="elsevierStylePara elsevierViewall">The use of I.V. ketamine attenuates the intensity of acute post-thoracotomy pain. Quality of evidence: moderate. Grade of recommendation: weak.</p><p id="par0680" class="elsevierStylePara elsevierViewall">Gabapentinoids combined with other analgesics improve post-thoracotomy pain control. Quality of evidence: moderate. Grade of recommendation: weak.</p><p id="par0685" class="elsevierStylePara elsevierViewall">The use of perioperative corticosteroids attenuates post-thoracotomy pain. Quality of evidence: moderate. Grade of recommendation: strong.</p><p id="par0690" class="elsevierStylePara elsevierViewall">Opioid-free anaesthesia protocols combined with regional techniques can improve postoperative pain control and reduce mean hospital stay. Quality of evidence: low. Grade of recommendation: weak.</p></span></span></span><span id="sec0330" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0350">Postoperative care units. Transferring patients directly from the operating room to the surgery ward, bypassing a postoperative care unit, significantly reduces the quality of patient monitoring, and therefore increases the risk of postoperative complications. Thoracic surgery patients are frequently transferred to postoperative critical care units (POCCU) immediately after surgery. However, the need for these patients to receive treatment in a POCCU has come under scrutiny in recent years.<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">195</span></a> The indiscriminate use of POCCUs after lung resection surgery is common practice in Spain; however, various scientific societies specifically advise against routine transfer to these units on the grounds that this could increase the incidence of nosocomial infections, delirium and unnecessary hospital costs.<a class="elsevierStyleCrossRefs" href="#bib0980"><span class="elsevierStyleSup">196–199</span></a> The decision to transfer a thoracic surgery patient to a POCCU after surgery should be taken on the basis of their comorbidity, and is indicated in patients classed as ASA III-I.V. or >3 on the age-adjusted Charlson comorbidity index (ACCI).<a class="elsevierStyleCrossRef" href="#bib1000"><span class="elsevierStyleSup">200</span></a> The type of surgery will also determine the patient’s postoperative destination. In this respect, pneumonectomy, bilobectomy, extensive pleural decortication, lung transplantation, or prolonged surgery are considered high risk. In addition, patients presenting intraoperative adverse events, such as massive bleeding or serious haemodynamic alterations, may require transfer to the POCCU instead of the ward</span><p id="par0695" class="elsevierStylePara elsevierViewall">The postoperative units available in Spain are the Post-Anaesthesia Care Unit (PACU), also known as the “recovery room”, the Intermediate Care Unit, and the Critical Care or Resuscitation Unit, but their availability differs considerably among hospitals (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Each hospital has a unique combination of postoperative units, staff, expertise, and technical equipment, and this greatly influences postoperative triage decisions and patient classification. Therefore, triage guidelines must take into account these circumstances, and must be developed by the multidisciplinary team involved in the management of this type of patient.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0335" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0355">Summary</span><p id="par0700" class="elsevierStylePara elsevierViewall">The use of postoperative care units in thoracic surgery is largely determined by the resources available in each centre, but the decision must be individualised on the basis of the preoperative evaluation, the type of surgery performed, and the intraoperative course.</p></span><span id="sec0340" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0360">Recommendations</span><p id="par0705" class="elsevierStylePara elsevierViewall">Patients undergoing minor pulmonary resections (up to lobectomy), with no serious comorbidities (ASA I-II or ACCI < 3) and no major intraoperative complications, should stay in a POCCU for less than 24 h. Quality of evidence: low. Grade of recommendation: strong.</p><p id="par0710" class="elsevierStylePara elsevierViewall">All other patients should be transferred to the Intermediate Care Unit or the Critical Care Unit for a stay of at least 24 h. Quality of evidence: low. Grade of recommendation: strong.</p></span></span><span id="sec0345" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0365">Prevention and management of perioperative arrhythmias</span><p id="par0715" class="elsevierStylePara elsevierViewall">Postoperative arrhythmias are among the most common complications in thoracic surgery. Atrial fibrillation and atrial flutter (AFlut), which are associated with increased morbidity and mortality, are the most common alterations. The prevention and management of these arrhythmias is still the focus of many clinical studies. Numerous factors are involved in the pathogenesis of AFlut: inflammation, K<span class="elsevierStyleSup">+</span> and Na<span class="elsevierStyleSup">+</span> channel dysfunction, increased atrial pressure (heart valve disease, high blood pressure, pulmonary hypertension, sleep apnoea, etc.), age, male sex, history of congestive heart failure, and previous arrhythmias, among others.<a class="elsevierStyleCrossRef" href="#bib1005"><span class="elsevierStyleSup">201</span></a> The type of surgery performed must also be taken into account. The more extensive the surgery, the higher the incidence of postoperative arrhythmias. For example, pneumonectomies double the risk of developing AF compared to lobectomy.<a class="elsevierStyleCrossRef" href="#bib1010"><span class="elsevierStyleSup">202</span></a> Based on the evidence currently available, it is still unclear whether keyhole surgery reduces the appearance of postoperative arrhythmias.<a class="elsevierStyleCrossRefs" href="#bib1015"><span class="elsevierStyleSup">203,204</span></a></p><p id="par0720" class="elsevierStylePara elsevierViewall">It is important to differentiate between strategies for preventing AF and those used to manage this complication. Although a recent meta-analysis<a class="elsevierStyleCrossRef" href="#bib1025"><span class="elsevierStyleSup">205</span></a> showed that beta-blockers are effective in preventing AF, the 2014 American Association for Thoracic Surgery<a class="elsevierStyleCrossRef" href="#bib1030"><span class="elsevierStyleSup">206</span></a> guidelines advise against their use in this context because they can cause bronchospasm and hypotension in patients undergoing lung resection. However, beta blocker withdrawal can trigger a rebound phenomenon and increase the incidence of arrhythmias, so it is recommended to continue them during the perioperative period.</p><p id="par0725" class="elsevierStylePara elsevierViewall">In a systematic review of AF prophylaxis after lung surgery, the authors found that amiodarone is more effective than digoxin or calcium channel blockers in the prevention of postoperative AF.<a class="elsevierStyleCrossRef" href="#bib1035"><span class="elsevierStyleSup">207</span></a> Amiodarone is associated with few postoperative complications, but in post-pneumonectomy patients and in those receiving high doses of amiodarone careful monitoring should be considered due to the risk of acute pulmonary toxicity. Despite this, amiodarone has now been shown to be effective and safe.<a class="elsevierStyleCrossRef" href="#bib1040"><span class="elsevierStyleSup">208</span></a></p><p id="par0730" class="elsevierStylePara elsevierViewall">Magnesium has also proven effective in reducing the risk of AF. Both the Society of Thoracic Surgeons<a class="elsevierStyleCrossRef" href="#bib1045"><span class="elsevierStyleSup">209</span></a> and the American Society of Thoracic Surgeons<a class="elsevierStyleCrossRef" href="#bib1030"><span class="elsevierStyleSup">206</span></a> recommend i.v. magnesium replacement when levels are low. In a randomized study, Khalil et al., showed that amiodarone is as effective as magnesium in the prevention of AF in patients undergoing lung resection.<a class="elsevierStyleCrossRef" href="#bib1050"><span class="elsevierStyleSup">210</span></a></p><p id="par0735" class="elsevierStylePara elsevierViewall">Calcium channel blockers are less effective than the aforementioned drugs, and are associated with bradycardia and hypotension. They should be used in patients with normal cardiac function who have not previously been treated with beta-blockers.</p><p id="par0740" class="elsevierStylePara elsevierViewall">The use of statins before thoracic surgery decreases the incidence of AF in cardiac and non-cardiac surgery. In thoracic surgery, Amar et al. showed that statins reduced the incidence of AF 3-fold.<a class="elsevierStyleCrossRef" href="#bib1055"><span class="elsevierStyleSup">211</span></a> Digoxin, far from preventing AF may even increase incidence postoperatively.<a class="elsevierStyleCrossRef" href="#bib1060"><span class="elsevierStyleSup">212</span></a> Colchicine has been used to prevent cardiac complications after cardiac surgery.<a class="elsevierStyleCrossRef" href="#bib1065"><span class="elsevierStyleSup">213</span></a> It has also been used in lung resection surgery by some groups, but was not found to be beneficial.<a class="elsevierStyleCrossRef" href="#bib1070"><span class="elsevierStyleSup">214</span></a> It is currently being analysed in a global multicentre study (NCT03310125).</p><span id="sec0350" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0370">Summary</span><p id="par0745" class="elsevierStylePara elsevierViewall">The prophylactic use of beta-blockers, magnesium, amiodarone, or calcium channel blockers may be considered when there is a high risk of postoperative AF; however, there is insufficient evidence to recommend these drugs in all patients undergoing lung resection surgery. Further studies are needed to assess the risk-benefit of implementing these measures based on patient type and extent of lung resection.</p></span><span id="sec0355" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0375">Recommendations</span><p id="par0750" class="elsevierStylePara elsevierViewall">We do not recommend widespread use of pharmacological postoperative AF prophylaxis in thoracic surgery. Quality of evidence: low. Grade of recommendation: strong.</p><p id="par0755" class="elsevierStylePara elsevierViewall">We recommend not withdrawing beta-blockers if the patient has previously taken them. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0760" class="elsevierStylePara elsevierViewall">To prevent postoperative AF, we recommend replacing magnesium intravenously when levels are low Quality of evidence: low. Grade of recommendation: weak.</p><p id="par0765" class="elsevierStylePara elsevierViewall">Digoxin should not be used for FA prophylaxis. Quality of evidence: high. Grade of recommendation: weak.</p></span></span><span id="sec0360" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0380">Surgical approach</span><p id="par0770" class="elsevierStylePara elsevierViewall">Major developments in the surgical access to the thorax over the past 20 years have reduced surgery-related morbidity and expedited postoperative recovery.<a class="elsevierStyleCrossRef" href="#bib1075"><span class="elsevierStyleSup">215</span></a> The knowledge that less invasive techniques are associated with less postoperative stress has prompted researchers to develop these approaches for many types of surgery, including thoracic surgery. Minimally invasive thoracic surgery has considerably reduced the pain and perioperative morbidity associated with conventional thoracotomy.<a class="elsevierStyleCrossRef" href="#bib1080"><span class="elsevierStyleSup">216</span></a> VATS has been compared with open surgery in very few randomised controlled studies.<a class="elsevierStyleCrossRefs" href="#bib1085"><span class="elsevierStyleSup">217,218</span></a> Most evidence comes from meta-analyses comparing these 2 approaches, which show that VATS reduces the intensity of postoperative pain, perioperative complications, hospital stay, the duration of chest drainage, and the impact of surgery on quality of life compared to thoracotomy.<a class="elsevierStyleCrossRefs" href="#bib1095"><span class="elsevierStyleSup">219–221</span></a> The benefits of keyhole surgery - less surgical aggression, less postoperative pain, speedier recovery - are at the core of IR protocols. These benefits are even more evident in frail and high-risk patients.<a class="elsevierStyleCrossRefs" href="#bib1110"><span class="elsevierStyleSup">222,223</span></a></p><p id="par0775" class="elsevierStylePara elsevierViewall">Concerns have been raised over the effect of VATS on prognosis in cancer surgery. This technique was initially recommended solely in patients with T1 tumours, due to concerns over the effectiveness of lymphadenectomy performed by VATS and, therefore, long-term outcomes.<a class="elsevierStyleCrossRef" href="#bib1120"><span class="elsevierStyleSup">224</span></a> Two recent retrospective studies, however, have showed similar survival rates with VATS and open surgery,<a class="elsevierStyleCrossRefs" href="#bib1125"><span class="elsevierStyleSup">225,226</span></a> no doubt due to the experience in VATS acquired by thoracic surgeons over the years. VATS is now a widely used technique with clear benefits: less postoperative pain, less impact on respiratory function, less inflammatory response, shorter hospital stay, and the possibility of early administration of adjuvant therapy.</p><p id="par0780" class="elsevierStylePara elsevierViewall">Other approaches that can further reduce surgical aggression have recently been developed, such as uniportal VATS,<a class="elsevierStyleCrossRef" href="#bib1135"><span class="elsevierStyleSup">227</span></a> subxiphoid access with one or more ports,<a class="elsevierStyleCrossRefs" href="#bib1140"><span class="elsevierStyleSup">228,229</span></a> or approaches using finer (5 mm diameter) endostitch devices.<a class="elsevierStyleCrossRef" href="#bib1150"><span class="elsevierStyleSup">230</span></a> Little information is currently available on the advantages or superiority of any of these variants. The largest body of evidence comes a randomized study that compared uniportal against multiportal VATS, without finding significant differences.<a class="elsevierStyleCrossRef" href="#bib1155"><span class="elsevierStyleSup">231</span></a> Several literature reviews and meta-analyses have concluded that robotic surgery and VATS have similar perioperative outcomes, but none of these studies found any additional advantages for either of these techniques.<a class="elsevierStyleCrossRefs" href="#bib1160"><span class="elsevierStyleSup">232,233</span></a></p><p id="par0785" class="elsevierStylePara elsevierViewall">Techniques for reducing surgical aggression and its consequences when the open approach is unavoidable, such as muscle sparing thoracotomy, have been shown to reduce 30-day postoperative pain, spare the intercostal nerve, facilitate management of the rib spreader, rib approximation, and intracostal closure.<a class="elsevierStyleCrossRefs" href="#bib1170"><span class="elsevierStyleSup">234–236</span></a> Some surgical manoeuvres that mitigate the risk of intercostal nerve injury during rib spreading and rib approximation, such as the creation of an intercostal flap or the use of intracostal sutures, have also been described. This type of suture can reduce postoperative pain and consumption of analgesics over the 12 months following surgery compared to conventional pericostal sutures.<a class="elsevierStyleCrossRef" href="#bib1180"><span class="elsevierStyleSup">236</span></a> The intracostal suture technique consists of drilling small holes through the lower rib to avoid entrapment of the intercostal nerve. This manoeuvre can be used in combination with the creation of an intercostal flap that protects the neurovascular bundle.<a class="elsevierStyleCrossRef" href="#bib1185"><span class="elsevierStyleSup">237</span></a></p><span id="sec0365" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0385">Summary</span><p id="par0790" class="elsevierStylePara elsevierViewall">In summary, VATS is the approach of choice in patients with early-stage lung cancer. In patients contraindicated for VATS, muscle-sparing thoracotomy with techniques that avoid entrapment of the intercostal nerve during intercostal separation and closure should be used.</p></span><span id="sec0370" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0390">Recommendations</span><p id="par0795" class="elsevierStylePara elsevierViewall">Prioritise VATS over conventional thoracotomy in patients with early-stage lung cancer. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0800" class="elsevierStylePara elsevierViewall">We recommend performing muscle-sparing thoracotomy whenever the VATS approach is not feasible. Quality of evidence: moderate. Grade of recommendation: strong.</p><p id="par0805" class="elsevierStylePara elsevierViewall">In such cases, additional intercostal nerve-sparing techniques, including the creation of an intercostal muscle flap and the use of intracostal sutures can be used. Quality of evidence: moderate. Grade of recommendation: strong.</p><p id="par0810" class="elsevierStylePara elsevierViewall">Robotic surgery outcomes are similar to those achieved with VATS. Quality of evidence: moderate. Grade of recommendation: weak.</p></span></span><span id="sec0375" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0395">Management of chest tubes and suction after major lung resection</span><p id="par0815" class="elsevierStylePara elsevierViewall">At the end of lung resection surgery, the pleural cavity must be drained to remove any residual air, fluid or blood. This also allows the lungs to expand and restore the negative pressure required in the pleural cavity. Management of chest tubes (CT) affects not only the duration of drainage, but also the length of hospital stay, health costs, the intensity of postoperative pain, and postoperative respiratory function.<a class="elsevierStyleCrossRef" href="#bib1190"><span class="elsevierStyleSup">238</span></a> For these reasons, CT management is one of the cornerstones of IRLS protocols.<a class="elsevierStyleCrossRef" href="#bib1195"><span class="elsevierStyleSup">239</span></a> Despite the availability of various CT guidelines,<a class="elsevierStyleCrossRefs" href="#bib1200"><span class="elsevierStyleSup">240,241</span></a> surveys have shown that management usually follows the hospital’s accepted practise and the surgeon’s personal preference.</p><p id="par0820" class="elsevierStylePara elsevierViewall">Various factors involved in CT management can affect the postoperative course.</p><span id="sec0380" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0400">Number of chest tubes</span><p id="par0825" class="elsevierStylePara elsevierViewall">Two CTs are usually inserted, one anterior for air evacuation, and the other posterior to evacuate fluid and blood while the patient is in the supine position. Several randomized studies have shown that in standard pulmonary resections, a single CT is as effective and safe as 2 CTs, and clinical practice guidelines on CT management<a class="elsevierStyleCrossRefs" href="#bib1200"><span class="elsevierStyleSup">240,241</span></a> now recommend using 1 CT, provided there is no significant risk of bleeding or residual pleural space. Postoperative pain is less intense when only 1 CT is used.<a class="elsevierStyleCrossRef" href="#bib1210"><span class="elsevierStyleSup">242</span></a> Zhang et al. published a meta-analysis showing that 1 vs. 2 CTs gave similar results in terms of safety, duration of hospital stay, development of subcutaneous emphysema, and need for tube reinsertion. However, the use of a single CT was associated with shorter drainage time (RR − 0.43; 95% CI − 0.57, −0.19), less postoperative pain, less need for thoracentesis, and lower cost.<a class="elsevierStyleCrossRef" href="#bib1215"><span class="elsevierStyleSup">243</span></a></p></span><span id="sec0385" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0405">Summary</span><p id="par0830" class="elsevierStylePara elsevierViewall">Placing a single CT instead of 2 CTs at the end of the intervention is safe and improves postoperative pain scores.</p></span><span id="sec0390" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0410">Recommendations</span><p id="par0835" class="elsevierStylePara elsevierViewall">The use of a single CT after standard pulmonary resection reduces the intensity of postoperative pain without affecting clinical safety. Quality of evidence: moderate. Grade of recommendation: strong.</p></span><span id="sec0395" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0415">Chest drainage systems: analogue or digital</span><p id="par0840" class="elsevierStylePara elsevierViewall">Digital CTs objectively measure air leaks and intrapleural pressures. They thus eliminate interobserver subjectivity and make way for standardised protocols on the timing of tube withdrawal or the need for early re-intervention.<a class="elsevierStyleCrossRef" href="#bib1220"><span class="elsevierStyleSup">244</span></a> The Translational Medicine Society recommends the use of electronic drainage systems as a means of standardising CT management.<a class="elsevierStyleCrossRef" href="#bib1200"><span class="elsevierStyleSup">240</span></a> Digital drainage systems are easily carried by the patient, and are therefore appropriate for use in IRLS protocols.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Although the implementation of digital systems is costly, the expense is offset by improved outcomes (shorter hospital stays and duration of drainage). In a recent randomized controlled study, Plourde et al., found no difference between digital and analogues drains in terms of duration of drainage, hospital stay, need for postoperative chest radiographs, or need for CT reinsertion. However, a higher number of patients with analogue collectors underwent trial clamping before drain removal (47% vs.19%).<a class="elsevierStyleCrossRef" href="#bib1225"><span class="elsevierStyleSup">245</span></a> Aldaghlawi et al. recently published a systematic review comparing digital and analogue CT drainage systems, and concluded that the scant evidence available favours digital over analogue systems in terms of duration of drainage and hospital stay.<a class="elsevierStyleCrossRef" href="#bib1230"><span class="elsevierStyleSup">246</span></a> In their meta-analysis, Wang et al. compared both drainage systems, and observed that digital devices reduced the risk of prolonged air leak (RR 0.54; 95% CI 0.40−0.73), the duration of drainage (mean difference −0.35; 95% CI − 0.60; −0.09) and length of hospital stay (mean difference −0.35; 95% CI − 0.61; −0.09), but warned that the studies included were not blinded, so postoperative management could have influenced the results.<a class="elsevierStyleCrossRef" href="#bib1235"><span class="elsevierStyleSup">247</span></a></p></span><span id="sec0400" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0420">Summary</span><p id="par0845" class="elsevierStylePara elsevierViewall">Digital CT systems objectively measure air leaks and intrapleural pressures, thus eliminating interobserver subjectivity in CT management, and making way for standardised protocols on the timing of tube withdrawal or the need for early re-intervention if air leaks are detected. Analogue drainage, however, is safe and also facilitates early prediction of prolonged air leak. Another consideration is cost, since not all studies found that digital drainage systems reduce drainage time or mean postoperative hospital stay. It is clear that the presence of prolonged air leaks depends on other clinical factors, not on the type of drainage system used.</p></span><span id="sec0405" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0425">Recommendations</span><p id="par0850" class="elsevierStylePara elsevierViewall">We recommend using digital drainage in the postoperative period of lobectomy because it reduces uncertainty in CT management and the need for clamping trials. Quality of evidence: low. Grade of recommendation: strong.</p><p id="par0855" class="elsevierStylePara elsevierViewall">We recommend using digital systems to shorten duration of CT drainage and hospital stay. Quality of evidence: low. Grade of recommendation: weak.</p></span><span id="sec0410" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0430">Chest tube suction</span><p id="par0860" class="elsevierStylePara elsevierViewall">Suctioning chest tubes has the theoretical advantage of improving parietal-to-visceral pleural contact. However, suction can prolong air leaks and reduces patient mobilization, particularly in the case of conventional systems in which the patient is connected to wall suction. Its use has generated much controversy and has been the subject of several systematic reviews.<a class="elsevierStyleCrossRefs" href="#bib1200"><span class="elsevierStyleSup">240,248–250</span></a> The use of suction in CT drainage has no advantages over the water seal method,<a class="elsevierStyleCrossRefs" href="#bib1200"><span class="elsevierStyleSup">240,241,245</span></a> and is therefore only used during the first postoperative hours, or if there is evidence of subcutaneous emphysema or significant residual pleural space.</p></span><span id="sec0415" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0435">Summary</span><p id="par0865" class="elsevierStylePara elsevierViewall">The routine use of suction CT drainage has not been validated, except in certain clinical situations.</p></span><span id="sec0420" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0440">Recommendations</span><p id="par0870" class="elsevierStylePara elsevierViewall">Suction should only be applied to CT drains during the first 24 postoperative hours, and if there is evidence of subcutaneous emphysema. Quality of evidence: low. Grade of recommendation: strong.</p></span><span id="sec0425" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0445">Type and size of chest tubes</span><p id="par0875" class="elsevierStylePara elsevierViewall">There is no evidence from good quality studies to recommend a particular CT, since the safety and efficacy of Blake drains up to size 24 F after pulmonary or mediastinal surgery, empyema and chylothorax has not been evaluated in randomized studies. Although Blake drains appear to be effective for fluid evacuation, they may be suboptimal for air drainage.<a class="elsevierStyleCrossRef" href="#bib1255"><span class="elsevierStyleSup">251</span></a> In addition, Blake drains must be connected to suction to obtain fluid drainage performance comparable to larger conventional tubes.<a class="elsevierStyleCrossRef" href="#bib1205"><span class="elsevierStyleSup">241</span></a> For all these reasons, and in the absence of further studies, we recommend using medium to large silicone drains (24−28 F), particularly when there is a bleeding risk.<a class="elsevierStyleCrossRefs" href="#bib1205"><span class="elsevierStyleSup">241,252</span></a></p></span><span id="sec0430" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0450">Summary</span><p id="par0880" class="elsevierStylePara elsevierViewall">There are no good quality studies to recommend a particular type of chest tube; therefore, in the absence of further studies, we recommend using medium to large drains (24−28 F), especially if there is a bleeding risk.</p></span><span id="sec0435" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0455">Recommendations</span><p id="par0885" class="elsevierStylePara elsevierViewall">We recommend using medium to large silicone drains (24−28 F), particularly when there is risk of bleeding. Quality of evidence: low. Grade of recommendation: strong.</p></span><span id="sec0440" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0460">Removal of drains</span><p id="par0890" class="elsevierStylePara elsevierViewall">Chest drains should only be removed in the absence of air leak, chylothorax, or haemothorax. They should be removed on full expiration while performing a Valsalva manoeuvre.<a class="elsevierStyleCrossRef" href="#bib1265"><span class="elsevierStyleSup">253</span></a></p><p id="par0895" class="elsevierStylePara elsevierViewall">Regarding drain output, prospective and randomized studies have shown that chest tubes can be removed when the daily serosanguinous output is up to 450 ml,<a class="elsevierStyleCrossRef" href="#bib1200"><span class="elsevierStyleSup">240</span></a> bearing in mind that the use of suction and lower lobe resection increases the daily drain output.<a class="elsevierStyleCrossRefs" href="#bib1200"><span class="elsevierStyleSup">240,254</span></a></p><p id="par0900" class="elsevierStylePara elsevierViewall">If output is high, the protein/blood ratio in pleural fluid should be measured. The tube can be removed safely if the ratio is less than 0.5, in other words, the fluid is transudate. In this case, tube output can also be reduced by administering diuretics to force diuresis with diuretics.<a class="elsevierStyleCrossRef" href="#bib1200"><span class="elsevierStyleSup">240</span></a></p><p id="par0905" class="elsevierStylePara elsevierViewall">Regarding clamping trials, although no studies have been specially designed to review this issue, electronic drainage systems are known to reduce the need for clamping trials, even in high-risk patients.<a class="elsevierStyleCrossRef" href="#bib1275"><span class="elsevierStyleSup">255</span></a> In the absence of evidence, we recommend that drain clamping only be performed in exception circumstances, for example, in the presence of a particular clinical factor.</p></span><span id="sec0445" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0465">Summary</span><p id="par0910" class="elsevierStylePara elsevierViewall">Chest tubes should only be removed in the absence of air leak, chylothorax, or haemothorax. There is no evidence that clamping trials are useful.</p></span><span id="sec0450" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0470">Recommendations</span><p id="par0915" class="elsevierStylePara elsevierViewall">Chest tubes may only be removed in the absence of air leak, chylothorax and haemothorax. Quality of evidence: high. Grade of recommendation: strong.</p><p id="par0920" class="elsevierStylePara elsevierViewall">Chest tubes should be removed on full expiration while performing a Valsalva manoeuvre. Quality of evidence: moderate. Grade of recommendation: strong.</p><p id="par0925" class="elsevierStylePara elsevierViewall">Chest tubes can be removed with a daily serosanguinous output of up to 450 ml. Quality of evidence: moderate. Grade of recommendation: weak.</p><p id="par0930" class="elsevierStylePara elsevierViewall">If output is high due to the presence of transudate, it can be reduced by increasing the glomerular filtration rate with diuretics, unless specifically contraindicated. Quality of evidence: moderate. Grade of recommendation: weak.</p><p id="par0935" class="elsevierStylePara elsevierViewall">Trial clamping should only be performed in exception circumstances, for example, in the presence of a particular clinical factor. Quality of evidence: low. Grade of recommendation: weak.</p></span><span id="sec0455" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0475">Use of sealants</span><p id="par0940" class="elsevierStylePara elsevierViewall">The incidence of prolonged air leak (PAL) after lung resection surgery ranges from 22.7% in lung volume reduction surgery to 6% in segmentectomies.<a class="elsevierStyleCrossRef" href="#bib1280"><span class="elsevierStyleSup">256</span></a> In addition to prolonging the duration of drainage, PAL increases the risk of pain secondary to CT drainage, limits patient mobility, and prolongs hospital stay,<a class="elsevierStyleCrossRef" href="#bib1285"><span class="elsevierStyleSup">257</span></a> all of which should be avoided in IRLS protocols. PAL, together with inadequate postoperative pain control, is considered to be the most common cause of prolonged hospital stay after thoracic surgery.<a class="elsevierStyleCrossRefs" href="#bib1290"><span class="elsevierStyleSup">258,259</span></a> PAL, particularly when minor, may be overlooked during intraoperative aerostasis, particularly in VATS, where it can be technically difficult to perform a lung immersion test. In a recent study, the authors suggest using the mechanical ventilator to identify the presence of air leaks.<a class="elsevierStyleCrossRef" href="#bib1300"><span class="elsevierStyleSup">260</span></a> Surgical sealants have been used to both prevent and treat air leaks, and even to control bleeding. Belda-Sanchis et al. conducted a systematic review in 2010 showing that the use of surgical sealants reduced the volume of air leaks, although the incidence of pleural space infection may increase.<a class="elsevierStyleCrossRef" href="#bib1305"><span class="elsevierStyleSup">261</span></a> Another meta-analysis and systematic review published the same year<a class="elsevierStyleCrossRef" href="#bib1310"><span class="elsevierStyleSup">262</span></a> also observed that sealants reduced PAL, but the authors were unable to confirm that they increased pleural infections. In 2018, a new meta-analysis on polymeric sealants<a class="elsevierStyleCrossRef" href="#bib1315"><span class="elsevierStyleSup">263</span></a> confirmed that they reduced the risk of PAL (OR 0.55; 95% CI 0.35−0.87) and reduced hospital stay by almost 1 day (mean difference −0.96 ; 95% CI − 1.74; −0.18) without increasing the incidence of pleural infections. According to this meta-analysis, these sealants may be more beneficial in patients at high risk of developing PAL (malnutrition, active smoking, poor quality lung parenchyma, incomplete lobar fissure, volume reduction surgery, or reintervention).</p></span><span id="sec0460" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0480">Summary</span><p id="par0945" class="elsevierStylePara elsevierViewall">Given the clinical significance of PAL, particularly in IRLS protocols, it is important to implement measures that can reduce the incidence of this complication. Lung tissue sealants are more or less successful in preventing air leaks; however, routine use of this strategy has been questioned due to the expense involved.</p></span><span id="sec0465" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0485">Recommendations</span><p id="par0950" class="elsevierStylePara elsevierViewall">All patients undergoing lung resection should be checked for air leaks at the end of the procedure. Quality of evidence: moderate. Grade of recommendation: strong.</p><p id="par0955" class="elsevierStylePara elsevierViewall">Sealants can reduce the incidence and duration of PAL after lung resection surgery. Quality of evidence: moderate. Grade of recommendation: weak.</p><p id="par0960" class="elsevierStylePara elsevierViewall">We do not recommend the routine use of sealants; they should be reserved for cases with a high risk of PAL. Quality of evidence: low. Grade of recommendation: strong.</p></span><span id="sec0470" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0490">Physiotherapy and early postoperative mobilization</span><p id="par0965" class="elsevierStylePara elsevierViewall">Measures to improve lung function in thoracic surgery patients can already be started in the immediate postoperative period, provided pain is well controlled. The first measure consists of placing the patient in a semi-seated position on the bed. This facilitates diaphragmatic movement, improves ventilation, increases lung volume, and reduces atelectasis.<a class="elsevierStyleCrossRef" href="#bib1320"><span class="elsevierStyleSup">264</span></a> In some hospitals, patients are seated in a chair the same afternoon of surgery, and are even encouraged to walk around the post anaesthesia care within 1 h of admission.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This could well be one of the main obstacles to overcome in RI protocols, as it calls for significant changes in the clinical practice of postoperative care units. RI protocols promote early mobilization after surgery,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,265</span></a> and although this practice was called into question in 2 systematic reviews, the quality of the studies included was poor and the results were inconsistent.<a class="elsevierStyleCrossRefs" href="#bib1330"><span class="elsevierStyleSup">266,267</span></a></p><p id="par0970" class="elsevierStylePara elsevierViewall">In their randomized controlled trial, Jonsson et al. observed that patients included in an intense physiotherapy programme after lung surgery showed better physical activity 3 months after surgery compared to those who had received standard postoperative treatment. However, spirometry and 6-minute walk test results were similar in both groups.<a class="elsevierStyleCrossRef" href="#bib1340"><span class="elsevierStyleSup">268</span></a> According to some reports, starting physical exercise on the second postoperative day can significantly reduce the incidence of respiratory tract infections and dyspnoea and shorten hospital stay.<a class="elsevierStyleCrossRef" href="#bib1345"><span class="elsevierStyleSup">269</span></a> Other authors have observed that starting exercise programmes 14 days after surgery reduces fatigue compared to starting the same programme 14 weeks after surgery.<a class="elsevierStyleCrossRef" href="#bib1350"><span class="elsevierStyleSup">270</span></a> A recent systematic review of randomized controlled trials found that while preoperative respiratory exercise programmes attenuate the inevitable decline in postoperative lung function, the benefits of programmes started postoperatively are less obvious.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Unfortunately, there is very little information on the effects of combining these programmes before and after surgery.</p><p id="par0975" class="elsevierStylePara elsevierViewall">Different postoperative physiotherapy techniques have also been used to help patients clear excess bronchial secretions by coughing effectively with minimum discomfort.<a class="elsevierStyleCrossRef" href="#bib1355"><span class="elsevierStyleSup">271</span></a> However, their potential to protect against the appearance of PPCs has not been demonstrated.<a class="elsevierStyleCrossRef" href="#bib1360"><span class="elsevierStyleSup">272</span></a></p><p id="par0980" class="elsevierStylePara elsevierViewall">Some studies have also evaluated the use of non-invasive mechanical ventilation to minimise the appearance of PPCs in thoracic surgery by opening alveoli in the collapsed airways and increasing the patient’s functional residual capacity, which in turn improves oxygenation and reduces the work of breathing. In 2019, Torres et al. performed a meta-analysis of 5 studies in a total of 346 patients undergoing lung resection surgery to evaluate the effectiveness of postoperative continuous positive airway pressure (CPAP) to prevent PPCs.<a class="elsevierStyleCrossRef" href="#bib1365"><span class="elsevierStyleSup">273</span></a> The authors found that this practice did not reduce the incidence of PPCs or the length of hospital stay. However, 3 subsequent randomized controlled studies consistently showed better postoperative results in patients who received prophylactic CPAP in this type of surgery.<a class="elsevierStyleCrossRefs" href="#bib1370"><span class="elsevierStyleSup">274–276</span></a> The magnitude of these studies- a total of 697 patients - would suffice to override the results of the aforementioned meta-analysis.</p></span><span id="sec0475" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0495">Summary</span><p id="par0985" class="elsevierStylePara elsevierViewall">Early mobilization is one of the cornerstones of IR programmes. Although the harmful effects of bed rest are well known, more good quality studies are needed to prove the benefits of early mobilization and strategies designed to avoid postoperative physical inactivity. Recent studies showing the advantages of prophylactic non-invasive ventilation may change clinical practice in the near future, particularly in patients at high risk of developing PPCs.</p></span><span id="sec0480" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0500">Recommendations</span><p id="par0990" class="elsevierStylePara elsevierViewall">Mobilising patient within 24 h of surgery and encouraging them to perform respiratory physiotherapy can improve postoperative outcomes. Quality of evidence: low. Grade of recommendation: strong.</p><p id="par0995" class="elsevierStylePara elsevierViewall">The prophylactic use of non-invasive mechanical ventilation may improve postoperative outcomes. Quality of evidence: moderate. Grade of recommendation: weak.</p></span></span></span><span id="sec0485" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0505">Discussion</span><p id="par1000" class="elsevierStylePara elsevierViewall">These are the first IRLS guidelines published jointly by the Spanish scientific societies involved in the perioperative care of patients undergoing lung cancer surgery. We believe introducing these recommendations into clinical practice will help optimise the patient's preoperative status and reduce the perioperative stress inevitably associated with this type of surgical intervention. Morbidity and mortality in this surgery remain high, This is due, on the one hand, to patient characteristics (cancer and pre-existing disease mostly related to past or current smoking) and, on the other, to the type of surgery (intense pain that interferes with respiratory function, and loss of lung parenchyma).</p><p id="par1005" class="elsevierStylePara elsevierViewall">Although we were able to extract most of the recommendations from studies in lung cancer surgery, others had to be extrapolated from other interventions. This, and the existence of some recommendations with a low level evidence but a strong grade of recommendation, should serve as an incentive for researchers to undertake further studies in thoracic surgery.</p><p id="par1010" class="elsevierStylePara elsevierViewall">It is generally accepted that the management of patients undergoing lung cancer surgery is based on 3 pillars: good postoperative pain control, rapid removal of chest tubes, and the use of VATS. However, we believe that this approach should be extended to include other, less well known, seldom implemented measures that can improve outcomes. Keeping patients bedridden, delaying removal of chest drains, not monitoring blood glucose, temperature, etc., may lead to disappointing outcomes, and we feel compelled to draw attention to the potential added benefit that can be derived from the marginal gains obtained from other elements or actions recommended in this review. We believe these recommendations should be progressively implemented as far as practically possible in each hospital in order to standardize management and ensure the prompt recovery of patients undergoing lung cancer surgery.</p><p id="par1015" class="elsevierStylePara elsevierViewall">In conclusion, a multidisciplinary team must be created to discuss these recommendations and draw up a protocol that includes all the measures that have proven effective in minimising perioperative stress in patients undergoing lung cancer surgery.</p></span><span id="sec0490" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0510">Conflict of interests</span><p id="par1020" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1718527" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1518689" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1718526" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1518690" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:22 [ 0 => array:3 [ "identificador" => "sec0020" "titulo" => "Information and preoperative education" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Recommendations" ] ] ] 1 => array:3 [ "identificador" => "sec0035" "titulo" => "Prehabilitation and preoperative physical exercise" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Recommendations" ] ] ] 2 => array:3 [ "identificador" => "sec0050" "titulo" => "Incentive spirometry" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Recommendations" ] ] ] 3 => array:3 [ "identificador" => "sec0065" "titulo" => "Smoking cessation" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0070" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0075" "titulo" => "Recommendations" ] ] ] 4 => array:3 [ "identificador" => "sec0080" "titulo" => "Alcohol consumption" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0090" "titulo" => "Recommendations" ] ] ] 5 => array:3 [ "identificador" => "sec0095" "titulo" => "Preoperative optimization of haemoglobin" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0100" "titulo" => "Iron" ] 1 => array:2 [ "identificador" => "sec0105" "titulo" => "Erythropoietin" ] 2 => array:2 [ "identificador" => "sec0110" "titulo" => "Summary" ] 3 => array:2 [ "identificador" => "sec0115" "titulo" => "Recommendations" ] ] ] 6 => array:3 [ "identificador" => "sec0120" "titulo" => "Fasting and preoperative use of carbohydrate drinks" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0125" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0130" "titulo" => "Recommendations" ] ] ] 7 => array:3 [ "identificador" => "sec0135" "titulo" => "Preoperative anxiolysis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0140" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0145" "titulo" => "Recommendations" ] ] ] 8 => array:3 [ "identificador" => "sec0150" "titulo" => "Preoperative nutrition" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0155" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0160" "titulo" => "Recommendations" ] ] ] 9 => array:3 [ "identificador" => "sec0165" "titulo" => "Thromboprophylaxis in thoracic surgery" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0170" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0175" "titulo" => "Recommendations" ] ] ] 10 => array:3 [ "identificador" => "sec0180" "titulo" => "Antibiotic prophylaxis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0185" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0190" "titulo" => "Recommendations" ] ] ] 11 => array:3 [ "identificador" => "sec0195" "titulo" => "Prevention of intraoperative hypothermia" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0200" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0205" "titulo" => "Recommendations" ] ] ] 12 => array:3 [ "identificador" => "sec0210" "titulo" => "Perioperative glycaemic control" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0215" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0220" "titulo" => "Recommendations" ] ] ] 13 => array:3 [ "identificador" => "sec0225" "titulo" => "Intraoperative fluid management" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0230" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0235" "titulo" => "Recommendations" ] ] ] 14 => array:3 [ "identificador" => "sec0240" "titulo" => "Maintenance of hypnosis (inhalational/intravenous agents)" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0245" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0250" "titulo" => "Recommendations" ] ] ] 15 => array:3 [ "identificador" => "sec0255" "titulo" => "Maintenance of arterial oxygen saturation during one-lung ventilation" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0260" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0265" "titulo" => "Recommendations" ] 2 => array:2 [ "identificador" => "sec0270" "titulo" => "Dependent lung ventilation during one-lung ventilation" ] 3 => array:2 [ "identificador" => "sec0275" "titulo" => "Summary" ] 4 => array:2 [ "identificador" => "sec0280" "titulo" => "Recommendations" ] ] ] 16 => array:3 [ "identificador" => "sec0285" "titulo" => "Neuromuscular blockade" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0290" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0295" "titulo" => "Recommendations" ] ] ] 17 => array:3 [ "identificador" => "sec0300" "titulo" => "Perioperative analgesia in thoracic surgery" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0305" "titulo" => "Perioperative regional analgesia" ] 1 => array:2 [ "identificador" => "sec0310" "titulo" => "Perioperative systemic analgesia" ] 2 => array:2 [ "identificador" => "sec0315" "titulo" => "Summary" ] 3 => array:3 [ "identificador" => "sec0320" "titulo" => "Recommendations" "secciones" => array:1 [ …1] ] ] ] 18 => array:3 [ "identificador" => "sec0330" "titulo" => "Postoperative care units. Transferring patients directly from the operating room to the surgery ward, bypassing a postoperative care unit, significantly reduces the quality of patient monitoring, and therefore increases the risk of postoperative complications. Thoracic surgery patients are frequently transferred to postoperative critical care units (POCCU) immediately after surgery. However, the need for these patients to receive treatment in a POCCU has come under scrutiny in recent years. The indiscriminate use of POCCUs after lung resection surgery is common practice in Spain; however, various scientific societies specifically advise against routine transfer to these units on the grounds that this could increase the incidence of nosocomial infections, delirium and unnecessary hospital costs. The decision to transfer a thoracic surgery patient to a POCCU after surgery should be taken on the basis of their comorbidity, and is indicated in patients classed as ASA III-I.V. or >3 on the age-adjusted Charlson comorbidity index (ACCI). The type of surgery will also determine the patient’s postoperative destination. In this respect, pneumonectomy, bilobectomy, extensive pleural decortication, lung transplantation, or prolonged surgery are considered high risk. In addition, patients presenting intraoperative adverse events, such as massive bleeding or serious haemodynamic alterations, may require transfer to the POCCU instead of the ward" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0335" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0340" "titulo" => "Recommendations" ] ] ] 19 => array:3 [ "identificador" => "sec0345" "titulo" => "Prevention and management of perioperative arrhythmias" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0350" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0355" "titulo" => "Recommendations" ] ] ] 20 => array:3 [ "identificador" => "sec0360" "titulo" => "Surgical approach" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0365" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "sec0370" "titulo" => "Recommendations" ] ] ] 21 => array:3 [ "identificador" => "sec0375" "titulo" => "Management of chest tubes and suction after major lung resection" "secciones" => array:21 [ 0 => array:2 [ "identificador" => "sec0380" "titulo" => "Number of chest tubes" ] 1 => array:2 [ "identificador" => "sec0385" "titulo" => "Summary" ] 2 => array:2 [ "identificador" => "sec0390" "titulo" => "Recommendations" ] 3 => array:2 [ "identificador" => "sec0395" "titulo" => "Chest drainage systems: analogue or digital" ] 4 => array:2 [ "identificador" => "sec0400" "titulo" => "Summary" ] 5 => array:2 [ "identificador" => "sec0405" "titulo" => "Recommendations" ] 6 => array:2 [ "identificador" => "sec0410" "titulo" => "Chest tube suction" ] 7 => array:2 [ "identificador" => "sec0415" "titulo" => "Summary" ] 8 => array:2 [ "identificador" => "sec0420" "titulo" => "Recommendations" ] 9 => array:2 [ "identificador" => "sec0425" "titulo" => "Type and size of chest tubes" ] 10 => array:2 [ "identificador" => "sec0430" "titulo" => "Summary" ] 11 => array:2 [ "identificador" => "sec0435" "titulo" => "Recommendations" ] 12 => array:2 [ "identificador" => "sec0440" "titulo" => "Removal of drains" ] 13 => array:2 [ "identificador" => "sec0445" "titulo" => "Summary" ] 14 => array:2 [ "identificador" => "sec0450" "titulo" => "Recommendations" ] 15 => array:2 [ "identificador" => "sec0455" "titulo" => "Use of sealants" ] 16 => array:2 [ "identificador" => "sec0460" "titulo" => "Summary" ] 17 => array:2 [ "identificador" => "sec0465" "titulo" => "Recommendations" ] 18 => array:2 [ "identificador" => "sec0470" "titulo" => "Physiotherapy and early postoperative mobilization" ] 19 => array:2 [ "identificador" => "sec0475" "titulo" => "Summary" ] 20 => array:2 [ "identificador" => "sec0480" "titulo" => "Recommendations" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0485" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0490" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-10-08" "fechaAceptado" => "2021-02-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1518689" "palabras" => array:3 [ 0 => "Thoracic surgery" 1 => "Perioperative medicine" 2 => "Multimodal rehabilitation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1518690" "palabras" => array:3 [ 0 => "Cirugía torácica" 1 => "Medicina perioperatoria" 2 => "Rehabilitación multimodal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">En los últimos años se están implementando programas multidisciplinares que incluyen diferentes actuaciones durante el periodo pre, intra y postoperatorio, encaminadas a disminuir el estrés perioperatorio y por tanto a mejorar los resultados de los pacientes sometidos a intervenciones quirúrgicas. Inicialmente, estos programas se desarrollaron para cirugía colorrectal y de ahí se han ido extendiendo a otras cirugías. La cirugía torácica, considerada de elevada complejidad, al igual que otras cirugías con una alta tasa de morbi-mortalidad postoperatoria, puede ser una de las especialidades que más se beneficien de la implantación de estos programas. En esta revisión se presentan las recomendaciones elaboradas por diferentes especialidades implicadas en los cuidados perioperatorios de los pacientes que requieren la resección de un tumor pulmonar. Para la elaboración de las recomendaciones presentadas en esta guía se han tenido en cuenta los meta-análisis, revisiones sistemáticas, estudios controlados aleatorizados y no aleatorizados y estudios retrospectivos realizados en pacientes sometidos a este tipo de intervenciones. Para la clasificación de las recomendaciones se ha empleado la escala GRADE, valorando por un lado el nivel de evidencia publicado sobre cada aspecto concreto y por otro la fuerza de la recomendación con la que los autores proponen su aplicación. Las recomendaciones consideradas más importantes para este tipo de cirugía son las que se refieren a la prehabilitación, a la minimización de la agresión quirúrgica, la excelencia en el manejo del dolor perioperatorio y a los cuidados postoperatorios encaminados a proporcionar una rápida rehabilitación postoperatoria.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Garutti I, Cabañero A, Vicente R, Sánchez D, Granell M, Fraile CA, et al., Recomendaciones de la Sociedad Española de Cirugía Torácica y de la Sección de Cardiotorácica y Cirugía Vascular de la Sociedad Española de Anestesia, Reanimación y Terapéutica del Dolor, para los pacientes sometidos a cirugía pulmonar incluidos en un programa de recuperación intensificada, Revista Española de Anestesiología y Reanimación. 2022. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.redar.2021.02.005">https://doi.org/10.1016/j.redar.2021.02.005</span></p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AF, atrial fibrillation; CCU, critical care unit; CPAP, continuous positive airway pressure; CT, chest tube; IMCU, intermediate care unit; LMWH, low molecular weight heparin; NSAIDs, nonsteroidal anti-inflammatory drugs; OLV, one-lung ventilation; PAL, prolonged air leak; PCV, pressure-controlled ventilation; PEEP, positive end expiratory pressure; PONV, postoperative nausea and vomiting; rNMB, residual neuromuscular blockade; VATS, video-assisted thoracoscopy; VCV, volume controlled ventilation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Quality of evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grade of recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Information and preoperative education</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Providing the patient with adequate information before surgery can improve postoperative outcomes in thoracic surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Pre-rehabilitation</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Physical training programmes lasting more than 4 weeks improve preoperative physical capacity. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">These programs will reduce the rate of postoperative complications in patients undergoing pulmonary surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Incentive spirometry</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Performing IS during surgery waiting time vs. not performing IS improves respiratory function \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">These measures reduce the incidence of postoperative pulmonary complications, and may help shorten the length of hospital stay. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Smoking cessation</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients should be advised to quit smoking from the moment they are scheduled for surgery, starting at least 4 weeks before the procedure. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients should be offered pharmacotherapy to help them stop smoking from the moment they are scheduled for surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Alcohol consumption</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We recommend asking all patients about their alcohol consumption habits when taking the preoperative clinical history. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients should avoid alcohol for at least 4 weeks prior to surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Preoperative optimization of haemoglobin</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We recommend measuring haemoglobin levels from the moment the patient has been scheduled for lung surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We do not recommend giving blood transfusion to correct preoperative anaemia. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients with anaemia, clinicians should investigate the cause and consider administering intravenous iron and/or folic acid prior to surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We do not recommend administering erythropoietin (or similar) to correct anaemia in cancer patients undergoing thoracic surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Use of carbohydrate drinks</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We recommend administering carbohydrate drinks up to 2 h before surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low (extrapolated) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Preoperative sedation</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Do not administer benzodiazepines before surgery to reduce patient anxiety. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Preoperative nutrition</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">All patients must undergo preoperative nutritional screening. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Give patients that are malnourished or at high risk of malnutrition oral nutritional supplements. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We recommend administering immune modulating formulas to malnourished patients undergoing major cancer surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low (extrapolated) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Thromboprophylaxis in thoracic surgery</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use mechanical and pharmacological measures to prevent thromboembolism in patients undergoing lung cancer surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate (extrapolated) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continue prophylactic LMWH for 1 month (instead of 1 week) in high-risk patients. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate (extrapolated) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Antibiotic prophylaxis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients tolerant of penicillin, administer 2 g cefazolin 30−60 min before the incision. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Repeat the dose of prophylactic antibiotic if surgery lasts more than 4 h and/or intraoperative blood loss > 1,500 ml. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use alcoholic chlorhexidine as an antiseptic during surgical preparation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trim hair instead of shaving if it needs to be removed to prepare the surgical site. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Prevention of intraoperative hypothermia</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We recommend performing continuous temperature monitoring during thoracic surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We recommend the routine use of active heating devices. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Perioperative glycaemic control</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maintain perioperative blood glucose levels between 140 and 200 mg/dl in diabetic and non-diabetic patients throughout the perioperative period. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Monitor blood glucose levels every hour during surgery (in patients taking insulin or oral antidiabetics). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treat blood glucose above 200 mg/dl with insulin and closely monitor glycaemia. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Intraoperative fluid therapy in thoracic surgery</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Administer fluids to achieve a neutral fluid balance on the day of surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resume oral hydration early in the postoperative period. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Maintenance of hypnosis (inhalational/intravenous)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inhalational vs. intravenous anaesthesia (propofol) attenuates the pulmonary inflammatory response in thoracic surgery under one-lung ventilation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inhalational anaesthesia vs. propofol is associated with lower airway resistance. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Propofol reduces the incidence of PONV compared to inhalational anaesthesia. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Propofol is associated with better preservation of postoperative cognitive status. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The choice of intraoperative hypnotic affects prognosis in cancer patients undergoing thoracic surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Maintenance of arterial oxygen saturation during one-lung ventilation</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use fibreoptic bronchoscopy to confirm correct placement of the pulmonary isolation device. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Delivering oxygen to the dependent lung during OLV, with or without positive pressure (CPAP or apnoeic oxygenation), improves arterial oxygen. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PCV provides better oxygenation than VCV during ONV. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Dependent lung ventilation during one-lung ventilation</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">During OLV, we recommend using a lung protective ventilation strategy, based on LVt, low airway pressures, low driving pressure, recruitment manoeuvres, and optimal PEEP. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Neuromuscular blockade</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Always use quantitative monitoring methods to ensure the absence of rNMB before extubating patients that have received neuromuscular blockade. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High (extrapolated) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Regional analgesia in thoracic surgery</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Regional anaesthesia reduces perioperative opioid consumption. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Epidural and paravertebral nerve block are the analgesic techniques of choice in open thoracotomy. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paravertebral nerve block and thoracic epidural analgesia provide similar relief of acute post-thoracotomy pain, but the former has a better safety profile. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Regional analgesia in VATS</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Regional anaesthesia reduces perioperative opioid consumption. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The use of other ultrasound-guided peripheral chest wall nerve blocks provide good perioperative pain control. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Systemic analgesia</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paracetamol combined with NSAIDs is useful in the management of post-thoracotomy pain. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The use of intravenous or epidural ketamine attenuates the intensity of acute post-thoracotomy pain. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gabapentinoids combined with other analgesics improve post-thoracotomy pain management. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The use of perioperative corticosteroids attenuates post-thoracotomy pain. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Postoperative care units</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with no serious comorbidities who have undergone minor pulmonary resections (up to lobectomy) with no significant intraoperative complications should stay in a postoperative care unit for < 24 h. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other cases should stay in the CCU or IMCU for at least 24 h. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Prevention and management of arrhythmias in the perioperative period</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We do not recommend widespread use of pharmacological postoperative AF prophylaxis in thoracic surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We recommend not withdrawing beta-blockers if the patient has previously taken them. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To prevent postoperative AF, we recommend replacing magnesium intravenously when levels are low. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Digoxin should not be used for FA prophylaxis. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Surgical approach</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prioritise VATS over conventional thoracotomy in patients with early-stage lung cancer. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We recommend performing muscle-sparing thoracotomy whenever the VATS approach is not feasible. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In such cases, additional intercostal nerve-sparing techniques, including the creation of an intercostal muscle flap and the use of intracostal sutures, can be used. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Robotic surgery outcomes are similar to those achieved with VATS. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Management of chest tubes and suction after major lung resection</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Number of chest tubes</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The use of a single chest tube after standard pulmonary resection reduces the intensity of postoperative pain without affecting patient safety. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Chest drainage systems: analogue or digital</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We recommend using digital drainage in the postoperative period of lobectomy, because it reduces uncertainty in CT management and the need for trial clamping. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We recommend using digital systems to shorten duration of CT drainage and hospital stay. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Chest tube suction</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suction should only be applied to CT drains during the first 24 postoperative hours, and if there is evidence of subcutaneous emphysema. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Type and size of drains</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We recommend using medium to large silicone drains (24−28 F) when there is a risk of bleeding. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Removal of drains</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chest drains may only be removed in the absence of air leak, chylothorax and haemothorax. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chest drains should be removed on full expiration while performing a Valsalva manoeuvre. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chest tubes can be removed with a daily serosanguinous output of up to 450 ml. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If output is high due to the presence of transudate, it can also be reduced by increasing the glomerular filtration rate with diuretics, unless specifically contraindicated. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trial clamping should only be performed in exceptional circumstances, for example, when indicated by the presence of a particular clinical factor. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Use of sealants</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">All patients undergoing lung resection should be checked for air leaks at the end of surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sealants can reduce the incidence and duration of PAL after lung resection surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">We do not recommend the routine use of sealants; they should be reserved for cases with a high risk of PAL. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Physiotherapy and early postoperative mobilization</span>Mobilising patient within 24 h of surgery and encouraging them to perform respiratory physiotherapy can improve postoperative outcomes. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strong \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The prophylactic use of non-invasive mechanical ventilation may improve postoperative outcomes. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2917666.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Summary of recommendations.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">BiPAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure; ECG, electrocardiogram; CCU, critical care unit; IMCU, intermediate care unit; PACU, postanaesthesia care unit.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PACU \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intermediate units \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CCU \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low to moderate risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate to high risk that do not require full resources (haemodynamic and/or respiratory) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate to high risk that require specialized organ support or unstable patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Location \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adjacent to the operating room \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adjacent to the IMCU or part of the IMCU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Independent area \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Equipment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Invasive/non-invasive mechanical ventilation (CPAP, BiPAP), continuous ECG, pulse oximetry, blood pressure, suction system \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Invasive/non-invasive mechanical ventilation (CPAP, BiPAP), continuous ECG, pulse oximetry, blood pressure, suction system \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Same, plus specialized organ support (kidney, neurological, use of vasoactive mediation) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Expected length of stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><24 h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> or >24 h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>24 h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cost \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of thoracic surgery<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pleurodesis, pleural or lung biopsy, mediastinoscopy, pneumothorax, sympathectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lobectomy, segmentectomy, or wedge resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pneumonectomy or bilobectomy, lung volume reduction surgery, lung transplant, or diaphragm resection surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Staff \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nurses trained in postoperative care, anaesthesiologist or anaesthesia resident \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nurses trained in postoperative care. On-duty anaesthesiologist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Specialist critical care nurses, on-duty anaesthesiologist or intensivist \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2917665.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">In patients with no severe comorbidities (ASA I-II and/or ACCI <3) and no significant intraoperative complications.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "**" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Type of surgery in patients who do not present severe associated comorbidity or intraoperative complications.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Characteristics of postoperative care units.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:276 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ …1] "host" => array:1 [ …1] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ …1] "host" => array:1 [ …1] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ …1] "host" => array:1 [ …1] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ …1] "host" => array:1 [ …1] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ …1] "host" => array:1 [ …1] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ …1] "host" => array:1 [ …1] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 28 => array:3 [ "identificador" => "bib0145" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 29 => array:3 [ "identificador" => "bib0150" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 30 => array:3 [ "identificador" => "bib0155" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 31 => array:3 [ "identificador" => "bib0160" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 32 => array:3 [ "identificador" => "bib0165" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 33 => array:3 [ "identificador" => "bib0170" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 34 => array:3 [ "identificador" => "bib0175" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 35 => array:3 [ "identificador" => "bib0180" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 36 => array:3 [ "identificador" => "bib0185" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 37 => array:3 [ "identificador" => "bib0190" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 38 => array:3 [ "identificador" => "bib0195" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 39 => array:3 [ "identificador" => "bib0200" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 40 => array:3 [ "identificador" => "bib0205" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 41 => array:3 [ "identificador" => "bib0210" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 42 => array:3 [ "identificador" => "bib0215" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 43 => array:3 [ "identificador" => "bib0220" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 44 => array:3 [ "identificador" => "bib0225" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 45 => array:3 [ "identificador" => "bib0230" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 46 => array:3 [ "identificador" => "bib0235" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 47 => array:3 [ "identificador" => "bib0240" "etiqueta" => "48" "referencia" => array:1 [ 0 => array:2 [ …2] ] ] 48 => array:3 [ "identificador" => "bib0245" "etiqueta" => "49" "referencia" 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Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program
Recomendaciones de la Sociedad Española de Cirugía Torácica y de la Sección de Cardiotorácica y Cirugía Vascular de la Sociedad Española de Anestesia, Reanimación y Terapéutica del Dolor, para los pacientes sometidos a cirugía pulmonar incluidos en un programa de recuperación intensificada
I. Garuttia,w,
, A. Cabañerob, R. Vicentec, D. Sánchezd, M. Granelle, C.A. Frailef, M. Real Navacerradag, N. Novoah, G. Sanchez-Pedrosaa, M. Congregadoi, A. Gómezj, E. Miñanak, P. Piñeiroa, P. Cruza, F. de la Galaa, F. Querol, L.J. Huertam, M. Rodríguezn, E. Jiménezo, L. Puente-Maestup..., S. Aragonq, E. Osorio-Salazarr, M. Sitgess, M.D. Lopez Maldonadoc, F.T. Riosc, J.E. Moralese, R. Callejasq, S. Gonzalez-Bardancast, S. Botellac, M. Cortésg, M.J. Yepesu, R. Iranzov, J. SayaspVer más
Autor para correspondencia
a Servicio Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
b Servicio de Cirugía Torácica, Hospital Universitario Ramón y Cajal, Madrid, Spain
c Servicio de Anestesia y Reanimación, Hospital La Fe, Valencia, Spain
d Servicio de Cirugía Torácica, Hospital Clínic, Barcelona, Spain
e Servicio de Anestesia y Reanimación, Hospital General, Valencia, Spain
f Servicio de Cirugía Torácica, Hospital Universitari Arnau de Vilanova, Lleida, Spain
g Servicio de Anestesia y Reanimación, Hospital Universitario 12 de Octubre, Madrid, Spain
h Servicio de Cirugía Torácica, Complejo Asistencial Universitario de Salamanca (CAUS), Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
i Servicio de Cirugía Torácica, Hospital Virgen de la Macarena, Sevilla, Spain
j Unitat de Rehabilitació Cardiorespiratòria, Hospital Universitari Vall d’Hebron, Barcelona, Spain
k Servicio de Anestesia y Reanimación, Hospital de la Ribera, Alzira, Valencia, Spain
l Servicio de Cirugía Torácica, Hospital Universitario Virgen de las Nieves, Granada, Spain
m Servicio de Cirugía Torácica, Hospital General Universitario Gregorio Marañón, Madrid, Spain
n Servicio de Cirugía Torácica, Clínica Universidad de Navarra, Madrid, Spain
o Fisioterapia Respiratoria, Hospital Universitario A Coruña, La Coruña, Spain
p Servicio de Neumología, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
q Servicio de Anestesia, Reanimación y Tratamiento del Dolor, Hospital Clínico Universitario, Valencia, Spain
r Servicio de Anestesia y Reanimación, Hospital Universitari Arnau de Vilanova, Lleida, Spain
s Bloc Quirúrgic i Esterilització, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
t Servicio de Anestesia y Reanimación, Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
u Servicio de Anestesia y Reanimación, Clínica Universidad de Navarra, Navarra, Pamplona, Spain
v Servicio de Anestesia y Reanimación, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
w Departamento de Farmacología y Toxicología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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