Answer:

Patients usually arrive at the hospital on the day of surgery, making traditional oral or parenteral premedication before transport to the operating room largely obsolete. Bronchoscopy and mediastinoscopy are generally ambulatory procedures, necessitating a relatively rapid hospital discharge.

EBUS-guided lymph node biopsy has become more popular in the past decade as a minimally invasive, highly accurate alternative to cervical mediastinoscopy for staging of lung cancer. It is usually performed either under sedation or general anesthesia. When combined with esophageal ultrasound-guided biopsies, it allows staging of the entire mediastinal lymphatic chain (from station 1 through 11, including 8 and 9, accessible via esophageal approach). On-site cytologic exam is usually performed during the procedure. Mediastinal, hilar, lobar, and interlobar lymph nodes are accessible with this technique with a complication rate of 1.4%. Coughing (if the airway is not adequately topicalized) and bronchospasm are common perioperative complications. The incidence of pneumothorax is rare and depends on the location of the lymph node to biopsy or the presence of bullous disease rather than the type of anesthesia and the ventilation modality. Bleeding is also a rare instance, therefore not requiring aggressive reversal of preoperative anticoagulation as generally required for a mediastinoscopy.

Cervical mediastinoscopy is now reserved for small lymph nodes not readily accessible via EBUS or in the presence of inconclusive results. During mediastinoscopy, intermittent compression or occlusion of the innominate artery can occur. Therefore, the blood pressure cuff should be placed on the left arm and the pulse oximeter on the right hand. In the case of innominate artery compression, a dampening of the pulse oximetry trace will be evident, whereas blood pressure measurements will remain accurate. Although rare, injury to vascular structures (such as the azygos veins and innominate artery) can occur, potentially necessitating a median sternotomy. Patient positioning and placement of electrocardiography leads should be considered accordingly. Arterial access is not routinely used for this procedure unless the patient has clinical indications for continuous hemodynamic monitoring. In this case, the catheter should be placed in the left radial artery as well to avoid falsely low readings related to innominate artery compression. Noninvasive continuous blood pressure monitoring can be used as an alternative. Artifacts related to compression of the reading site, especially if the arms are tucked, will affect the accuracy and precision of the monitoring, making it the main limitation to its use. Body temperature should be monitored and a warming blanket applied. Despite the potential of being a short procedure, hypothermia can occur, especially in elderly patients. Induction, maintenance of anesthesia, and muscle relaxation can be achieved with relatively short-acting agents. Propofol is frequently used for induction of general anesthesia followed by rocuronium, vecuronium, or cisatracurium to facilitate tracheal intubation via a single-lumen endotracheal tube (ETT). Anesthesia can be maintained with a potent inhalational agent in oxygen or air if adequate oxygen saturation can be maintained. Two to 3 µg per kg of fentanyl often provides sufficient analgesia for the procedure. Local anesthetic can be infiltrated in the wound by the surgeon at the beginning or at the end of the procedure. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used as adjuvant agents, in addition to intravenous acetaminophen, if not contraindicated. Finally, many clinicians choose to avoid the use of nitrous oxide because of the potential for the mediastinoscope to enter the pleural space and create a pneumothorax. The advent of sugammadex has allowed to prolong patient paralysis until the end of the procedure. Recommended reversal doses are based on the train of four (2 milligram per kilogram for two or more twitches, 4 milligram per kilogram in case of no twitches). Hypersensitivity reactions as well as anaphylaxis have been reported with the use of sugammadex and should be considered when the medication is administered.

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