3. Introduction
Thoracic surgical patients :elderly, coexistent disease, current smoking, underlying
carcinoma, and chronic lung disease.
prone to respiratory complications
~20% of patients undergoing lung resection suffer one or more complications
after surgery, and about 2% die.
These risks are doubled following pneumonectomy, less common after limited
wedge resection.
Important factors: Pulmonary hygiene and physiotherapy, fluid and pain
management and management of pleural spaces.
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4. Common complications : Atelectasis, haemorrhage, pulmonary oedema, atrial
fibrillation, wound infection, pneumonia, persistent air leak, and respiratory failure.
Less frequent complications : bronchopleural fistula, empyema, cardiac herniation,
pulmonary torsion, chylothorax, thromboembolism, right ventricular failure, and
neurological injury
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5. Post op pain
A source of complications ,Controlled pain less respiratory complications
Locoregional :epidural analgesia,extrapleural or paravertebral block
Systemic analgesics, PCA ,and IV,IM , PO analgesics
Multiple different agents ,reduce dose and adv effects.
Oral : Shortec/Longtec(oxycodone), MST/ Sevredol (morphine) ,codeine, co-codamol,
paracetamol
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6. Atelectasis
Collapse of segment/lobe or lung -V/Q mismatch-hypoxia
Most common post-op complication
Usually 1-2 days post lung resection in 40% of patients, 5-10%
significant
RF : Inability to cough, sputum retention, hypovent due to pain ,
sedation, diapgragmatic splinting , pleural effusion,
CXR:
Mx : Prevention always better
Non –invasive: regular physio, early mobilise,out of bed,Inc.
Spirometry, Breathing exercises,NEBs,Humodified O2
Invasive: Naso-trach suction,CPAP,bronch,mini-trachy
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7. Respiratory Failure
Causes : Narcotic overdose /inadequate reversal ,bronchospasm,atelectasis,
pneumonia,pulmonary oedema, minimal reserve preop , PE, ARDS
Classification:Type I –Hypoxaemia ,Type II ventilatory or primary hypercapnia,
Mixed :hypoxaemia with hypercapnia
Main cause of mortality , in2% , -50-100% mortality
Mx : O2 (mask-CPAP) ,Naloxone,dieuretics,Abx, Anticoagulation, NEBs , Bronch, -
TT and Mech ventilation
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8. ARDS
Acute lung injury ,Bilateral pulm infiltrations,Severe
hypoxia,No cardiogenic pulmonary oedema
Increased alv-cap permeability excessive fluid in
alveolar space ,
2-3 days post surgery, dyspnea,hypoxia
Rapid deterioration ,
5% post pneumonectomy , 2% post lobectomy,
CXR : widespread bilat infiltrations,
Mechan vent
Mortality > 75%
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9. Pulmonary Oedema
Accumulation of fluid in the alveoli and lung paranchyma
impaired gas exchange
Causes to avoid : excessive fluid administration, LVF, RVF
(following pneumon),rapid expansion of collapsed lung
Post op pneumonia
Nosocomial infection , sputum retention,atelectasis
Staph,strep pneum ,HI,Pseud,Kleb,E-coli
CXR ; Patchy consolidation
Mx :Abx, O2,Chest physio
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10. Air leak
Persistent or prolonged > or = 7days(STS >5 days) , 10-
15% following lobectomy ,
RF: age>70,COPD,Steroids,poor nutrition,redo,incomplete
fissure, LVRS ,decortication, lobectomy,incomplete lung
expansion,
Mx: if lung is fully inflated , most AL will heal in time:
watchful waiting
Talc pleurodesis
Blood patch 60-150 mls of patient's blood into pleural cav.
Reduce suction, connect to portex bag or flutter bag ,
mobilise
Bronch (stump dihescence ?)—if all fail surgery
Surgical emphysema:
ICD drainage is inadequate ,check drain , increase
suction, CXR is ICD satisfactory –CT scan, 2nd ICD ,
Worsening think of BPF , bronchoscopy .
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11. BPF
Communication bet Tracheo Bronch tree and pleural cavity
May happen after surgery , 1-2% post lob, 6-10% post
pneumo
Early Within 2 wks , late >2 months , R>L, elderly more
RF age >70, pre op chemo, radio, low FEV1 , post op
ventilation, incomplete resection, TB, extended LND,long
stump,
Productive cough(seraang fluid) ,fever, subcut emphysema,
air leak,empyema (late)
CXR : falling air-fluid level , increasing surg emphysema,
increased air space ,
Mx : protect other lung , ICD , Bronch, Abx , reoperation
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12. Post pneumonectomy syndrome
Mediastinal shift towards resected lung compression and stretching of T.B tree
and oesophagus
Rare
Months-years after pneumonectomy
More common in younger patients, F>M
Presents with : SOB ,some presents dysphagia , heartburn
In severe cases: reexploration to repostion mediastinum
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13. Bleeding
<5% of all lung resections
Sources :bronchial art., adhesions, intercostal art.segmental veins
RF: Pre op :redo,bronchiectasis ,coagulopathy,cyanosis. Intra-op
:adhesions,pleurectomy ,extrapleural resection, incomplete
fissures, inadequate haemostasis
Mx :
VS, examine, Drain output ,Hb, CXR ,
Monitor HD,Drain output progress overtime
ABC,IV F (colloid, blood)G&S , NBM, Coag(correct if need
FFP,PLT,Cryo) , Hb (keep >8g/l), CXR, Inform ,escalate
Re-exploration: (to control and evacuate)
HD Unstable despite IV Fluid
>200-300ml/hr for3-4 hrs
Significant haemothorax on CXR
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14. Arrythmias
Atrial fibrillation/flutter most common ,
10-15% following lobectomy, 40% post pneumonectomy
1st -3rd day post op, no difference bet. Vats vs open
Increased mortality , LOS
RISK FACTORS :
Pre-op >70,HTN,PMH of AF, CAD-Intra-op : Pneumonectomy,radical LN dissection,
Intrapericardial resection
Mx : talk to pt, to seniors , involve team, assess,
HD? Stability – Rate control, rhythm control,Electrolytes,Acidbase , Hypoxia,
Medications , metoprolol, bisoprolol, digoxin , Amiodaron
DC, acutely compromised
Anticoagulation if SR not restored
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15. Wound complications
Wound Haematoma: Inadequate haemostasis, anticoagulation , resolve spontan.If
large may require drainage .
Wound Seroma: plasma leak, muscle sparing thoracotomy or flaps,if large may need
drainage
Wound infection : rare for thoracotomy, superficial: Abx – may need debridment ,
deep infection underlying empyema ..empyema necessitans?
Dehiscence: reopening and debridement, pleural drainage,closure
Lung herniation :
protrusion of lung through wound dehiscence,utility port or ICD site
pain, swelling , cough impulse,localised inflammation
Surgical repair
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Hello every body, welcome to the Royal . I am Firas Al…, Here I present coplications we might encounter post thoracic surgery.
Thoracic surgical patients are frequently elderly, have substantial coexistent disease, and are particularly prone to respiratory complications. About 20% of patients undergoing lung resection suffer one or more complications after surgery, and about 2% die. These risks are doubled following pneumonectomy, and are far less common after limited wedge resection. Risk factors include patient age, current smoking, underlying carcinoma, and chronic lung disease.Anaesthetic and surgical techniques that assist early awakening and effective pain control will promote restoration of respiratory function, and this should lead to an uneventful postoperative course.
We can achieve excellent results by concentrating on the basics of postoperative care like
Postoperative haemorrhage
Immediate postoperative bleeding can be caused due to surgical bleeding or coagulopathy, surgical bleeding being more common. A set of standard coagulation tests are performed and coagulopathy is corrected accordingly. Depending on the coagulation profile factors like FFP, Platelets, cryoprecipitate or factor 7 is given if the patient is bleeding due to profound coagulopathy.The threshold for taking back a patient for re-exploration should be low, as a surgical cause of bleeding should be ruled out. Bleeding after thoracic surgery is rare. It occurs in less than 2% of video assisted Thoracoscopic procedures (VATS) and around 01% to 3% of open procedures. [35]- [38] Generally postoperative bleeding results from technical complications, but certain co morbidities may predispose a patient to bleeding. A chest tube output of 1000 ml in 1 hour necessitates an immediate return to the operating room with concurrent correction of coagulopathy. Serial drainage exceeding 200 ml per hour for 2 to 4 hours after correction of a coagulopathy also indicates surgical bleeding and dictates re-exploration. If the patient is hemodynamic ally stable but the chest output is high, checking the haematocrit on the chest tube drainage can be helpful in distinguishing active bleeding from a lymphatic leak. If a patient in the immediate postoperative period is hemodynamically unstable but the chest tube output does not suggest active haemorrhage, a chest radiograph may show radiopacity of the operative side with thrombosed chest tubes. [40]
Medications like aspirin, other antiplatelet agents’ warfarin could cause increased bleeding tendencies. Several herbs like garlic, ginseng etc. effect a prolonged bleeding time, which can result in peri operative haemorrhage. [39] The effect of herbal medications in thoracic surgery specifically is lacking, but discontinuing herbs 2 weeks before a lung resection is recommended. [40]
Recommendation for perioperative antiplatelet the current recommendations aim at providing the best option for patients. There are issues regarding continuing or discontinuing these medications. These recommendations are mainly form observational data. [41], [42], [43]
In the current era Aspirin is a lifelong therapy and it is not necessary to stop
t for surgery when there are specific indications like prevention after stroke, acute coronary syndrome, MI, or coronary revascularization, regardless of the time since the event that led to the recommendation of aspirin. [44]
Dual antiplatelet therapy is recommended during the two weeks after simple dilatation, six weeks after bare-metal stents, and at least 12 months after drug-eluting stents. [41], [42], [43] Elective operations should be postponed beyond these delays but most of the thoracic procedures have to be done as soon as possible as a bulk of cases are due to malignancy hence unless the hemorrhagic risk is excessive, dual antiplatelet therapy should not be interrupted before surgery.
Even if clopidogrel treatment must be interrupted in high-risk surgical situations, aspirin must be continued without interruption.41,42,43 Heparin has no antiplatelet activity and therefore is not an adequate substitution for aspirin or clopidogrel treatment because stent thrombosis is a platelet-mediated phenomenon. [42] Although not proven by any randomised controlled trials bridging therapy with a short-acting platelet glycoprotein IIb/IIIa inhibitor like tirofiban is a possible substitution for clopidogrel while aspirin is being maintained. [46] After the operation, antiplatelet therapy is resumed within the first 12 to 24 hours; clopidogrel therapy is reinitiated with a 300-mg loading dose, which reduces the time to achieve maximal platelet inhibition to four to six hours and decreases the risk of hyporesponsiveness from competition of other drugs with hepatic cytochromes.
Ticagrelor is used more often these days and should be stopped 36 to 48 hours prior to a planned procedure. It is reversible P2Y12 adenosine disphosphate receptor binder with shorter duration of action unlike clopidogrel which is irreversibly binds to it. The perioperative management for it is similar to the clopidogrel.
Warfarin should be discontinued 3 days preoperatively, the INR checked. I
Warfarin should be discontinued 3 days preoperatively, the INR checked. It should be substituted with heparin and APTT checked.
Conversion to an open thoracotomy for control of bleeding is done in case of bleeding due to VATS. Intraoperative bleeding can be massive from injury to the pulmonary artery or vein. Proximal control of the pulmonary artery before dissection of its branches is a safe preventive measure in open lobectomies. Rarely vascular stapler on a pulmonary vessel can cause bleeding and so can its used in the parenchyma. Suturing of the lung is done to control bleeding. Bleeding can also happen from peribronchial tissue, parenchyma, adhesions, intercostal vessels, and muscles.
In some patients, postoperative bleeding develops that is not hemodynamically significant enough to indicate re-exploration but results in a residual clotted hemothorax. As is true for a posttraumatic clotted hemothorax, treatment options include VATS or open exploration and evacuation of the hematoma to prevent development of a trapped lung, respiratory compromise, and empyema.
