A quick review of Post op care in Thoracic Surgery

1. Thoracic Post op Care
Col (Dr)N Kannan
Prof Surgery and Surgical Oncology
AH(R&R)
New Delhi 110010
majkannan@gmail.com

2. “Choose well Cut well Sleep well”
Preempt management of a complication
prevention
anticipation
ICC 2013 : 23 Nov 2013

3. Pre-emptive measures
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Adequate pulmonary reserve
Cardiac evaluation
Cessation of smoking
Anticoagulation
Antibiotics
Exercise
Glycemic control
ICC 2013 : 23 Nov 2013

4. What is Special
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Pulmonary issues
Cardiac issues
Pain
Fluid therapy
Issues peculiar to the surgery
Sepsis
Specific issues
ICC 2013 : 23 Nov 2013

5. Pulmonary issues
Pain
Atelectasis
Decreased
respiratory
excursions
Pneumonitis
Hypoxia
Pulmonary injury
ICC 2013 : 23 Nov 2013

6. Pulmonary issues
• Adequate analgesia
– Epidural narcotics
– Parenteral
• PEEP
– Mechanical ventilation
– C-PAP
– Spirometry
• Manage bronchial obstruction
– Loosen, liquify and expell
• Oxygen supplementation
• Ambulate early
ICC 2013 : 23 Nov 2013

7. Tracheobronchial toilet
• Liquify, loosen and expell
– Forced expiration better than coughing
• Bronchoscopic lavage
• Tracheostomy
– Easier secretion extraction
– Reduces airway resistance
– Helps weaning from ventilation
– Not without complications
ICC 2013 : 23 Nov 2013

8. Cardiac Issues
• Exacerbation of a pre-existing cardiac state
– CAD
– Cor pulmonale
• New cardiac issue
– Arryhthmias commonly AF and SVT
– Ischemia
– Tamponade
– Torsion
– Herniation
ICC 2013 : 23 Nov 2013

9. Fluid Therapy
• Fluid overload and pulmonary edema can be
disastrous
• Intraoperative and Post op restriction
• Accept a lower urine output on first day
• Supportive low dose inotropes
• Colloid vs Crystalloid debate
• Care with Blood products
ICC 2013 : 23 Nov 2013

10. Pain
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Epidural analgesia with narcotics
IV/IM analgesics
PCA
Intrapleural analgesia
Paravertebral
Neuroablative procedures
ICC 2013 : 23 Nov 2013

11. Chest Drains
• Commonly 1 sometimes 2 tubes
– Respiratory effort reduced
• Water seal vs Suction
– Suction when lung not expanded
• When to remove
– 100-200ml in 24hrs
ICC 2013 : 23 Nov 2013

12. Prolonged Air leak
• Air leak persisting after 7 days
– Inspiratory
– Expiratory
– Both
• Types
– Alveolar
– Open bronchus
• Management
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Prevent by stapling/staple reinforcements
Conservative
Talc pleurodesis
Re exploration
ICC 2013 : 23 Nov 2013

13. Thoracic duct leak
• Commonly noted early 1-3 days
• Sometimes late presentation after 7 days
• Conservative
– Fat free diet
– TPN
• Early intervention
– Thoracoscopic / Open
– Pre emptive ligation
ICC 2013 : 23 Nov 2013

14. Chest wall Excision
• Small segments and posterior – no major
impact
• Larger segments >3ribs and anterolateral
chest wall
– Paradoxical movement
– Atelectais
– Hypoxia
– Retained secretions
– Rigid /Semirigid Fixation and Ventilation
ICC 2013 : 23 Nov 2013

15. Re-exploration
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Air leak
Thoracic Duct Leak
Anastomotic leak
Bleeding
Infection
Torsion / Herniation
ICC 2013 : 23 Nov 2013

16. Soft Signs
• Unexplained
– Tachycardia
– Arrhythmias SVT/AF
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Hypotension
Bronchospasm, aspiration
Hypoxia, Abdominal distension
Pulmonary embolism
Pneumothorax
Inflamatory response in post CCRT patients is not
the same as others
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17. “Choose well Cut well Care well Sleep well”
Preempt management of a complication
prevention
anticipation
knowledge
ICC 2013 : 23 Nov 2013

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