General Principles of Postoperative Care

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General Principles of Postoperative Care
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• The mortality of elective surgery of pulmonary
  and esophageal resection remains 2 to 4 times
  than that of elective coronary artery bypass
  surgery.

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PREOPERATIVE PREPARATION

• Cessation of smoking, aided by oral or
  transdermal nicotine or antidepressants and
  pulmonary rehabilitation can decrease respiratory
  complications.
• IV antibiotics before skin incision
• Pulsatile stocking and heparin SC before skin
  incision

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EPIDURAL ANALGESIA

• The limitations of intermittently administrated
  systemic narcotics include inconstant tissue
  levels, and resulting in somnolence and
  respiratory depression.
• Intercostal block by cryoanalgesia or phenol
  injection can result in neuralgia.
• The epidural space begins at the foramen magnum.

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EPIDURAL ANALGESIA

• Lumbar and thoracic epidural can be used.
• The advantage of thoracic epidural is that
  analgesia delivered directly into the dermatomal
  epicenter of the incision.
• The disadvantage of thoracic epidural is the
  difficulty of epidural catheter placement for
  angle of the spinal process.

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EPIDURAL ANALGESIA

• The incidence of spinal cord injury is less than
  1 .
• The most commonly used drug is bupivacaine, which
  is less fat soluble than fentanyl.
• The main disadvantage of epidural analgesia is
  cardiovascular side effects.
• Excessive IV fluid administration should be
  avoided to treat epidural analgesia induced
  hypotension.

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EPIDURAL ANALGESIA

• The complications of epidural analgesia are entry
  into the subarachnoid apace, hematoma, urinary
  retention, itching, nausea, and respiratory
  depression.
• All patients with epidural analgesia should have
  a Foley catheter and the catheter should be left
  6 hours after the epidural is removed.

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PREVENTION OF PULMONARY INSUFFICIENCY

• Predicted postoperative DLCO or FEV1 is less than
  40 predicted correlates increased morbidity.
• The inability to extubate a patient immediately
  is a poor prognosis sign.
• Limitation of IV fluid, chest physiotherapy,
  bronchodilator, incentive spirometry, ambulation
  with physical therapy, control of secretion and
  nutrition support can prevent pulmonary
  insufficiency.

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Chest Physiotherapy, Incentive Spirometry, and
Ambulation

• Careful induction of anesthesia decreases
  aspiration.
• Risk factors of pneumonia are prolonged
  preoperative hospitalization, pneumonectomy, poor
  lung reserve and smoking.
• Risk factors of atelectasis are poor cough,
  impaired lung function, diaphragm dysfunction,
  chest wall instability and sleeve resection.

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Chest Physiotherapy, Incentive Spirometry, and
Ambulation

• Chest physiotherapy includes vibratory
  percussion, ambulation 3 to 4 times daily, and
  secretion control.
• Respiratory treatment includes mist inhalation to
  loosen secretions.

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MONITORING

• Arterial lines are rarely used postoperatively
  but cardiac monitoring and pulse oximetry are
  used.
• If chest tube output is minimal, blood pressure
  and heart rate are normal, urinary output is
  adequate( 0.5 ml/kg per hour ) serial hemograms
  and electrolyte levels are not necessary.

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INTRAVENOUS FLUID MANAGEMENT

• Lung surgery does not cause large fluid shifts,
  as does intraperitoneal surgery.
• Deflation and expansion of lung, barotrauma and
  surgical manipulation can induce lung edema.
• Large volume of fluid should not be given to
  treat epidural dosing induced hypotention.
  a-agonist is preferred.

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INTRAVENOUS FLUID MANAGEMENT

• For esophageal resection, a-agonist is avoided to
  prevent ischemia.
• Diuretics are used to treat pulmonary edema.
• If diuretics are not useful and no septic or
  cardiogenic etiology exists, the patient may have
  ARDS.

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POSTOPERATIVE HEMORRHAGE

• The incidence of postoperative hemorrhage of
  elective chest surgery is minimal.

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MANAGEMENT OF CHEST TUBE AND AIR LEAK

• Persistent air leak after lung resection is 15 to
  50 .
• Persistent air leak can be prevented
  intraoperatively by careful inspection and
  control by suturing, stapling.
• When air leak is present, we must decide it is
  from lung or not.
• If air leak is maximal, bronchopleural fistula
  must be considered.

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MANAGEMENT OF CHEST TUBE AND AIR LEAK

• Many studies support that water seal is superior
  to suction for cessation of earlier expiratory
  and forced expiratory air leaks.
• Heimlich valve or bedside chemical pleurodesis is
  also used.
• Cerfolio prefers two 28 Fr. Chest tubes placement
  after chest surgery.