- Initial postoperative management of the thoracic surgical patient is best performed in an intermediate or high acuity area.
- These patients are generally at increased risk of respiratory complications, which carry a high mortality rate. Aggressive chest physiotherapy and early ambulation, together with meticulous attention to analgesia, fluid management, glycemic control and nutrition are key to a successful recovery.
- It is important that the treating team be familiar with the anatomy and physiology of the chest, and the management of the different chest drainage systems.
The patient is a 64-year-old gentleman with severe COPD and an FEV1 of 38% predicted who was found to have a 1.5-cm left upper lobe mass on a chest x-ray obtained during an evaluation for pneumonia. He underwent bronchoscopy, mediastinoscopy and thoracoscopic left upper lobectomy under general anesthesia. He is brought to the ICU awake and on oxygen by face mask. He is hemodynamically stable, having received a total of 800 mL of lactated ringer's solution and 400 mL of colloid solution intraoperatively. A thoracic epidural catheter at the level of T6-7 is in place that was bolused at the beginning of the case with hydromorphone 600 mcg. A 0.125% bupivacaine infusion with 10 mcg/mL of hydromorphone was started intraoperatively at 5 mL/h and continues to infuse.
The patient described in the vignette represents a common case scenario for patients undergoing pulmonary resection. While pulmonary resections are performed frequently in North America, this patient population represents a high morbidity group that merits special attention in the postoperative period. The increasing use of video-assisted thoracoscopic surgery (VATS) over the past 2 decades has led to decreased complications, but the overall goals and challenges of care in the thoracic surgery population remain.1 In this chapter, we discuss the approach to routine postoperative care of the thoracic surgical patient. This will include risk stratification and initial assessment, pulmonary care and chest tube management, goals for fluid optimization, nutrition, glycemic control, and venous thromboembolism prophylaxis. Common respiratory, cardiovascular, and renal postoperative complications and their management have been discussed in Chapter 23. Analgesic strategies for thoracic surgical procedures will be covered in Chapter 24.
Optimal postoperative management of the thoracic surgical patient begins with a careful review of the patient's comorbidities and a clear understanding of the intraoperative course. It is useful to risk stratify these patients into low, intermediate and high risk categories using their predicted postoperative FEV1 (ppFEV1), and especially the predicted postoperative DLCO (ppDLCO). Patients in the high-risk category benefit the most from aggressive chest physiotherapy, judicious fluid management and optimal postoperative analgesia. If limited resources are available in the postoperative care unit (eg, only 1 respiratory therapist is available for 6-8 patients), they should be concentrated on the high-risk patients. For a more extensive discussion of risk stratification please refer to Chapter 9.
Thoracic surgical patients generally require an intermediate or high acuity area ...