Chapter 23

1. Respiratory complications occur in 12% to 26% patients and account for the majority of morbidity and mortality following thoracic surgery. Postoperative predicted DLCO (ppDLCO) may be used to identify high-risk patients preoperatively. Prolonged air leak is the most common respiratory complication following thoracic surgery.

2. Renal complications following thoracic procedures are uncommon and usually occur in the setting of sepsis. Use of NSAIDs, dehydration, and preexisting renal disease are all predisposing factors. Pharmacologic therapy is generally not effective, and prevention continues to be the desired strategy.

3. Supraventricular arrhythmias are common after lung resection and are typically transient, but increase morbidity and hospital length of stay. Diltiazem appears to be effective in preventing postoperative atrial fibrillation.

A 72-year-old man with long-standing smoking history underwent a thoracotomy and right pneumonectomy for nonsmall cell lung cancer and was admitted to the surgical ICU postoperatively. He has diet controlled diabetes mellitus type II and hypertension. Preoperative medications include lovastatin and lisinopril.

Pneumonectomy is one of the surgical curative options for nonsmall cell lung cancer (NSCLC).1,2 It is usually considered for extensive tumors or for tumors located in specific anatomic areas, often as part of a multimodal approach combined with perioperative chemo3 and radiation treatment.4

Despite strict selection criteria, improved surgical and anesthetic techniques, and enhanced postoperative care, patients like the one described in the clinical vignette still suffer significant postoperative complications following lung resection surgery. There is considerable variability in the reported mortality rates after pneumonectomy (5%-6%) which depend on the case volume of the hospital, the age of the patient, the side of surgery4-7 and the use of induction chemotherapy.3 Old age, poor nutritional status, current smoking, and coronary artery disease8 are all well-known risks factors associated with an increased morbidity and mortality after lung resection. Respiratory complications are especially prevalent and a major contributor to morbidity in this patient population, who often exhibits preexisting pulmonary disease. The presence of COPD may increase the risk of developing bronchopleural fistulas and acute respiratory failure.8 Additionally, predicted postoperative DLCO (ppDLCO) is the strongest predictor of increased operative mortality and respiratory morbidity, independently from the presence of COPD9,10 (see Chapter 9). Unfortunately not all centers perform routine DLCO measurements, more so in the presence of normal spirometric measurements.

As a result of all the above, great effort should be tailored in preventing postoperative complications, since they are associated with an increase in ICU admission rates, hospital length of stay and mortality rates.8 This chapter focuses on important respiratory, renal, and cardiovascular complications following thoracic surgery.

POD1:  The patient's (from Clinical Vignette) oxygenation worsened and he was placed on 100% nonrebreather mask. His condition continued to deteriorate and was reintubated on the morning of POD2. His CXR showed diffuse pulmonary infiltrates on the left lung and normal postoperative changes in the right hemithorax.

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