General Principles of Postoperative Care

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

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

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.

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.

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.

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.

PREVENTION OF PULMONARY INSUFFICIENCY Predicted postoperative DLCO or FEV 1 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.

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.

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.

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.

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. α-agonist is preferred.

INTRAVENOUS FLUID MANAGEMENT For esophageal resection, α-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.

POSTOPERATIVE HEMORRHAGE The incidence of postoperative hemorrhage of elective chest surgery is minimal.

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.

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.