post op care thoracic surgery
DESCRIPTION
A quick review of Post op care in Thoracic SurgeryTRANSCRIPT
Thoracic Post op Care
Col (Dr)N KannanProf Surgery and Surgical Oncology
AH(R&R)New Delhi 110010
ICC 2013 : 23 Nov 2013
“Choose well Cut well Sleep well”
Preempt management of a complicationpreventionanticipation
ICC 2013 : 23 Nov 2013
Pre-emptive measures
• Adequate pulmonary reserve• Cardiac evaluation • Cessation of smoking• Anticoagulation• Antibiotics• Exercise • Glycemic control
ICC 2013 : 23 Nov 2013
What is Special
• Pulmonary issues• Cardiac issues• Pain• Fluid therapy• Issues peculiar to the surgery• Sepsis • Specific issues
ICC 2013 : 23 Nov 2013
Pulmonary issues
Pain
AtelectasisDecreased respiratory excursions
Hypoxia
Pneumonitis
Pulmonary injury
ICC 2013 : 23 Nov 2013
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
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
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
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
Pain
• Epidural analgesia with narcotics• IV/IM analgesics• PCA• Intrapleural analgesia• Paravertebral• Neuroablative procedures
ICC 2013 : 23 Nov 2013
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
Prolonged Air leak
• Air leak persisting after 7 days– Inspiratory– Expiratory– Both
• Types– Alveolar– Open bronchus
• Management– Prevent by stapling/staple reinforcements– Conservative– Talc pleurodesis– Re exploration
ICC 2013 : 23 Nov 2013
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
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
Re-exploration
• Air leak• Thoracic Duct Leak• Anastomotic leak• Bleeding• Infection• Torsion / Herniation
ICC 2013 : 23 Nov 2013
Soft Signs
• Unexplained– Tachycardia– Arrhythmias SVT/AF
• Hypotension• Bronchospasm, aspiration • Hypoxia, Abdominal distension• Pulmonary embolism• Pneumothorax• Inflamatory response in post CCRT patients is not the
same as others
ICC 2013 : 23 Nov 2013
“Choose well Cut well Care well Sleep well”
Preempt management of a complicationpreventionanticipationknowledge
ICC 2013 : 23 Nov 2013
ICC 2013 : 23 Nov 2013
ICC 2013 : 23 Nov 2013
ICC 2013 : 23 Nov 2013
ICC 2013 : 23 Nov 2013
ICC 2013 : 23 Nov 2013
ICC 2013 : 23 Nov 2013