Christopher C.C. Hudson
Jordan K.C. Hudson
Steven E. Hill
• 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.
ASSESSMENT UPON ADMISSION
Thoracic surgical patients generally require an intermediate or high acuity area for recovery until their respiratory status and analgesia are optimized. Patients who require mechanical ventilation postoperatively are generally admitted to the intensive care unit. It is important that the providers caring for these patients be familiar with the management of chest tubes, epidural catheters, and respiratory equipment.
Upon admission to the recovery area, the admitting team must carefully examine the patient, paying particular attention to level of consciousness, analgesia, and respiratory status. The chest tubes need to be inspected and any obstruction ruled out, and the quantity and quality of the drainage noted. A portable chest x-ray is routinely obtained in the immediate postoperative period to confirm lung re-expansion and correct chest tube placement, and to rule out contralateral disease. A baseline ABG is also generally obtained to assess oxygenation and to rule out hypercarbia, which is common in the postoperative period and is usually mild and transient, but may manifest itself as hypertension and somnolence or agitation if severe. Other laboratory tests are obtained as indicated by the extent of the resection.
Hypertension should be treated with short acting intravenous antihypertensive medications only after hypercarbia, pain and a distended bladder have all been ruled out as the primary cause.
POSTOPERATIVE VENTILATORY SUPPORT
Not all patients will meet extubation criteria following thoracic surgery, and many will require a temporary period of noninvasive ventilatory support following extubation. In patients requiring invasive postoperative ventilation, the standard of care is to apply lung protective strategies according to ARDSNet guidelines unless contraindicated.2 However, high PEEP should be avoided to minimize the risk of developing a bronchopleural fistula.
Noninvasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP) are options for the management of patients requiring additional ventilatory support after extubation, who are able to protect their airways and are not at increased risk of aspiration. These strategies have been implemented successfully in patients following lung resection and lung transplant.3-5 Noninvasive ventilation improves postoperative oxygenation and FEV1 in patients with decreased preoperative FEV1 and on those who used NIPPV or CPAP pre-operatively.4 Caution should be used in esophagectomy patients, as they may be at increased risk of pulmonary aspiration.
PULMONARY PHYSIOTHERAPY AND EARLY AMBULATION
Physiotherapeutic interventions are typically instituted on the first postoperative day, and may begin immediately after surgery if the patient is able to participate. Although prophylactic chest physiotherapy has been widely accepted, its routine use is of uncertain benefit.6 Possible approaches include chest physiotherapy alone or in combination with incentive spirometry or noninvasive ventilation. Chest physiotherapy typically includes deep breathing exercises, airway clearance maneuvers, and early mobilization. Randomized controlled trials are currently underway to further evaluate the efficacy of various physiotherapy maneuvers in order to determine an evidence-based approach to postoperative care. In patients with acute respiratory failure after lung resection, chest physiotherapy combined with noninvasive ventilation reduces pulmonary complications, improves patient recovery, and reduces the need for intubation and invasive ventilation.7
When possible, early postoperative ambulation should be encouraged. Mobilization can begin as early as the first hour postoperatively, with staff accompaniment. A fast-track approach to rehabilitation consists of immediate postoperative extubation, early oral feeding, physiotherapy, and early removal of chest tubes, urinary catheters, and invasive lines. Appropriate patient selection is crucial, with low preoperative morbidity, adequate pain management, and avoidance of oversedation all being prerequisites. The fast-track approach has been shown to reduce postoperative complications and hospital length of stay after lobectomy.8
Patients undergoing thoracic surgery are at increased risk of morbidity and mortality compared to the general surgical population.9,10 Major respiratory complications, including pneumonia and respiratory failure are very common, occurring at an incidence of 13% in a recent review of the US data.11 Pneumonia after lung resection has a mortality rate of 20% to 25%.12 The most common causative organisms are community-acquired bacteria, notably Enterobacter, Streptococcus pneumoniae, Staphylococcus aureus, and Hemophilus influenzae. Risk factors include older age, cardiopulmonary comorbidities, smoking, worse pulmonary function, and more extensive surgical resections (pneumonectomy).13 While most risk factors are not modifiable, preoperative smoking cessation, minimizing surgical and anesthetic duration, aggressive pulmonary physiotherapy, and fast-track rehabilitation may help to reduce the incidence of postoperative pneumonia.
CHEST TUBE MANAGEMENT
Chest tube management is a routine part of the postoperative care of thoracic surgical patients. Following lung resection, chest tubes are placed to allow closed drainage of air and fluid from the pleural space, permitting re-expansion of the remaining lung to fill the intrathoracic cavity. The tubes are attached to a drainage system that permits one-way drainage only. These systems have evolved from the single bottle version developed in the late 1800s to compact versions of the three-bottle system described by Howe in 1952. Traditional chest drainage devices are generally composed of three chambers: the collecting chamber, the water-seal chamber, and the suction control chamber (Figure 22–1). Newer chest drain models are now equipped with a one-way valve that replaces the traditional water seal bottle. This valve requires no water, and hence maintains the patient seal even if the unit is tipped over. Newer systems also incorporate a dry suction system, where the suction pressure level is controlled by a self-compensating regulator instead of a column of water. This provides several advantages over the wet system: It can achieve higher suction pressures; fluid does not evaporate; requires virtually no maintenance; and it has a quieter operation, since there is no continuous bubbling in the suction chamber. Newer devices also share several common features: automatic and manual high negative pressure relief valves, a positive pressure relief valve, sampling ports, serrated, tapered catheter connectors, and an air leak meter14 (Figure 22–2).
Figure 22–1. The traditional three-bottle system. Suction is applied to the system until it reaches the pressure that will draw ambient air into the open tube of the suction control bottle. At this point, the suction pressure will equal the height of the column of water in this bottle, and the suction level will be maintained regardless of the amount of additional suction applied, since this will only draw more air into the bottle.
Figure 22–2. Components of a modern pleural drainage system. Note the one-way valve replacing the traditional water seal (second bottle in the three-bottle system) and the dry suction system replacing the traditional suction control bottle. (Reproduced with permission from Pleur-evac. Teleflex Medical).
The chest tubes and drainage system should be examined daily for patency, function, air leak, volume and character of drained fluid, and condition of the placement site. Chest tube drainage of less than 200 cc/d or 2 cc/kg/d is considered physiologic.15,16 The character of chest tube fluid should gradually change from sanguineous to serous; purulent drainage is suggestive of empyema. Fluid oscillation in the water seal that is synchronous with patient respiration—known as “tidaling”—may be seen in the properly functioning chest tube and is a reflection of intrapleural pressure changes and a patent chest tube. These oscillations disappear once the lung is reinflated or if the chest tube is blocked or kinked. Blockages can be cleared by suction catheter aspiration, although this maneuver carries the risk of infection (empyema). “Stripping” refers to simultaneously occluding the tubing and pulling it away from the patient to produce a local suction effect. Pressures of up to –400 cm water have been reported to result from this maneuver and it is therefore generally discouraged.17
Care must be exercised to ensure the connecting tubing is not allowed to droop below the top of the drainage system, since any fluid that accumulates in the loop prevents the suction applied to the drainage system to reach the pleura.14 A chest tube should never be clamped, unless it is done temporarily to allow replacement of the collection system or with accidental disconnections.
Chest radiography should be performed early in the postoperative period to ensure proper chest tube placement and adequate lung re-expansion, but daily chest radiographs are otherwise not indicated in stable patients.18
An air leak is defined as bubbling in the water-seal chamber after the air in the pleural space has been drained, and is termed “persistent” or “prolonged” if it persists beyond 4 to 7 days after chest tube insertion, or if it prolongs hospital stay.19 Persistent air leaks occur in approximately 10% cases, and represent the most common pulmonary complication after lung resection surgery.11 Most commonly, the leak is caused by inspired gas moving from denuded lung parenchyma into the pleural space, and onto the chest tube and collecting system with each respiratory effort or cough episode.
Factors that have been shown to predict a persistent air leak after lung resections are FEV1% of less than 79%, a history of steroid use, male gender, preoperative radiotherapy or chemotherapy exposure, and lobectomy operations.20,21
In order to assess for an air leak, the patient should be asked to take 2 or 3 deep breaths and any bubbles consistently moving into the air leak reservoir should be noted. The patient should then be instructed to cough to rule out a forced expiratory air leak.
Air leaks have been classified according to their timing during the respiratory cycle (inspiratory [I], expiratory [E], forced expiratory [FE], or continuous [C]) and their extent (1, least severe, through 7, most severe, based on how many columns are filled with air bubbles upon observation of the air leak meter on the pleural drainage system)22 (Figure 22–3). Digital air leak meters that allow a more precise quantification of air leaks are also available, and they have been shown to reduce hospital length of stay if used continuously during the postoperative period.23
Figure 22–3. Air leak meter. The seven columns allow a semi-quantitative evaluation of air leaks at the bedside. (Reproduced with permission from Pleur-evac. Teleflex Medical).
While expiratory and forced expiratory air leaks are common following thoracic surgery, a large inspiratory or continuous air leak is concerning for large lung tissue disruptions, bronchopleural fistula, or a malfunctioning chest tube or drainage system. Small air leaks such as forced expiratory (FE) or low-volume expiratory (E1-E3) have in general a good prognosis and resolve within a few days with the use of water seal. Larger leaks may require surgical repair or discharge to home with a chest tube, flutter (Heimlich) one-way valve and collection system in place.22
Occasionally, the chest tube becomes dislodged or partially pulled outside of the pleural cavity, allowing one or more of its side-holes to entrain room air with each inspiratory effort in the spontaneously ventilated patient. This will similarly be signaled by continuous bubbling in the pleural drainage system.
Once air leak ceases, the chest tube output decreases to acceptable levels, and chest radiography demonstrates good lung expansion, chest tube removal can be considered. Despite misconceptions to the contrary, chest tubes can be safely removed at either end-inspiration or end-expiration.24 In addition, removal of the chest tube can be safely performed while on suction, and protocols requiring weaning to water seal resulted in much longer chest tube duration and a greater number of chest radiographs.25 Chest radiography is generally performed 1 to 3 hours after chest tube removal to look for significant pneumothorax. Two studies have demonstrated that this routine may be overly conservative in nonmechanically ventilated patients and suggested that chest radiography should be based on the individual’s clinical signs and symptoms.26,27
Subcutaneous emphysema is a common and troublesome complication after pulmonary resection, occurring in approximately 6% patients.28 Air entering the pleural space is generally drained by the chest tube(s) and trapped into the pleural drainage system. Occasionally, the tube becomes obstructed by thrombus or a kink, or is inadvertently left clamped. This impedes the air in the pleura to escape and forces it to advance through the path of least resistance, dissecting through the recently surgically disrupted tissue planes into the subcutaneous fascia. Another mechanism for the development of subcutaneous emphysema is the adhesion of disrupted lung parenchyma onto the thoracotomy or thoracoscopy site, allowing the passage of air directly from the lung into the subcutaneous tissue through what is essentially a pulmonary alveolar-subcutaneous fistula.
Subcutaneous air in the chest wall is able to dissect through the soft tissue of the face, neck, chest, and shoulders, and may cause significant patient distress. Fortunately, more serious complications such as pneumomediastinum and pneumopericardium are exceedingly rare. Standard treatment of postoperative subcutaneous emphysema is to gradually increase the chest tube suction to higher pressures (20-40 cm of water). If this is unsuccessful, the insertion of a second chest tube, also placed to high suction, may alleviate the symptoms. In one-third of patients, such maneuvers will be unsuccessful—treatment options then include performing a small incision at the base of the neck or above the clavicle to allow air to escape, or simply waiting for the problem to resolve spontaneously over time. Early thoracoscopic pneumolysis and chest tube placement has been proposed as a management alternative and has been shown to reduce hospital stay in patients who develop this complication and do not respond to increased levels of chest tube suction.28
Following pneumonectomy, the goals of pleural drainage differ from lesser lung resections. The pleural space rapidly becomes fluid-filled, and a careful balance between fluid accumulation and drainage needs to be maintained. Rapid fluid and/or air evacuation may lead to mediastinal shift toward the operative side, contralateral lung overinflation and potentially pulmonary edema, and even caval compression and a reduction in cardiac output. On the contrary, accumulation of air and fluid in the pneumonectomy space without drainage may cause mediastinal shift toward the nonoperative side, compromising lung function.29 Therefore, a balanced approach to the management of intrathoracic volumes and pressures is necessary. The goal is to maintain the trachea in a midline position, classically accomplished by the careful drainage or injection of air into the operative side.30 This is achieved by the use of “pneumonectomy” or “balanced drainage” systems commercially available today.31-33 These systems are composed of three chambers: a collection chamber and two underwater valves for controlling both negative and positive pressures. They typically maintain pleural cavity pressure between +1 and –13 cm H2O, thus avoiding large pressure differences and mediastinal shift. This technique also permits drainage and quantification of blood, as well as irrigation if deemed clinically necessary.
Perioperative fluid management is an essential component of patient care especially with regards to thoracic surgery patients. In recent years, the optimal approach to fluid management has been controversial, due to a number of studies demonstrating adverse consequences of both liberal and restrictive fluid regimens.34-37 Established doctrines such as third-spacing and fluid replacement algorithms based on deficits, maintenance, and losses are being increasingly challenged in favor of goal-directed individualized approaches.38 It is clear that there are risks associated with both hypovolemia (organ hypoperfusion, systemic inflammatory response syndrome, and multi-organ failure) and hypervolemia (edema, ileus, nausea, pulmonary complications, and cardiac stress).34-37,39
The controversy of restrictive versus liberal fluid management has not materialized in thoracic surgery to the same extent as in other surgical populations due to the abundance of evidence that liberal fluid regimes result in poor outcomes following pulmonary surgery.40-43 One of the most dire complications following lung resection, particularly pneumonectomy, is pulmonary edema. Post-pneumonectomy pulmonary edema, also known as post-lung resection pulmonary edema, noncardiogenic pulmonary edema, postoperative acute lung injury and postperfusion pulmonary edema is a severe form of acute lung injury that is associated with significant morbidity and mortality and has been partially linked to overzealous administration of fluids in the perioperative period (see Chapter 23).41 In 1995, a landmark review article by Slinger summarized the existing knowledge of post-pneumonectomy pulmonary edema and proposed a goal-directed approach to the fluid management for thoracic surgery patients (Table 22–1).44 Though there have been no randomized trials of goal-directed fluid management therapies in thoracic surgery patients, there is increasing evidence in other populations of the efficacy of this approach.34,36,37,45-47
Table 22–1. Goal-Directed Fluid Management for Thoracic Surgery
Prophylactic antibiotics should be administered one hour prior to skin incision and discontinued within 24 hours of the surgical end time. Current guidelines recommend the use of a first- or second-generation cephalosporin in patients undergoing thoracic surgery, with substitution of vancomycin or clindamycin in cephalosporin-allergic patients. It is important to note that although prophylactic antibiotics are administered to prevent surgical site infections, they will not necessarily be effective against other postoperative infectious complications. For example, although cefazolin is the most widely used prophylactic antibiotic for skin incision, a recent study demonstrated only 18% causative organisms for pneumonia were susceptible to cefazolin.12 Bacterial resistance to antibiotics is an ever-present challenge affecting all areas of medicine, and new trials are necessary in order to update the existing guidelines.48
Malnutrition in hospitalized patients is a very common condition affecting up to 50% surgical patients.49 Furthermore, surgery induces a hyper-metabolic and catabolic state that further exacerbates nutritional deficiencies.50 Malnutrition is not a benign process and can lead to numerous problems including increased mortality, infection, length of stay, and poor wound healing.51,52 It is therefore essential that every effort should be made to optimize patients’ nutritional status.
Nutrition should be initiated as early as possible in the postoperative period.53-55 The European Society of Parenteral and Enteral Nutrition (ESPEN) published guidelines for both intensive care and surgical patients.56,57 They recommend that enteral feeding (by mouth or feeding tube) be the preferred route, and that it be initiated within hours after the surgery. Furthermore, parenteral nutrition should be considered early in patients who are unable to receive and absorb adequate amounts of enteral feeds in the first postoperative week.
Two particularly unique populations are the esophagectomy and pneumonectomy patients. Pneumonectomy patients are extremely vulnerable to developing pneumonia, which is associated with a mortality rate of 20% to 30%.58 It is essential to ensure that these patients are capable of swallowing and able to protect their airway prior to initiation of feeding.
Feeding following esophagectomy is particularly challenging due to the esophageal resection site.59 Most surgeons allow a period of 5 to 7 days before enteral nutrition is introduced because of the delicate nature of the anastomosis and risk of leaks. Many times, a feeding jejunostomy is performed at the time of surgery to provide enteral nutrition. Transition to oral nutrition should be done judiciously following a clinical swallowing study and radiographic assessment to rule out esophageal leakage. In addition, esophagectomy patients have a reduced capacity to store food and therefore need to ingest small frequent meals in order to maintain adequate nutrition. Lastly, because these patients lack a gastroesophageal sphincter and are at risk of reflux and aspiration, it is recommended that they avoid lying flat, particularly 30 to 60 minutes after eating.
Increasing evidence suggests that in hospitalized patients, the presence of hyperglycemia is associated with poor clinical outcomes. This is true for diabetics and nondiabetics alike. Diabetes increases the risk of mortality, infection, metabolic derangements, and renal and cardiac complications.60-63 In a landmark randomized controlled trial of more than 1500 surgical intensive care unit patients, Van den Berghe found that intensive insulin therapy (target blood glucose 80-110 mg/dL) significantly reduced mortality and morbidity compared to standard therapy (target blood glucose 180-200 mg/dL).61Regrettably, the results of this study have not been validated by subsequent trials and intensive insulin therapy has been linked to increased mortality and stroke due to hypoglycemia.64-67
This new conflicting data has resulted in the development of a new consensus statement on inpatient glycemic management.68 For critically ill patients, insulin therapy should be initiated at a blood glucose level no greater than 180 mg/dL (10.0 mmol/L) and a target range of 140 to 180 mg/dL (7.8-10.0 mmol/L). Intravenous insulin infusions are the preferred method of administration and frequent glucose monitoring is essential to minimize hypoglycemia. For noncritically ill patients, the target glucose level should be less than 140 mg/dL, and blood glucose measurement can be performed more infrequently. Following lung resection surgery, most patients will be placed on a clear liquid diet and their diet advanced quickly. Sliding scale insulin coverage and resumption of their home oral and/or insulin regimen is generally sufficient to provide adequate glucose control in the postoperative period.
VENOUS THROMBOEMBOLISM PROPHYLAXIS
Cancer is a leading risk factor for venous thromboembolism, with the highest incidence found in hospitalized cancer patients receiving active therapy.69 The use of anticoagulant medications, whether prophylactic or therapeutic, is frequently encountered in the thoracic surgery population and can complicate the management of neuraxial analgesia. In the absence of contraindications, the American College of Chest Physicians recommends using low molecular weight heparin, low-dose unfractionated heparin, or fondaparinux for routine thromboembolic prophylaxis of all patients undergoing major thoracic surgery.70 In addition, early mobilization is strongly recommended, as well as utilization of graduated compression stockings and intermittent pneumatic leg compression devices.70
While a relatively high-risk procedure, pulmonary resection is essential for curative management of lung cancer. With elevated postoperative morbidity and mortality, this patient population represents a group for which postoperative management has potential to markedly improve outcome. Attention to detail and utilization of a comprehensive approach to patient care as outlined in this chapter should benefit patients such as the one described in the vignette.
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