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General Principles of Postoperative Care

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.

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General Principles of Postoperative Care

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  1. General Principles of Postoperative Care

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

  3. 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

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. PREVENTION OF PULMONARY INSUFFICIENCY • Predicted postoperative DLCO or FEV1 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.

  9. 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.

  10. 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.

  11. 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.

  12. 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.

  13. 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.

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

  15. 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.

  16. 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.

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