Postoperative care of the thoracic surgery patient requires an active rehabilitative approach. Both the type of surgical procedure and the underlying disease can present a significant challenge to postoperative management. An illustration of this approach is early ambulation after surgery. Early postoperative ambulation confers multiple systemic benefits in any surgical setting but is uniquely valuable to the recovering thoracic surgery patient (Table 8-1). Ambulation promotes airway clearance and decreases the risk of pneumonia. These benefits are amplified in patients who have surgically related or underlying lung dysfunction. Thus the nature and extent of surgical resection in thoracic patients require a well-trained staff and specialized equipment for monitoring patient status, which together can have a significant impact on morbidity and mortality.
Table 8-1Brat Staging Protocol |Favorite Table|Download (.pdf) Table 8-1Brat Staging Protocol
|STAGE ||ACTIVITY ||ROOM AIR O2 SATURATION LTP ||ROOM AIR O2 SATURATION |
|0 ||Resting ||<85 ||<90 |
|1 ||Resting ||>85 ||>90 |
|2 ||Sitting ||>85 ||>90 |
|3 ||Standing ||>85 ||>90 |
|4 ||Walking 1–6 minutes ||>85 ||>90 |
|5 ||Walking >6 minutes ||>85 ||>90 |
Principles of Postoperative Care
Although many principles of postoperative care in the thoracic surgery population are common to other areas of surgery, there are some important differences. For example, fluid management in thoracic patients differs significantly from strategies used in nonthoracic patients. Lung edema and its effect on pulmonary compliance are closely linked to extracellular fluid volume. Many maneuvers made during thoracic surgery result in an increase in lung water. To compensate, it may be appropriate to restrict fluid administration postoperatively. In general, minimizing total body water improves pulmonary compliance and overall lung function.
Mediastinal dissection, whether for mediastinal tumor or esophageal surgery, can be associated with idiopathic pleural and pericardial effusions. Similarly, esophageal surgery, whether for motility disorder, reflux disease, or tumor, is associated with an increased risk for aspiration pneumonia. An additional consequence of esophagectomy is that it entails a complete vagotomy. In the acute setting, the complete vagotomy may result in prolonged dysmotility, enhancing the risk of malnutrition and even aspiration.
The range of issues that affect the recovery period include extubation, pain, air leak/chest tube management, fluid management, aspiration, ventilation, and the prevention of atrial fibrillation or pulmonary embolism. Specific complications related to a particular thoracic procedure may involve thoracic duct injury, vocal cord paralysis, pulmonary edema after lobectomy, esophageal anastomotic leak, and bronchopleural fistula.
Early extubation is the overriding goal of thoracic anesthesia and should be performed immediately after the surgical procedure. Immediate extubation not only ...