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INTRODUCTION

The postoperative thoracic surgery patient benefits from a well-trained staff, an active rehabilitative approach, and specialized equipment to monitor progress during postoperative recovery. The care team’s understanding of both the type of surgical procedure and the underlying disease is important for proactive patient management. A frequently underappreciated aspect of surgical recovery is an active approach to rehabilitation. Early ambulation confers multiple systemic benefits in any surgical setting but is uniquely vital to the recovering thoracic patient. Ambulation promotes airway clearance and decreases the risk of pneumonia in postoperative patients with surgically impaired or abnormal respiratory physiology. Specialized equipment, including ambulatory monitoring, is useful in facilitating early mobilization and rehabilitation. Together, these components of postoperative care can have a significant impact on perioperative morbidity and mortality.

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 of the surgical and anesthetic maneuvers during thoracic surgery result in an increase in lung water. To compensate, it may be appropriate to restrict perioperative fluid administration. 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 increased risk for aspiration pneumonia. An additional consequence of esophagectomy is a complete vagotomy. In the acute setting, the vagotomy may result in prolonged bowel dysmotility—enhancing the risk of malnutrition and even aspiration.

The issues that affect the recovery period include extubation, pain, air leak/chest tube management, fluid management, aspiration, ventilation, and 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.

Extubation

Early extubation is the overriding goal of thoracic anesthesia and should be performed immediately after the surgical procedure. Immediate extubation not only improves patient mobilization but also promotes airway clearance. In rare circumstances, it may be beneficial to ventilate the postoperative patient overnight. Indications for postoperative ventilation include (1) bleeding that requires large-volume resuscitation, (2) inadequate pain control requiring high-dose parenteral narcotics, (3) decortication or visceral pleurectomy, and (4) a high-risk airway.

Pain

Postoperative pain control is essential for recovery, particularly in patients undergoing thoracotomy or sternotomy. For patients with severely impaired lung function, a preoperative epidural catheter is often indicated, even for thoracoscopic procedures. Chest wall pain can result in a restrictive chest wall and low lung volumes. Diminished forced vital capacity (FVC) ...

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