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Post op care thoracic Surgery

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A quick review of Post op care in Thoracic Surgery

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Post op care thoracic Surgery

  1. 1. Thoracic Post op Care Col (Dr)N Kannan Prof Surgery and Surgical Oncology AH(R&R) New Delhi 110010 majkannan@gmail.com
  2. 2. “Choose well Cut well Sleep well” Preempt management of a complication prevention anticipation ICC 2013 : 23 Nov 2013
  3. 3. Pre-emptive measures • • • • • • • Adequate pulmonary reserve Cardiac evaluation Cessation of smoking Anticoagulation Antibiotics Exercise Glycemic control ICC 2013 : 23 Nov 2013
  4. 4. What is Special • • • • • • • Pulmonary issues Cardiac issues Pain Fluid therapy Issues peculiar to the surgery Sepsis Specific issues ICC 2013 : 23 Nov 2013
  5. 5. Pulmonary issues Pain Atelectasis Decreased respiratory excursions Pneumonitis Hypoxia Pulmonary injury ICC 2013 : 23 Nov 2013
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. Pain • • • • • • Epidural analgesia with narcotics IV/IM analgesics PCA Intrapleural analgesia Paravertebral Neuroablative procedures ICC 2013 : 23 Nov 2013
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. Re-exploration • • • • • • Air leak Thoracic Duct Leak Anastomotic leak Bleeding Infection Torsion / Herniation ICC 2013 : 23 Nov 2013
  16. 16. 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
  17. 17. “Choose well Cut well Care well Sleep well” Preempt management of a complication prevention anticipation knowledge ICC 2013 : 23 Nov 2013
  18. 18. ICC 2013 : 23 Nov 2013
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