**4. Post operative care**

#### **4.1. Pain management**

Pain management is of paramount importance post operatively as it is essential for patients to comply for chest physiotherapy and ambulation and they will be unable to do so if they have severe pain. There are various ways by which pain is managed. They include epidural catheters preoperatively, paravertebral methods pre or intraoperatively or intravenous patient control‐ led analgesia. On withdrawing these agents patients will need oral analgesics for duration of time till they are pain free. These include paracetamol, NSAID and narcotic agents.

#### *4.1.1. Epidural analgesia*

The catheter is placed approximately with the midpoint of the dermatomal distribution of the skin incision. Epidural local anaesthetics increase segmental bioavailability of opioids in the cerebrospinal fluid and increase the binding of opioids to m receptors and the blocking of the release of substance P in the substantia gelatinosa of the dorsal horn of the spinal cord [28]. The thoracic segmental effects of local anaesthetic and opioid combinations is the only way to minimize motor and sympathetic blockade maintain conscious level and cough reflex and reliably produce increased analgesia with movement and increased respiratory function after thoracotomy [29]. Generally the most popular regimens are fentanyl or diamorphine combined with levobupivacaine [29]. The regimens can be administered as an infusion, patient controlled analgesia or both.

Potential issues include failure, technical difficulty and hypotension. It can also reduce the effectiveness of coughing, especially in patients who already have a low FEV1. It is not offered when there is local or systemic sepsis.

Paravertebral block is an effective modality to provide pain relief. It can be done by the anaesthesiologist before the start of surgery or by the surgeon before closure. It offers several technical and clinical advantages and is indicated for anaesthesia and analgesia when the afferent pain input is predominantly unilateral from the chest and/or abdomen. We prefer placing the catheter under direct vision during thoracic surgery and give pain relief as a continuous infusion. The chest drain loss of local anaesthetic is four times lower than that of interapleural block [30].

#### *4.1.2 Systemic analgesics*

**3.2. Use of staplers and glues to reduce and seal air leaks**

60 Principles and Practice of Cardiothoracic Surgery

procedures

mal surgery.

should be considered.

**4. Post operative care**

**4.1. Pain management**

*4.1.1. Epidural analgesia*

Various procedures like wedge resections, lobectomies, excision of bullae may cause pro‐ longed air leaks especially if patients have COAD. Traditionally diathermy dissection and ligation was used and later staplers were used for parenchymal resections. Although certain studies pointed towards improved results with regards to air leaks using staplers [21] and reported that surgical morbidity due to air leaks decreased with this technique other studies have not shown any particular reduction in duration of air leaks using staplers alone. [22]

The air leaks caused by the holes of the suture needles are of the same magnitude as that caused by the surface tension between the parallel staple lines when the lung inflates. Nevertheless staplers are quicker to use and they have a big role in minimally invasive Thoracoscopic

Polyglycolic acid fabric, polydioxan ribbon, bovine pericardial strips, bovine collagen, and recently, expanded polytetrafluoroethylene have been employed in an attempt to reinforce the staple lines, especially for resections performed in emphysematous lungs [23]- [27]. Other techniques like the electrothermal bipolar sealing have shown good results in lung parenchy‐

Air leaks are common after pulmonary resections. They can be inspiratory, expiratory, continuous and forced expiratory. Most of the leaks are expiratory or forced expiratory. Inspiratory leaks happen on positive pressure ventilation. If there is no pleural space then they are managed by underwater seal. If there is a space negative suctions is applied to the underwater seal. If the leak persists beyond a particular time frame then TALC or reopening

Pain management is of paramount importance post operatively as it is essential for patients to comply for chest physiotherapy and ambulation and they will be unable to do so if they have severe pain. There are various ways by which pain is managed. They include epidural catheters preoperatively, paravertebral methods pre or intraoperatively or intravenous patient control‐ led analgesia. On withdrawing these agents patients will need oral analgesics for duration of

The catheter is placed approximately with the midpoint of the dermatomal distribution of the skin incision. Epidural local anaesthetics increase segmental bioavailability of opioids in the cerebrospinal fluid and increase the binding of opioids to m receptors and the blocking of the release of substance P in the substantia gelatinosa of the dorsal horn of the spinal cord [28]. The thoracic segmental effects of local anaesthetic and opioid combinations is the only way to

time till they are pain free. These include paracetamol, NSAID and narcotic agents.

Opioids remain the mainstay of postoperative analgesia and have demonstrated their efficacy in the management of severe pain. The side effects include nausea, vomiting, ileus, biliary spasms and respiratory depression, Opioids can be administered IM, subcutaneously, or IV.

A very efficient method of delivery of opioids is via PCA (Patient Controlled Analgesia) devices. Numerous studies have demonstrated the safety and opioid-sparing effect of PCA. After thoracic surgery PCA is often combined with other modalities to offer adequate pain relief.

### *4.1.3. Intrapleural*

Intrapleural local anaesthetics produce a multi-level intercostal block. However, the analgesia is extremely dependent on patient position, infusion volume, and the type of surgery. With the drains insitu most of the anaesthetic is drained out and hence the efficacy of the procedure is less. In spite of occasional successes most clinicians have not found the reliability of intrapleural techniques adequate to justify their use on a routine basis. [31]

#### *4.1.4. Other techniques*

Cryoanalgesia is the application of a -600ºC probe to the exposed intercostal nerves intraoperatively produces an intercostal block that can persist for up to six months. This can be moderately efficient to decrease post-operative pain, but is associated with an incidence of chronic neuralgia that has lead many centres to abandon the technique [32]. Transcutaneous electrical nerve stimulation (TENS) may be useful in mild to moderate pain but is ineffective when pain is severe. [33]

#### **4.2. Management of fluid electrolytes**

Patients are managed generally in a high dependency unit post surgery or the wards if it is a dedicated thoracic unit. Post thoracic surgery especially in resections intravenous fluids are given in reduced amounts to prevent pulmonary insufficiency. Care is taken not to overhydrate the patient and oral feeding in encouraged as soon as possible. Intravenous fluids should be used judiciously and a conservative strategy of administration of maintenance fluids is recommended at 1–2 ml/kg/h in the intra- and post-operative periods and that a positive fluid balance of 1.5 l should not be exceeded, to mitigate the risk of multifactorial post operative acute lung injury/ARDS. Caution should be exercised with regard to silent hypovolaemia, impaired oxygen delivery and acute kidney injury. A high index of suspicion for pulmonary insufficiency should be adopted if there is volume overload. If a patient develops signs of hypo perfusion after these thresholds are exceeded, inotropic/vasopressor support should be considered. [34]

patients are initially kept on nasogastric feeds and based on recovery are put on graded diet

Postoperative Care and Complications After Thoracic Surgery

http://dx.doi.org/10.5772/55351

63

The prophylaxis should start when the patients are admitted in the hospital. Everyone should be given a prophylactic dose of heparin subcutaneously if not contraindicated at a dose 5000 IU twice daily and this is continued in the postoperative period till discharge. All patients should have stockings and the high-risk patients should be on compression stockings. If there are signs of DVT then a Doppler in arranged and patients put in treatment dose of heparin

Immediate postoperative bleeding can be caused due to surgical bleeding or coagulopathy, surgical bleeding being more common. A set of standard coagulation tests are performed and coagulopathy is corrected accordingly. Depending on the coagulation profile factors like FFP, Platelets, cryoprecipitate or factor 7 is given if the patient is bleeding due to profound coagul‐ opathy.The threshold for taking back a patient for re-exploration should be low, as a surgical cause of bleeding should be ruled out. Bleeding after thoracic surgery is rare. It occurs in less than 2% of video assisted Thoracoscopic procedures (VATS) and around 01% to 3% of open procedures. [35]- [38] Generally postoperative bleeding results from technical complications, but certain co morbidities may predispose a patient to bleeding. A chest tube output of 1000 ml in 1 hour necessitates an immediate return to the operating room with concurrent correction of coagulopathy. Serial drainage exceeding 200 ml per hour for 2 to 4 hours after correction of a coagulopathy also indicates surgical bleeding and dictates re-exploration. If the patient is hemodynamic ally stable but the chest output is high, checking the haematocrit on the chest tube drainage can be helpful in distinguishing active bleeding from a lymphatic leak. If a patient in the immediate postoperative period is hemodynamically unstable but the chest tube output does not suggest active haemorrhage, a chest radiograph may show radiopacity of the

Medications like aspirin, other antiplatelet agents' warfarin could cause increased bleed‐ ing tendencies. Several herbs like garlic, ginseng etc. effect a prolonged bleeding time, which can result in peri operative haemorrhage. [39] The effect of herbal medications in thoracic surgery specifically is lacking, but discontinuing herbs 2 weeks before a lung re‐

Recommendation for perioperative antiplatelet the current recommendations aim at providing the best option for patients. There are issues regarding continuing or discontinuing these medications. These recommendations are mainly form observational data. [41], [42], [43]

beginning from thickened fluids.

**5. Complications**

**5.1. Postoperative haemorrhage**

**4.5. Deep Venous thrombosis prophylaxis**

infusion and an IVC filter put in if necessary.

operative side with thrombosed chest tubes. [40]

section is recommended. [40]

#### **4.3. Intercostal catheter**

Intercostal catheter is watched for drainage and air leak. If the postoperative chest X-ray shows expanded lung fields the no suction is applied even if there is bubbling. If there is airspace the suction is applied. It is preferable to use a balanced drainage system in all patients. In pneu‐ monectomy patients no suction is applied after surgery and the balanced drainage system is filled with 1cm of liquid unlike routine thoracic cases where it is filled with 2 cm of fluid. In pneumonectomy patients the drains are removed the next day and in lobectomy patients as soon as possible. Suction is also applied in cases of pleurodesis with talc so that the visceral and parietal pleurae are approximated. If the drains have to stay due to persistent minimal bubbling and if the parenchyma is expanded without any suction a Heimlich valve container is attached for earlier complete ambulation or discharge.

#### **4.4. Physiotherapy and early mobilisation.**

Postoperative insufficiency occurs because of infection, inability to clear secretions or oedema around day 2 or 3, to prevent these from happening attention should be given to physiother‐ apy, bronchodilators, restriction of intravenous fluids and tracheal toilet. Chest physiotherapy includes deep breathing and coughing exercises and incentive spirometry. Pulmonary insufficiency is more common in patients have low FEV1. If there is inability to do so then endotracheal suctioning or mini tracheostomy should be used for clearing secretions. Diuretics are used if necessary and antibiotics are started if clinically indicated without waiting for radiological deterioration.

Early postoperative ambulation and physiotherapy reduces complications like atelectasis, pneumonia, empyema and DVT.

Aspiration should be prevented postoperatively as it can result in multiorgan dysfunction and sepsis. Patients should be allowed to eat only when they are fully alert and sitting up. If there is a tendency to aspirate patients are kept nil by mouth and nasogastric feeding initiated as required. If there is damage to the vocal cords then a speech pathology is sought for and patients are initially kept on nasogastric feeds and based on recovery are put on graded diet beginning from thickened fluids.

#### **4.5. Deep Venous thrombosis prophylaxis**

The prophylaxis should start when the patients are admitted in the hospital. Everyone should be given a prophylactic dose of heparin subcutaneously if not contraindicated at a dose 5000 IU twice daily and this is continued in the postoperative period till discharge. All patients should have stockings and the high-risk patients should be on compression stockings. If there are signs of DVT then a Doppler in arranged and patients put in treatment dose of heparin infusion and an IVC filter put in if necessary.
