Postoperative care of the thoracic patient

Abstract

This chapter focuses principally on the organization of postoperative care of the thoracic patient. Unfortunately, evidence-based guidelines regarding this period is not well-defined or supported by a sufficient number of studies addressing the different challenges. The anesthesiologist is an important part of the multidisciplinary context of perioperative medicine, directly involved in the decisions made during the pre-and intraoperative periods which can affect the postoperative outcome. One of such decisions is the question where to send the patient after surgery: Scoring systems do not help much while local conditions play an important role; overall, there is a decrease in the requirement of the intensive care unit for postoperative care. Enhanced Recovery After Surgery (ERAS) protocols have obtained a very important new step to help the philosophy of perioperative medicine; current ERAS protocols for thoracic surgery are welcome (constituting another chapter in this book); but unfortunately, still more suggestion-based than evidence-based. Management of chest tubes is another postoperative issue where newer suggestions aim to achieve a faster recovery without increasing the risk. Improvements in technology help to deal with the challenges: Regarding the postoperative period, two new tools have to be underlined: Ultrasound is now used routinely for many purposes, with abilities and advantages beyond chest x-ray. Thermodilution techniques have been considered to have very limited—if any—indications; current findings have shown that it can be helpful for evaluation of the right ventricular function. These devices and new studies can change our paradigms regarding the fluid therapy to keep the patient safely in euvolemic status. The scope of these innovations is also beyond the fluid therapy. Mechanical ventilation is unphysiologic, and can cause complications (ventilator associated lung injury [VALI] and ventilator associated pneumonia [VAP]). Therefore it is indicated only in patients in whom a gas exchange is indeed impossible with other approaches. In these cases, ventilation should be even more protective than general suugestions: even lower tidal volumes, rather no recruitment maneuver etc. To avoid the disadvantages of mechanical ventilation, newer approaches, such as noninvasive ventilation and high-flow oxygen therapy are now used more frequently. In most extreme cases, exceptional solutions like extracorporeal lung support or differential lung ventilation can be indicated. As patients after thoracic surgery comprise a spesific group for mechanical ventilation, weaning also plays a more important role. Each center has to define a protocol for weaning, based both on scientific evidence and on center-specific prerequisites. Electronic data recording systems can help to follow these protocols.