Under preparation. Please refer to Protocols page
Peri and Post Operative Management
1.) General Principles
Thoracic surgical patients have very intense monitoring in the immediate postoperative period, intensive physiotherapy (which is essential), high intensity nursing in Thoracic HDU and the ward of significant medical input.
2.) Intraoperative Care
The patients will be catheterised by the SHO in the anaesthetic room once the patient is asleep, the x rays placed on the x ray box in theatre and the patient placed on the appropriate side. The patient will be moved into theatre. The anaesthetist wills mange fluids / blood intraoperatively and will the initial dose of antibiotics.
3.) Management in Recovery
Thoracic surgical patients are routinely woken in theatre and go to general recovery, in recovery a chest x ray is performed to ensure the lung is fully expanded, a FBC, U&E's, and ABG should be performed, if the patient has had significant blood transfusion the coagulation should also be checked .The SHO involved in the patients operation should arrange this, including phoning the labs/ X ray. The intercostal drains are placed on low suction as appropriate: -
Lobectomy / Decortication / Lung Biopsy
Drains on suction at 5 - 10 cm H2O (3-5 kPa)
Drains NEVER on suction (This would cause Mediastinal shift, impairment of venous drainage and Cardiac Arrest)
The CXR and blood results should be reviewed prior to return to the ward.
4.) Early Post Operative Care
a) Antibiotic Prophylaxis
The normal regime is cefuroxime 1.5g iv at induction followed by 3 doses of cefuroxime 750mg iv
If the patient was an inpatient in another hospital prior to surgery then additional prophylaxis: -
Teicoplanin 400mg iv at induction, Teicoplanin 400mg iv 3 doses post op should be given
If the patient is on a treatment regime of antibiotics for a confirmed infection these should be continued and altered according to any sensitivities obtained.
The current regime is the use of TED stockings and Enoxaparin 40mg SC BD until mobile, early mobilisation is also part of the regime and the patients will often be moved to the chair on the first day.
c) Analgesia and Antiemetics
After the majority of thoracic procedures the patients will have an epidural in situ, in addition to this regular paracetamol and diclofenac, if there are no contraindications, should be prescribed. Once the epidural has stopped at between 2 and 3 days post op, Sevredol 10 - 20mg PO 1 - 2 hourly should be considered.
Postoperative nausea is relatively common thus regular antiemetics are helpful, typically we use:-
Metoclopramide 10mg tds iv
Ondansetron 4mg tds iv
Cyclizine 50mg tds iv (Slowly)
d) Investigations post op
CXR are performed immediate postoperatively and then as clinically indicated and after the removal of any intercostal drains. The first morning: FBC, U & E's
e) Urine Output
This is monitored hourly and we aim for a minimum of 0.5ml/kg/hr, post op thoracic surgical patients are very sensitive to fluid, especially those undergoing Pneumonectomy. Pulmonary oedema in these patients is extremely serious, relatively easily precipitated and frequently fatal.
Thus fluids should be given with care, assessing CVP and response to a small fluid bolus (i.e. Haes 6% 250ml over 1 hr). If urine output is falling in the face of a high CVP, then small boluses of Frusemide 10 – 20mg iv should be considered. If this is unsuccessful consider starting Dopamine at a so called “ Renal Dose” i.e. 2.5 – 5.0 mcgs/kg/min
Maintaining an adequate CVP.
5.Management of Chest Drains
A significant proportion of patients have intercostal drains insitu, they are initially on suction in most patients, except those who have undergone Pneumonectomy or pleuropneumonectomy where the drains are NEVER on suction.
The use of suction and the removal of drains is assessed on both the activity of drain i.e. how much they bubble and also on the CXR i.e. the degree of inflation of the remaining lung tissue. Drains are almost always taken out one at a time and a chest film should always be performed post drain removal. The site of insertion of the drain should be inspected periodically as infection is possible and any air leak at the site should be noted.
The decision to remove suction and to remove a chest drain is typically made by one of the SpR’s on the morning ward rounds.
6.Continuing Care /Referral
Many of the patients undergoing thoracic surgery require oncological referral for Radiotherapy / Chemotherapy, a referral form for the referral of patients to Consultant Clinical Oncologist.
1. Lung cancer patient should be followed-up for a period of five years post lung cancer surgery. This should consist of an initial six-weeks appointment post hospital discharge followed by six-monthly follow-up for the first two years and then yearly to complete the five years. At each follow-up, patient symptoms (to detect lung cancer recurrence or metastasis) should be reviewed, patient should be examined appropriately and a CXR should be performed. If in doubt, flag the CXR to the consultant or check for the formal report from the radiologist.
If patient wants to be followed-up locally, then please document in the clinic letter the patient’s preference and ask the referring chest physician to follow-up patient according to above protocol.
2. Patient with benign conditions (pneumothorax surgery, lung/pleural biopsies) should be discharged to the care of the referring chest physician, after the six-week appointment.
3. Patient who underwent metastasectomy should be referred back to the referring physician after the six-weeks follow-up.
4. Patient who had undergone endobronchial resection of carcinoid should be followed-up for life. This should consist, initially of OPD alternating with check bronchoscopy at regular intervals until consecutive check bronchoscopies are NAD. Then they should be followed-up yearly in OPD.
5. Patient with mesothelioma should have a six-weeks and then a three months appointment. Thereafter they should be discharged to their local chest physician.
6. Patient post decortication for empyema should be discharged to the care of their referring physician after the six-weeks appointment. If patient had a long-term intercostals chest drain or has undergone a Claggett’s procedure, then OPD management needs to be discussed with the responsible consultant.