Thoracic

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Esophagectomy

Procedure: Esophagectomy

Indication: CA

Description: Thoracic approach involves a thoracotomy and removal of esophagus and surrounding lymph nobes. General surgery performs from a transhiatal approach and creates a mid-abdominal incision and a cervical (neck) incision. The esophagus and surrounding lymph nodes are removed. Either approach uses what is left, either stomach or intestine, to create a tube and attach to the cervical esophagus to retain gastric continuity.

Post-op Implications:

Complications:

  • Pain: Epidural may be in place. IV opioids and opioid adjuncts will be used, no PO meds for 5-7 days.
  • Pulm: ARDS can develop due to inflammation and reduction of lymph clearance in thoracic cavity. The patient may have a chest tube. Aggressive pulmonary toileting is required due to frequency of pulmonary complications.
  • Hemo: Large fluid shifts can cause hypotension and edema.
  • Anastomosis leak: swallow study can confirm a leak. CT scan can visualize extraluminal collections; these must be drained. Give systemic AbX for suspected leak. Usually ruled out by day 5-7.
  • A-fib: can occur in 20% of cases.
  • Conduit ischemia: Can present as a rapid deterioration with s/s of septic shock. May need gastrostomy.
  • Laryngeal nerve injury: May present as hoarseness, aspiration pneumonia, and/or dyspnea. Consult OTO.
  • Chylothorax: Chyle leak into thoracic cavity from thoracic duct. Can be seen as fats in chest tube output. May require surgical intervention.

Meds: NPO, nothing per NGT.

Principles: Decreased lymph clearance from thoracic cavity can cause pulmonary edema with too much IVF, however, hemodynamic instability may warrant fluid boluses. MIV most likely at a rate of 100-200 overnight, UOP 30ml/hr is accurate indicator of sufficient fluid resuscitation. NG tube will be in place, no manipulation or replacement of tube if it becomes dislodged; tube passes through the esophageal anastomosis. NPO for 5-7 days until anastomotic leak is R/O. May have J-tube for enteral feeding as well. If unable to resume enteral feedings, TPN may be started.

Care Plan: Aggressive pulmonary toileting, hemodynamic monitoring and support, pain control, frequent turning, wound care, foley hygiene, NPO, manage IVF, don’t manipulate NGT or replace if dislodged. Chest tube, A-line, J-tube, and epidural care if applicable.

Course of Care: May come to SICU extubated or intubated. NPO 5-7 days. OOB as soon as able. NGT stays in place with no manipulation for 5-7 days. Foley stays in until mobilizing. Restart home Rx as soon as able. Stay in SICU until stable.

Room Setup: Possible vent setup. Possible for A-line, epidural, chest tube, and J-tube. Have Extra IV pumps available. Suction for oral, NGT, and chest tube. SCDs. Possible PCA.


Lobectomy

Procedure: Lobectomy (Open Vs. VATS), wedge resection, biopsy.

Indication: CA, mass, retrieve diagnostic samples.

Description: GA and intubated. Incisions are made to pass laparoscopic tools into thorax, operative lung is collapsed with CO2 in pleural space. Chest tubes are placed at end of procedure to drain air/fluid from pleural space.

Post-op Implications:

Complications:

  • Pulmonary edema: pulmonary tissue becomes susceptible to leakage after surgery, limit IVF to maintain adequate UOP >30ml/hr and MAP >60mmHg. “Keep ‘em dry”.
  • Hypotension: Minimal fluid resuscitation can create hypotension, consult physician for either fluid or possibly Phenylephrine drip.
  • Persistent airleak: Always keep chest tubes to suction immediately post-op. Air leak that does not go away can Develop, patient may be discharged with a one way valve.
  • Nerve Injury: Surgical procedure can damage nerves, pain control acute and chronic will be a challenge.

Meds: Pain: PCA and epidural are most common. Or PCEA (bipiv/fentanyl). Restart home pain meds ASAP. Pulm: restart home inhalers/nebs ASAP. Prophylactic IV ABX 8hrs post-op.

Principles: MAP goal >60mmHg. Limit IVF (prevent pulmonary edema). UOP goal >30ml/hr. Daily CXR. A-line for BP monitoring and blood gases.

Care Plan: Aggressive and frequent pulmonary hygiene. Skin care, wound care, chest tube care, foley hygeine and pain control. A-line and epidural care (if applicable).

Course of Care: Usually extubated in OR. POD #1: OOB, diet advanced as tolerated. Chest tubes out after minimal output and no air leak. D/C to floor when condition permits.

Room Setup: Possible A-line setup, epidural set-up. Standard IV pump. Possible PCA set-up. Oral suction + CT suction. Humidified 02, and SCDs.