Outline your postoperative management plan for a patient who has just -returned from the operating theatre after undergoing bilateral thoracoscopic lung reduction for emphysema
Although not stated in the question, it was expected that the plan would only cover the immediate postoperative period. Success of the operation is dependent on patient selection, preparation surgical skill and ICU care.
It should include:
(a) Airway/Breathing- the patient should be extubated as soon as possible to avoid the risks of barotrauma and nosocomial pneumonia.This is facilitated by a light general anaesthetic and thoracic epidural analgesia. ·
(b) Circulation·arterial line for BP monitoring and sampling. BP should be maintained with blood transfusion and low dose vasoconstrictor. Excessive amounts of crystalloid are avoided. Maintenance fluids (eg. lml/kglhour of 5% D +KCL +MgS04). ·
. (c) Analgesia- thoracic epidural. If ineffective PCA & regular paracetamol. (d) Drains underwater usually no suction.
{e) Early mobilisation into chair.
(f) Antibiotics as per preop sputum culture or 24 hours IV cephalothin.
(g) Bronchodilators as indicated.
(b) Investigations- CXR to check lung expansion.
(i) ABG to check for hypercarbia.
This question is really about managing an intubated patient with severe COPD, who happens to have recently had major thoracic surgery.
One can approach this systematically
Care for the patient recovering from lung reduction surgery is discussed with more detail in the "Required Reading" section.
This procedure is not frequently seen these days; to learn more about it I recommend a good review article from the ERJ:
Russi, E. W., U. Stammberger, and W. Weder. "Lung volume reduction surgery for emphysema." European Respiratory Journal 10.1 (1997): 208-218.
The anaesthetic perioperative management of these patients is deteailed here:
Hillier, J., and C. Gillbe. "Anaesthesia for lung volume reduction surgery."Anaesthesia 58.12 (2003): 1210-1219.