Postoperative analgesia:
Thoracotomy is a rather painful procedure because it involves division of many structures. Incision of the pleural space and irritation of the intercostal nerves in particular can cause severe pain. For this reason, effective postoperative analgesia is mandatory to allow deep breathing and thus avoid complications such as pneumonia and atelectasis.
→ with epidural catheter, supportive i.v. analgesia and possibly regional measures (intercostal block).
Follow this link to Prospect (Procedures Specific Postoperative Pain Management)
Postoperative care:
Opening the chest will create a pneumothorax. In order to remove the air from the chest cavity and allow the lungs to expand, one or two chest tubes are inserted at the end of the procedure, which create a vacuum via suction (15 cm to 20 cm water column).
Monitoring of the chest tube(s): In correctly inserted chest tubes the water level in the collection chamber moves synchronously with the patient’s breathing. Persistent “bubbling” in the collection chamber indicates either a continued air leak or an improperly attached connector in the tube system.
Blood clots may block the tube(s) time and again. These may often be removed by milking the tubes toward the collection chamber. Beware of tension pneumothorax due to blocked tube(s); irrigate with bladder syringe filled with saline 0.9%, if necessary.
The digital chest tube drainage and monitoring system Thopaz+ from Medela may be used as an alternative to the analog system. Unlike analog systems, Thopaz+ reliably controls the negative pressure in the patient's chest and digitally (and silently) monitors the key treatment parameters. Clinical studies have demonstrated that the Medela chest tube system improves the therapeutic success and optimizes care.
Chest tube removal: Remove the tubes on post-operative day 2 to 8 after the air and fluid losses have ceased. Chest tubes may only be removed once there is no more air loss. Secretions should have dropped to <100 ml/day. Then stop suction and take follow-up radiograph; in absence of pneumothorax remove the tube(s). Two hours after removing the tube(s) always take a chest radiograph! In case of pneumothorax re-institute suction.
Bronchoscopic inspection and cleaning of the bronchial tree in atelectasis or severe mucus accumulation.
Deep venous thrombosis prophylaxis:
Unless contraindicated, the moderate to high risk of thromboembolism calls for prophylactic physical measures and low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached.
Note: Renal function, HIT II (history, platelet check)
Ambulation:
As early as possible under adequate analgesia to avoid shallow breathing and prevent pneumonia and atelectasis.
Physical therapy:
Pneumonia prophylaxis is mandatory: Pre- and postoperative breathing exercises! Triflo incentive spirometer and related physical therapy.