Critical Care of the Thoracic Surgical Patient
- Critically ill patients, when cared for in ICUs that have a multidisciplinary, intensivist-staffed team, have reduced morbidity and mortality.
- Sepsis remains an important cause of mortality among surgical patients treated in ICUs; early diagnosis, source control, and antibiotic treatment are essential.
- Judicious fluid management is important in critically ill thoracic surgical patients but the optimal approach to fluid resuscitation in post-operative thoracic surgical patients remains controversial.
- Atrial arrhythmias are common after thoracic surgical procedures and amiodarone can be safely used short-term to treat acute onset atrial fibrillation.
- Acute respiratory failure and ARDS which develops after thoracic surgery remains associated with high morbidity and mortality.
- Lung protective ventilation strategies is the standard of care for patients with ARDS and should be applied to thoracic surgical patients who develop acute respiratory failure requiring invasive ventilator support.
- Early neuromuscular blockade and proning have been shown to improve survival in patients with severe ARDS. Increasingly ECMO has been used as a rescue modality in refractory ARDS. Appropriate patient selection for ECMO support remains paramount for achieving favorable clinical outcomes in this ICU-resource intensive therapy.
- Delirium is common in the ICU setting and can increase post-operative morbidity and mortality. Daily routine interruption of sedation and analgesia reduces time spent on the ventilator.
Most patients who undergo routine thoracic surgical procedures do not require prolonged critical care management in an intensive care environment. Usually these patients are placed on telemetry monitoring, and they recover well with effective post-operative pain control, bronchopulmonary hygiene, and early ambulation under close nursing assessment and monitoring. Recently, the role of enhanced recovery pathways has been demonstrated to shorten post-operative duration and patient recovery after thoracic surgery., These patients can be safely and efficiently managed by the thoracic surgical team, and with appropriate attention to perioperative details, most patients fortunately have uneventful post-operative courses such that specialized services by critical care intensivists are not routinely required.
Compared to the general surgical population, however, thoracic surgical patients tend to be older, often are previous or current smokers, and have higher rates of chronic co-morbid conditions including hypertension, chronic lung disease, cardiovascular disease, and chronic renal insufficiency. These patients will have diminished physiological reserve and limited ability to recover when faced with perioperative complications. Also a subset of thoracic surgical patients will often require critical care management in the post-surgical period: the very elderly, patients with multiple or significant co-morbidities, those requiring complex thoracic procedures not routinely performed, and patients who undergo emergent operative procedures are at risk of becoming critically ill.
Critical care has undergone significant developments over the last decade. As critical care outcomes research has expanded, so has the application of evidence-based principles to critical care. This has led to reduced morbidity and mortality. This chapter focuses on common critical care conditions that most often affect patients who undergo thoracic surgery and their relevant management considerations. It is not intended to be an extensive review of the critical care specialty; and though not addressed specifically in this chapter, general ICU care considerations remain equally relevant to thoracic surgical ICU management and should be routinely practiced; these considerations include glucose management, early nutritional therapy, venous thromboembolism and stress ulcer prophylaxes, and preemptive central venous catheter and indwelling urinary catheter care.
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