What is the intensive care unit (ICU) care protocol after a pneumonectomy?

From the Guidelines

ICU care after pneumonectomy should prioritize careful respiratory management, hemodynamic stability, and complication prevention, with a focus on protective lung strategies, fluid restriction, and multimodal analgesia. Patients require close monitoring of vital signs with continuous pulse oximetry maintaining oxygen saturations above 92% and arterial blood gases as needed 1. Ventilator management should use protective lung strategies with tidal volumes of 4-6 ml/kg ideal body weight and plateau pressures below 30 cmH2O to prevent barotrauma to the remaining lung.

Key Considerations

• Fluid management is critical, with the goal of restricting fluids to prevent pulmonary edema while maintaining adequate perfusion, typically targeting slightly negative fluid balance with careful titration of crystalloids 1.
• Pain control is essential using multimodal analgesia, although the use of thoracic epidural analgesia may be limited due to its safety profile, and first-line continuous paravertebral block may be preferred instead 1.
• Chest tube management requires vigilant monitoring of drainage and air leaks, with the remaining chest tube typically removed when drainage is less than 300 mL/day and air leaks are no longer observed 1.

Postoperative Care

• Early mobilization should begin within 24 hours if hemodynamically stable, as part of a postoperative ERAS protocol including at least early mobilisation 1.
• Provide postoperative multimodal physiotherapy rather than isolated chest physiotherapy 1.
• Watch closely for complications including respiratory failure, pneumonia, bronchopleural fistula, cardiac arrhythmias (particularly atrial fibrillation), and post-pneumonectomy pulmonary edema.
• Prophylactic measures include DVT prophylaxis with subcutaneous heparin or LMWH, stress ulcer prophylaxis, and pulmonary hygiene with incentive spirometry hourly while awake.

ICU Admission

• Postoperative admission to a critical care unit should not be systematic, but rather based on comorbidities and intraoperative events 1.
• Intermediate care unit admission may be considered based on individual patient needs and risk factors 1.

From the Research

ICU Care Protocol After Pneumonectomy

The intensive care unit (ICU) care protocol after a pneumonectomy involves several key considerations to minimize postoperative complications and optimize patient outcomes.

• Mechanical Ventilation: The use of lower tidal volumes in mechanical ventilation is recommended to reduce the risk of postoperative acute lung injury and acute respiratory distress syndrome (ARDS) 2.
• Monitoring and Management of Complications: Close monitoring for complications such as atrial fibrillation, prolonged intubation, vocal cord paralysis, deep vein thrombosis, and acute respiratory distress syndrome (ARDS) is crucial 3, 4.
• Fluid Management: Avoidance of fluid overload is important to prevent cardiogenic pulmonary edema and other complications 5, 3.
• Early Ambulation and Aspiration Precautions: Early ambulation and aspiration precautions can help prevent complications such as pneumonia and respiratory failure 3.
• Diagnosis and Management of ARDS: Early diagnosis and aggressive management of ARDS are essential to improve outcomes in patients who develop this complication 4.

Risk Factors for Postoperative Complications

Several risk factors for postoperative complications after pneumonectomy have been identified, including:

• Right-side pneumonectomy: Right-side pneumonectomy has been identified as an independent risk factor for ARDS and operative mortality 4.
• Higher Charlson Comorbidity Index: A higher Charlson Comorbidity Index has been identified as an independent risk factor for ARDS 4.
• Intraoperative tidal volume: Larger intraoperative tidal volumes have been associated with an increased risk of postoperative respiratory failure 5.

Outcome and Prognosis

The outcome and prognosis for patients who develop postoperative complications after pneumonectomy can be poor, with high operative mortality rates and low long-term survival rates 4. Therefore, it is essential to implement evidence-based ICU care protocols to minimize the risk of complications and optimize patient outcomes.