Critical care in post op Respi Patients.pptx

Critical care

1. Critical Care in Post Operative Patient in respiratory medicine

2. Care of Critically ill patients: Critical care is the process of looking after patients who either suffer from life-threatening conditions or are at risk of developing them. The intensive care unit (ICU) is a distinct geographical entity in which high staffing ratios, advanced monitoring and organ support can be offered to improve patient morbidity and mortality. Effective intensive care demands an integrated approach that stretches beyond the boundaries of the ICU. It requires prevention, early warning and response systems, a multidisciplinary approach before and during an ICU stay, as well as comprehensive follow-up or good quality palliative care. Cornerstones of intensive care management: Optimization of a patient’s physiology, the provision of advanced organ support, and the identification and treatment of underlying pathological processes. This is best achieved through a multidisciplinary team approach, with shared responsibility between the admitting ‘parent’ team and a specialized critical care team coordinated by a critical care physician  Jackson M, Cairns T. Care of the critically ill patient. Surg Oxf . 2021;39(1):29–36.

3. Perioperative factors associated with postoperative respiratory complications (PRCs). Eikermann M, Santer P, Ramachandran SK, Pandit J. Recent advances in understanding and managing postoperative respiratory problems. F1000Research. 2019;8.

4. Perioperative factors associated with postoperative respiratory complications (PRCs). Eikermann M, Santer P, Ramachandran SK, Pandit J. Recent advances in understanding and managing postoperative respiratory problems. F1000Research. 2019;8.

5. Perioperative factors associated with postoperative respiratory complications (PRCs). Eikermann M, Santer P, Ramachandran SK, Pandit J. Recent advances in understanding and managing postoperative respiratory problems. F1000Research. 2019;8.

6. Perioperative factors associated with postoperative respiratory complications (PRCs). Eikermann M, Santer P, Ramachandran SK, Pandit J. Recent advances in understanding and managing postoperative respiratory problems. F1000Research. 2019;8.

7. Critical organ support and monitoring support. RESPIRATORY:  Jackson M, Cairns T. Care of the critically ill patient. Surg Oxf . 2021;39(1):29–36.

8. Critical organ support and monitoring support. Cardiovascular  Jackson M, Cairns T. Care of the critically ill patient. Surg Oxf . 2021;39(1):29–36.

9. Critical organ support and monitoring support. RENAL & CNS  Jackson M, Cairns T. Care of the critically ill patient. Surg Oxf . 2021;39(1):29–36.

10. Critical organ support and monitoring support. GI and Other  Jackson M, Cairns T. Care of the critically ill patient. Surg Oxf . 2021;39(1):29–36.

11. Effects of respiratory drive on perioperative respiratory complication risk Eikermann M, Santer P, Ramachandran SK, Pandit J. Recent advances in understanding and managing postoperative respiratory problems. F1000Research. 2019;8.

12. Overview of the management of post-operative pulmonary complications

13. Post operative Pulmonary Complications Pulmonary complications are a major cause of morbidity and mortality during the postoperative period The reported incidence of postoperative pulmonary complications ranges from 5 - 80 %, depending upon the patient population and the criteria used to define a complication Incidence also varies across hospitals, with one study reporting lower rates of complications in hospitals with a high volume of patients than in hospitals with a lower volume following esophagectomy, pancreatectomy, and intact abdominal aortic aneurysm repair. Traditional definitions of postoperative pulmonary complications include atelectasis, bronchospasm, pneumonia, and exacerbation of chronic lung disease. However, the list can be expanded to include acute upper airway obstruction, complications from obstructive sleep apnea, pleural effusions, chemical pneumonitis, pulmonary edema, hypoxemia due to abdominal compartment syndrome, and tracheal laceration or rupture Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

14. ATELECTASIS One of the most common postoperative pulmonary complications, particularly following abdominal and thoracoabdominal procedures Postoperative atelectasis can be asymptomatic or it may manifest asincreased work of breathing and hypoxemia. Clinical Presentation : The onset of hypoxemia due to postoperative atelectasis tends to occur after the patient has left the post-anesthesia care unit. It typically becomes most severe during the second postoperative night and continues through the fourth or fifth postoperative night. Hypoxemia that develops earlier ( ie , in the post-anesthesia care unit) should prompt the consideration of postoperative complications other than atelectasis, such as hypoventilation due to residual anesthetic effects and upper airway obstruction due to airway tissue edema. Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

15. ATELECTASIS Pathogenesis : Postoperative atelectasis is usually caused by decreased compliance of lung tissue, impaired regional ventilation, retained airway secretions, and/or postoperative pain that interferes with spontaneous deep breathing and coughing. Management For patients without abundant secretions, continuous positive airway pressure may be beneficial. For patients with abundant secretions, chest physiotherapy and suctioning are appropriate. Some patients with abundant secretions may also benefit from bronchoscopy; the absence of air bronchograms may help identify patients who are more likely to benefit from bronchoscopy Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

16. BRONCHOSPASM Bronchospasm: Common during the postoperative period. Clinical manifestations : dyspnea, wheezing, chest tightness, tachypnea, small tidal volumes, a prolonged expiratory time, and hypercapnia. Postoperative bronchospasm can be caused by aspiration, histamine release incited by medications ( eg , opiates, tubocurarine, or atracurium), an allergic response to medications, or an exacerbation of a chronic pulmonary condition, such as asthma or COPD Can also be caused by reflex constriction of bronchial smooth muscles due to tracheal stimulation by secretions, suctioning, endotracheal intubation, or other surgical stimulation. Reflex bronchoconstriction is particularly common when the bronchodilatory effects of inhalational anesthetics wane Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

17. Treatment of Post Op Bronchospasm: Treatment consists of treating the underlying cause, removing potential contributors ( eg , medications), and pharmacotherapy. SABA( e.g.albuterol ) are bronchodilators that are considered first-line pharmacotherapy. Short-acting inhaled anticholinergic agent, ipratropium bromide, is also a bronchodilator that may have an additive effect. Patients who do not improve after one or two doses of the inhaled bronchodilators may benefit from the addition of systemic glucocorticoids. Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

18. PNEUMONIA Postoperative pneumonia has clinical manifestations and a diagnostic approach that is nearly identical to other types of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). Postoperative pneumonia tends to occur within five postoperative days May present with fever, leukocytosis, increased secretions, and pulmonary infiltrates on chest radiographs. Hypoxemia may develop, or the patient may require more supplemental oxygen to maintain the same oxyhemoglobin saturation. Respiratory distress, dyspnea, tachypnea, small tidal volumes, and hypercapnia may also occur. The minute ventilation often increases prior to the development of any blood gas abnormalities, a consequence of the patient becoming more catabolic due to the developing infection Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

19. PNEUMONIA-Diagnosis Postoperative pneumonia should be suspected in any patient who has clinical signs of infection ( eg , fever, purulent sputum, leukocytosis or leukopenia, and worsening oxygenation) and a new radiographic infiltrate Diagnosis can be difficult because there are many other postoperative causes of fever and/or pulmonary infiltrates, such as atelectasis, pulmonary edema, pulmonary embolism, and acute lung injury. Persistent PCT elevation on postoperative day 2 and beyond following abdominal surgery is more common in individuals developing hospital-acquired pneumonia versus those who do not develop hospital-acquired pneumonia (however more data needed) Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

20. Pneumonia- Pathogens Postoperative pneumonia is frequently caused by resistant organisms. This was demonstrated by a series of 837 patients with suspected postoperative pneumonia, occurring within the first 14 days following surgery. Microbiologic sampling was performed in 718 of the patients (86 %), including bronchoscopic sampling in 367 of the patients (44 %) Most cases of pneumonia occur within five postoperative days (61 %). Organisms were cultured from the respiratory samples of almost half of the patients (46 %). More than one organism was cultured from some patients (29 %). Most of the positive cultures were obtained from patients in whom pneumonia was diagnosed before the fifth postoperative day. Gram-negative bacteria and Staphylococcus aureus: Most commonly cultured microorganisms. Most frequent bacterial combinations: Enterobacteriaceae plus either Staphylococcus aureus or streptococci. Haemophilus influenzae and Streptococcus pneumoniae accounted for 19 percent and 10 percent, respectively, of the microorganisms isolated from respiratory and blood cultures. Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

21. Rrisk factors for postoperative pneumonia caused by particular microorganisms Haemophilus influenzae or Streptococcus pneumoniae – Traumatically injured patients appear to be at increased risk. Staphylococcus aureus – Neurosurgical patients (particularly those who are mechanically ventilated), victims of blunt trauma and coma, and patients who have sustained closed head injuries seem to be at increased risk. Additional risk factors for Staphylococcus pneumonia : chronic kidney disease, diabetes mellitus, a history of injection drug use, and recent influenza Risk Factors for MRSA: Previous antibiotic use, a positive nasal screen for (MRSA), long operations (>300 minutes), and emergency surgery Pseudomonas aeruginosa – No particular type of surgery has convincingly shown to increase likelihood of postoperative Pseudomonas pneumonia. However, risk factors include: intubation >8 days, structural lung disease ,corticosteroid therapy, malnutrition, prolonged exposure to antibiotics Acinetobacter species : Well-recognized cause of postoperative pneumonia, although no particular type of surgery has shown to predispose patients to postoperative Acinetobacter pneumonia. Most important risk factor: mechanical ventilation Anaerobic species – Uncertain role. Abdominal surgery is generally considered a risk factor Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

22. Others: ACUTE UPPER AIRWAY OBSTRUCTION EXACERBATION OF OBSTRUCTIVE SLEEP APNEA PLEURAL EFFUSION CHEMICAL PNEUMONITIS PULMONARY EDEMA PULMONARY EMBOLISM ABDOMINAL COMPARTMENT SYNDROME TRACHEAL LACERATION OR RUPTURE Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

23. POST-OPERATIVE RESPIRATORY FAILURE Accounts for > 20 % of all patients receiving ventilatory support Respiratory failure requiring unplanned reintubation in the postoperative period is associated with high morbidity, leading to a longer hospital stay, and increase in 30-day mortality Incidence of unanticipated reintubation in the first 72 hours is, in general, low (<1 %) but higher in older patients (up to 3 %) Other than low-flow oxygen, there is no single intervention in this population that is routinely used to prevent or treat postoperative acute respiratory failure. Other options: noninvasive ventilation (NIV) and oxygen delivered high flow nasal cannula (HFNC) Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

24. NIV NIV has been studied in the postoperative population. Not routinely applied as a primary prevention strategy Typically used as a secondary intervention for the treatment of hypoxemic respiratory failure that is refractory to or not suitable for low-flow or high-flow oxygen Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

25. HFNC High-flow nasal oxygen, which can oxygenate patients as well as provide a small amount of positive airway pressure and reduce dead space. Randomized trials evaluating the efficacy of HFNC are lacking such that HFNC is not routinely used as first line therapy for the treatment or prevention of postoperative respiratory failure. However, it may be an alternative to NIV, particularly in those in whom NIV is not tolerated. HFNC has been studied in the treatment and prevention of respiratory failure in the postoperative setting. Most of these trials compared HFNC with conventional low-flow oxygenation strategies and were performed in patients following thoracic surgery. Studies were flawed by low event rates, heterogeneity, imprecision, and indirectness. A meta-analysis of seven randomized trials involving 2781 patients: HFNC had a similar reintubation rate compared with either conventional oxygen therapy or NIV. However, in a subgroup analysis, critically-ill patients treated with HFNC had a lower reintubation rate compared with the COT group. In another meta-analysis of 14 studies, HFNC resulted in a reduction in intubation rate that was not significant and a reduction in the hospital length of stay. A subsequent meta-analysis of nine trials, compared with COT, use of HFNC post-operatively lowered reintubation rates and decreased the need to escalate respiratory support. HFNC had no effect on mortality, ICU and hospital length of stay, or rate of postoperative hypoxia Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate . Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

26. Critical Care Management Following Lung Transplantation

27. Need of Multidisciplinary team After successful transplant surgery  Patients routinely transferred to ICU immediately R ecipients are still intubated and some might require postop ECMO support. Regular ICU rounds by the transplant team are very important (over and above intensivist care) in order to monitor the patient’s clinical status and obtain a comprehensive update on the patient’s progress, including graft and other organ function, early immunosuppressive therapy, wound and drain monitoring, nursing information, and physical therapy Ideally, at least 1 daily round by a thoracic surgeon, a transplant physician, and the intensivist as a team is suggested. An infectious disease specialist should be part of daily transplant team rounds, since infections are the most frequent complications in the early postoperative period. A clinical pharmacist should also be involved in the multidisciplinary team due to the complexity of immunosuppressive therapy, which has a narrow therapeutic index, leading to potential severe adverse drug events and drug–drug interactions in critically ill patients. Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

28. Postoperative monitoring in the intensive care unit Patients typically arrive in the ICU with a pulmonary artery catheter (PAC) in addition to venous and arterial lines in place, chest tubes to drain pleural spaces, and an indwelling bladder catheter Patients should undergo a full physical examination, evaluation of hemodynamic parameters, and assessment of peripheral circulation and perfusion upon arrival in the ICU. Post Op patients are generally hypothermic  I ncreased pulmonary vascular resistance and the likelihood of bleeding and infection . Hence patients should be warmed using a forced air warming device. ICU monitoring is similar to intraoperative monitoring. Monitoring is essential because it provides information on the patient’s clinical status, diagnostic assessment of complications, and future management plans, while monitoring in the operating room is designed to assess acute changes in vital functions resulting from the patient’s response to medication and surgical manipulation. Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

29. Postoperative monitoring in the intensive care unit ABGs should be performed regularly. Venous blood samples to monitor CBC, coagulation- renal- hepatic profile, and lactate levels. Bedside ECG and portable chest radiography should be routinely performed. A PAC is routinely used starting in the operating room even though there is a paucity of data on its use in the Post Op lung transplantation period. Most common indications for PAC use: severe pulmonary hypertension The PAC can also be used to evaluate right ventricular (RV) function, which might be associated with the prognosis of lung transplantation Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

30. Postoperative monitoring in the intensive care unit However, several studies have suggested that RV function normalizes in adult patients after lung transplantation, even in patients with severe preoperative RV dysfunction. Therefore, there is no need to monitor pulmonary hypertension or RV function postoperatively unless there are other problems that affect the pulmonary artery pressure. Cardiac function could be evaluated with bedside echocardiography, including RV function. Therefore, the PAC itself can only be beneficial after lung transplantation if its use guides therapies that improve patient outcomes Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

31. Management of mechanical ventilation Goals of MV following lung transplantation: promote graft function, maintain adequate gas exchange, prevent ventilator-induced lung injury No large, multicenter trials are done to guide MV management after lung transplantation despite the critical role of MV in lung transplantation Currently applied lung protective MV strategies in lung transplantation have been extrapolated from the practice guideline for MV patients with ARDS, since experimental data suggest that all lung transplantation recipients are at risk of ventilator-induced lung injury The benefits of lung-protective ventilation also extend to surgical patients at risk for ARDS. However, a recent survey addressing MV practices after lung transplantation showed that many of the reported practices did not conform to the consensus guidelines on ARDS management. Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

32. Low tidal ventilation (usually 6 mL/kg of predicted body weight) has been the preferred strategy even in lung transplantation However, a survey on MV following lung transplantation indicated that recipient characteristics most commonly determine tidal volume. Titrating the tidal volume to the donor-predicted body weight rather than the recipient-predicted body weight reduces the risk of delivering insufficient or excessive tidal volume in size-mismatched allografts. However, undersized allografts might receive higher tidal volumes than oversized allografts based on the donor-predicted body weight. Therefore, adjustments of the adequate tidal volume should be made based on gas exchange over the next several hours following initial low-tidal volume ventilation. Management of mechanical ventilation Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

33. A driving pressure higher than 15 cmH2O has recently been shown to be strongly associated with mortality in patients with ARDS; this corresponds to the pressure required for alveolar opening (tidal volume/respiratory system compliance) and is calculated as the plateau pressure minus positive end-expiratory pressure (PEEP). This pressure can be used as an indicator of ventilator-induced lung injury risk. Therefore, driving pressure-guided ventilation has been proposed as another technique to reduce postoperative pulmonary complications and improve recovery in thoracic surgery patients. However, use of a high PEEP to reduce driving pressure is generally avoided due to its potential negative effects on the healing of bronchial anastomosis and alveolar overdistension in grafts. Management of mechanical ventilation Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

34. Weaning from MV is usually completed within 72 hours, and extubation is performed in the ICU in non-complicated patients after lung transplantation. Median MV duration after lung transplantation: 2 to 3 days. MV weaning is usually intentionally performed slowly in patients with a high risk of severe graft dysfunction or inadequate gas exchange. Lung allografts involve a disruption of the nerve supply as a consequence of harvesting from the donor. A weak cough, poor respiratory mechanics caused by deconditioning, and inadequate pain control lead to an inability to clear airway secretions. Early tracheostomy should be considered when more than 1 week elapses before weaning from MV Management of mechanical ventilation Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

35. Management of mechanical ventilation Routine use of inhaled Nitric Oxide (NO) in lung transplantation is not recommended, but its selective use is recommended for patients with severe graft dysfunction showing severe hypoxemia and elevated pulmonary artery pressure. Inhaled epoprostenol was recently reported to be equivalent to inhaled NO for preventing severe graft dysfunction. However, it remains unclear whether either inhaled NO or epoprostenol conferred any benefit and whether their routine use to prevent graft dysfunction should be supported Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

36. Management of mechanical ventilation In patients with severe graft dysfunction, MV may be insufficient to provide adequate gas exchange, and high ventilator settings may be harmful to the allograft. ECMO support is rescue therapy for this critical presentation. Data supports the use of ECMO to manage severe graft dysfunction, particularly to correct refractory hypoxemia and to reduce additional damage from MV to the already injured graft. The high incidence of complications, such as bleeding, vascular injury, and neurologic deficits, has been a major concern when using ECMO in the postoperative period after lung transplantation, although the incidence of such complications has dramatically decreased in recent years. Veno -venous ECMO is recommended to support most patients with severe graft dysfunction, even in the setting of hemodynamic compromise Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

37. Management of hemodynamics The initial hemodynamic management goal following lung transplantation: To maintain adequate organ perfusion, which is monitored by measuring lactate, urine output, and mixed venous oxygen saturation, if available However, transplanted lungs have varying degrees of pulmonary edema. In addition, increasing cardiac output with inotropes, with or without vasopressors, may also contribute to pulmonary edema by increasing the amount of flow through the lung allograft. Individualized management is required to maintain adequate perfusion pressure balance with the lowest possible cardiac output to reduce the exacerbation of pulmonary edema risk The implementation of a dedicated protocol that maintains specific hemodynamic targets has been shown to be associated with reduced graft dysfunction severity More aggressive diuresis and fluid restrictions in the early postoperative period after lung transplantation have potential benefits. Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

38. Management of hemodynamics Hypotension is common in the immediate postoperative setting Patients with low systemic vascular resistance may need additional vasopressor treatment, with norepinephrine and vasopressin being the preferred agents Vasopressin does not increase pulmonary vascular resistance since V1 receptors are not present in the pulmonary arteries. Choice of inotropes and vasopressors in postoperative lung transplantation care should be made with consideration of their effects on systemic and pulmonary vascular resistance and should be individualized based on patient response. Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

39. Management of hemodynamics Risk of pulmonary edema is higher with transient diastolic dysfunction of the left ventricle (LV), which becomes incapable of handling a normal preload in the early postoperative period in patients with significant pulmonary hypertension before lung transplantation. The small and “deconditioned” LV of patients with severe pulmonary hypertension is prone to developing diastolic dysfunction when exposed to a normal or high preload after transplantation, resulting in elevated left-sided filling pressures and pulmonary edema. Bridging this period with veno -arterial ECMO has been described for the postoperative management of recipients with severe pulmonary hypertension as a way to specifically address these issues and allow time for recovery of the “deconditioned” LV, which can take several days Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

40. Physiological effects of inotropes and vasopressors for critical care management in lung transplantation recipients CO, cardiac output; SVR, systemic vascular resistance; PVR, pulmonary vascular resistance. a)Based on a recent systematic review and meta-analysis of 23 trials that included 3,088 patients with distributive shock, the addition of vasopressin to catecholamine vasopressors compared with catecholamine vasopressors alone was significantly associated with a lower atrial fibrillation risk Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

41. Critical Care of Patients After Pulmonary Thromboendarterectomy Kratzert WB, Boyd EK, Saggar R, Channick R. Critical care of patients after pulmonary thromboendarterectomy. Journal of Cardiothoracic and Vascular Anesthesia. 2019 Nov 1;33(11):3110-26.

42. CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION (CTEPH) is a pulmonary vascular disease caused by chronic obstruction of pulmonary arteries and represents group 4 of the World Health Organization classification of pulmonary hypertension. Defined as precapillary pulmonary hypertension with mean pulmonary artery pressure ( PAPm ) ≥ 25 mmHg and pulmonary arterial occlusion pressure ≤15 mmHg by right heart catheterization in the presence of organized flow-limiting thrombi or emboli in the pulmonary arteries after at least 3 months of therapeutic anticoagulation. The prevalence of CTEPH is estimated at 3 to 30 individuals per million per year, with an incidence after pulmonary embolus of up to 3%. When untreated, mortality is high with only 30% - 80% of patients surviving 3 years. Medical therapy remains unsatisfactory, and surgical pulmonary thromboendarterectomy (PTE) offers the only curative intervention. With evolving expertise, mortality rates are now less than 5% in highly specialized centers The immediate postoperative course after PTE presents with several unique considerations for the intensivist. Preexisting pathophysiology and its sequelae, as well as intraoperative techniques, predispose these patients to specific postoperative complications and require expertise in their management.

43. Postoperative Complications After PEA - Neurological Kratzert WB, Boyd EK, Saggar R, Channick R. Critical care of patients after pulmonary thromboendarterectomy. Journal of Cardiothoracic and Vascular Anesthesia. 2019 Nov 1;33(11):3110-26.

44. Postoperative Complications After PEA - Pulmonary Kratzert WB, Boyd EK, Saggar R, Channick R. Critical care of patients after pulmonary thromboendarterectomy. Journal of Cardiothoracic and Vascular Anesthesia. 2019 Nov 1;33(11):3110-26.

45. Postoperative Complications After PEA - Haemodynamic Kratzert WB, Boyd EK, Saggar R, Channick R. Critical care of patients after pulmonary thromboendarterectomy. Journal of Cardiothoracic and Vascular Anesthesia. 2019 Nov 1;33(11):3110-26.

46. Postoperative Complications After PEA - Hematologic Kratzert WB, Boyd EK, Saggar R, Channick R. Critical care of patients after pulmonary thromboendarterectomy. Journal of Cardiothoracic and Vascular Anesthesia. 2019 Nov 1;33(11):3110-26.

47. Postoperative milestones

48. Post-PTE extubation protocol

49. Conclusion Postoperative management of patients after PTE confronts intensivists with significant challenges specific to CTEPH disease and PTE surgery. Knowledge of underlying physiology, intraoperative management, and postoperative complications is imperative to optimize outcomes. Intensive care unit management by a multidisciplinary team can provide contemporary care in an evolving field of highly specialized patients. Key attention is paid to avoidance and management of neurologic insults, residual pulmonary hypertension, RLI, RV failure, and postoperative recurrent thromboembolic events. Advancement of expert centers and collaboration among them may offer more evidence-based research in the future and is warranted to optimize postoperative ICU care for this population

50. The Society for Translational Medicine: Clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

51. Background Anesthesia for lobectomy in thoracic surgery is a great challenge as it requires single contralateral lung ventilation with collapse of the ipsilateral lung. Collapse of the operated lung and ventilation of the other lung may induce an inflammatory response. The ventilated lung is hyperperfused, receiving most of the cardiac output and may be damaged by mechanical ventilation. The collapsed lung is exposed to ischemia, reperfusion injury and shear stress on re-expansion and postresection ventilation. Consequently, patients who undergo lobectomy postoperatively may develop compromised lung function. Acute lung injury, reduced lung compliance and hypoxemia and an increase in pro-inflammatory cytokines, all are reported. Aim of mechanical ventilation during one-lung ventilation: To facilitate carbon dioxide elimination; To maintain oxygenation To minimize postoperative lung dysfunction Systematic literature search was performed to determine appropriate methods for mechanical ventilation Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

52. Therapeutic hypercapnia Hypercapnia, secondary to reduced alveolar ventilation has been noted as a component of protective lung ventilation in clinical practice In patients undergoing lobectomy with one-lung ventilation, hypercapnia facilitates inhibition of local and systemic inflammatory responses. Postoperative respiratory function, assessed by peak plateau pressure and dynamic compliance, was improved by hypercapnia induced by inhaled CO 2 Hypercapnia reduces systemic vascular resistance, increases cardiac index and pulmonary vascular resistance, as per evidence from small, pilot RCTs. hypercarbia is not harmful, except in the face of pulmonary hypertension, possibly cardiac arrhythmia and high intracranial pressure. Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

53. Recommendation for hypercapnia Permissive/therapeutic hypercapnia, to maintain a partial pressure of carbon dioxide of 50-70 mmHg potentially may be beneficial in patients undergoing single lung ventilation during pulmonary lobectomy operations (class IIa , level B). Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

54. Protective mechanical ventilation Although low mechanical ventilation rate, higher levels of PEEP and low inspired oxygen levels are considered to be “protective”, the primary components of protective ventilation (PV) include low tidal volume (LTV, tidal volume 6–8 mL/kg) and limited peak airway pressure, with or without PEEP. Landmark study by Amato and coworkers: Low tidal volume ventilation can effectively reduce mortality in patients with acute respiratory distress syndrome (ARDS) During operative lobectomy with one-lung ventilation, results of PV in improving patients’ outcomes are confusing Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

55. Studies investigating protective ventilation Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

56. Recommendation for Protective Ventilation PV with tidal volume of 6–8 mL/kg and a PEEP of 5 cmH2O is reasonable based on current evidence (class IIa , level B). Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

57. Recommendation for Alveolar recruitment Alveolar recruitment (open lung ventilation) may be potentially beneficial in patients undergoing lobectomy with one-lung ventilation (class IIb, level C). Low FIO2 may prevent absorption atelectasis Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

58. Recommendation for mode of mechanical ventilation PC or PCV-PG is recommended over VCV and can be used in patients undergoing lung resection with single-lung ventilation (class IIa , level B) Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

59. Recommendation for Pre-and post-operative noninvasive ventilation CPAP can be used in patients undergoing lobectomy and one lung ventilation, and is beneficial in improving short term oxygenation (class IIa , level A). Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

60. Recommendation for Non-intubated thoracoscopic lobectomy Thoracoscopic lobectomy without tracheal intubation may be an alternative to conventional one-lung ventilation, in selected patients (class II, level C). Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

61. Recommendation for Inspiratory to expiratory ratio (I:E) Controlled mechanical ventilation with I:E ratio of 1:1, or greater, is reasonable in patients undergoing one-lung ventilation (class IIa , level B). Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

62. Recommendation for Low inspired oxygen concentration Application of the lowest FIO2 necessary to maintain satisfactory arterial oxygen saturation is reasonable Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

63. Recommendation for Adjuvant drug use Adjuvant drugs such as nebulized budesonide, intravenous sivelestat and ulinastatin may have beneficial effect in attenuating inflammatory response following one-lung ventilation (class IIa , level B). Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

64. Post-Operative Care for Lung Decortication

65. Background: Lung decortication is a simple yet formidable procedure. It involves the excision of the thick fibrinous peel from the pleural surface, thereby permitting the expansion of the underlying lung parenchyma. Patients with long-standing empyema, pleural thickening, hemothorax, and pleural tumors are candidates for decortication. Postoperative Care Includes adequate analgesia, antibiotic therapy, hydration, and nutritional support. Sick patients often require mechanical ventilation. Therefore, intensive monitoring must be ensured during the initial postoperative period in these patients. Adequate care of the chest tubes must also be ensured. Apart from serial chest radiographs, periodic arterial blood gas analysis might be required in these patients. Nurses play a vital role in the postoperative lung expansion by ensuring periodic chest physiotherapy and incentive spirometry. The pharmacist might ensure that the patient is on appropriate formulation and doses of anticholinergic medications Detailed planning and discussion with the interprofessional team are highly recommended to decrease morbidity and to improve outcomes Kumar, Akshay, and Sachit Anand. "Lung Decortication." (2020).

66. Lung Decortication Complication and Management: Hemorrhage: Blood loss from the raw lung surfaces can result in a significant hemorrhage. A postoperative blood profile should be done to ascertain the need for blood transfusion. Persistent air-leak and bronchopleural fistula: Minor air-leaks can occur during decortication. However, these leaks resolve spontaneously after a few days. Large leaks must be closed with formal suturing to avoid the development of a bronchopleural fistula. Persistent lung collapse: Collapse, and non-expansion of the lung parenchyma is frequently noticed in post op period after decortication. Incentive spirometry and chest physiotherapy play a crucial role in the re-expansion of underlying parenchyma. However, a subset of patients may not show adequate lung expansion due to diseased/destroyed lung. Kumar, Akshay, and Sachit Anand. "Lung Decortication." (2020).

67. Lung Decortication Complication and Management: Injury to vital structures: Decortication must be performed carefully by experienced surgeons. Injury to vital structures, including subclavian vessels, diaphragm, esophagus, and pericardium, is common if the limits of peel removal are not followed. s Retained infective focus and sepsis: Removal of the pus and pleural toileting must be thoroughly performed during decortication. Retained pus is a nidus of infection and may lead to sepsis in the postoperative period. Severe postoperative pain: Any thoracotomy, especially those with rib resection, may lead to significant pain in the postoperative period. Adequate postoperative analgesia is a must and may require a combination of intravenous and epidural analgesia. Chest wall deformity and scoliosis Kumar, Akshay, and Sachit Anand. "Lung Decortication." (2020).

68. Enhancing Healthcare Team Outcomes Role of an experienced thoracic surgeon is important and also crucial it is to consult with an interdisciplinary team of specialists. An experienced pulmonologist and radiologist must be engaged in preoperative and postoperative management. Patients undergoing decortication for chronic empyema might also require intensive monitoring in the intensive care unit (ICU) during the initial postoperative period. Therefore, the involvement of an intensivist is always beneficial. Nurses also play a vital role in the postoperative lung expansion by ensuring periodic chest physiotherapy and incentive spirometry. The pharmacist might ensure that the patient is on appropriate formulation and doses of anticholinergic medications. Thus, detailed planning and discussion with the interprofessional team are highly recommended to decrease morbidity and to improve outcomes Kumar, Akshay, and Sachit Anand. "Lung Decortication." (2020).

69. Critical care post Pneumonectomy

70. Pneumonectomy An invasive procedure used as a management option for patients with advanced malignant and non-malignant lung disease. Proper patient selection, appropriate preoperative testing, multidisciplinary care are vital for optimal patient outcomes. Postoperative care is of great importance to decrease the incidence of complications. Ideally, patients should be managed in an intensive care unit. Extubation should be done early if deemed appropriate. Oxygen should be supplemented, if necessary, to maintain saturation while avoiding positive pressure whenever possible. Invasive monitoring should be continued. Care should be taken not to react to hypotension with fluid boluses as this may result in pulmonary edema and subsequent increase in morbidity and mortality. The chest tube, if present, should be off suction. The multimodal analgesic strategy should be employed. Esophageal dysmotility should be anticipated, and diet should be advanced gradually. Beshara , Michael, and Vaibhav Bora. "Pneumonectomy." (2020). https://www.ncbi.nlm.nih.gov/books/NBK555969/

71. Pneumonectomy Complications and Management Following pneumonectomy, pulmonary functions decrease but are usually less than anticipated for removal of 50% of lung, especially for residual volume, and this may be explained by overexpansion of the remaining lung tissue. FEV1, FVC, DLCO, and lung compliance decrease. Airway resistance increases. Patients with no disease in the remaining lung usually do have normal SaO2, PO2, and PaCO2 at rest. A chest X-ray immediately following pneumonectomy usually show the trachea in the midline and the postpneumonectomy space to be filled with air. Later, that space becomes filled gradually with fluid at a rate of 1 to 2 intercostal spaces/day. The ipsilateral diaphragm becomes elevated, and the mediastinum is gradually shifted towards the operative side. Resting heart rate typically increases, and stroke volume decreases. Pulmonary artery pressure, pulmonary vascular resistance, and central venous pressure usually do not change. Cardiac function in long-term survivors is usually compromised, and the altered position of the heart may explain this Beshara , Michael, and Vaibhav Bora. "Pneumonectomy." (2020). https://www.ncbi.nlm.nih.gov/books/NBK555969/

72. Complications: Cardiac arrhythmias: O ne of the most common complications after pneumonectomy. Atrial fibrillation/flutter is the most common and usually occurs in the first three days following surgery. Postpneumonectomy cardiac herniation: Usually occurs within the first 24 hours after surgery, but it has been reported up to 6 months following pneumonectomy. The condition presents with an abrupt drop in blood pressure and hemodynamic collapse. It requires and an immediate reoperation. Pulmonary complications like pneumonia, atelectasis, respiratory failure are also common. The incidence and severity of such complications increase with advanced age and may require reintubation and mechanical ventilation. Beshara , Michael, and Vaibhav Bora. "Pneumonectomy." (2020). https://www.ncbi.nlm.nih.gov/books/NBK555969/

73. Complications: Bronchopleural fistula About 1.5% to 4.5% of patients undergoing pneumonectomy will end up having a bronchopleural fistula. Associated with a mortality of 29% - 79%. Risk factor: Right-sided procedures, a large diameter bronchial stump, residual tumor, concurrent radiation or chemotherapy, age > 60 years, and prolonged postoperative mechanical ventilation. Symptoms: fever, cough, hemoptysis, subcutaneous emphysema. A persistent air leak is usually detected if a chest tube is still in place. A chest X-ray usually demonstrates a new air-fluid level or worsening of a preexisting air-fluid level. If the patient is still intubated and mechanically ventilated, measures to reduce airway pressure should be taken to limit the amount of leak. Some patients may require lung isolation using a double-lumen tube for proper oxygenation and ventilation. Management includes drainage of pleural space, systemic antibiotics. Surgical repair may be required in severe cases. Beshara , Michael, and Vaibhav Bora. "Pneumonectomy." (2020). https://www.ncbi.nlm.nih.gov/books/NBK555969/

74. Complications: Injury to the diaphragm, liver, spleen, or a major vessel is also known complications. Postpneumonectomy pulmonary edema. Occurs in 2% - 5% of cases and typically presents on postoperative days 2 to 3. Associated with a significant increase in mortality by up to 50%. Patients usually present with dyspnea and poor oxygenation with an increased alveolar-arterial gradient. More common after right-sided pneumonectomy. Liberal IV fluid administration has been implicated; however, it may still occur in patients with restrictive fluid management. Proposed mechanisms include increased capillary permeability, lymphatic damage, and ventilator-induced lung injury. A single intraoperative dose of methylprednisolone just before pulmonary artery ligation may decrease the risk of pulmonary edema as well as ARDS after pneumonectomy. Treatment is generally supportive, with ventilatory support as required together with restrictive fluid management and diuretics. Other potential complications: multiorgan dysfunction, acute lung injury, acute respiratory distress syndrome (ARDS), postoperative acute kidney injury Beshara , Michael, and Vaibhav Bora. "Pneumonectomy." (2020). https://www.ncbi.nlm.nih.gov/books/NBK555969/

75. THANK YOU