Analgesia, Extubation & Post-operative Care
Intra-operative & post-operative analgesia
Thoracic epidural analgesia (TEA) is the cornerstone. Multimodal: paracetamol + NSAIDs; nerve blocks — intercostal, paravertebral, serratus anterior plane, erector spinae plane; opioids; adjuncts dexmedetomidine / ketamine. Good analgesia allows deep breathing and early mobilisation — key to preventing pulmonary complications.
⚠️ Intra-operative complications to anticipate
Hypoxaemia · sudden severe hypotension (surgical compression of the heart/great vessels or mediastinal shift) · arrhythmia · bronchospasm · massive haemorrhage · hypothermia · neurovascular (positioning) injuries.
🫁 Extubation
- Functional intercostal drain with an underwater seal in place; check bilateral air entry; extubate awake; avoid coughing/straining (protects the bronchial stump).
- Guided by ppoFEV₁ (see Pre-op tab): >40% extubate on table; <30% staged weaning.
🛏️ Post-operative management
- Nurse in the sitting position; early mobilisation; avoid high airway pressures (protect the stump); early oral nutrition; early chest-drain removal; avoid salt & fluid overload; chest physiotherapy.
Post-operative complications
PulmonaryAtelectasis · pneumonia · empyema/subcut. emphysema · pneumothorax · bronchopleural fistula · pulmonary oedema
CardiovascularRight heart failure · arrhythmias (AF) · MI
Visceral / neurovascularSVC / aorta injury · Horner's syndrome · phrenic, vagus & recurrent laryngeal nerve injury
Post-pneumonectomy pulmonary oedema and bronchopleural fistula are the two dreaded, high-mortality complications — driven respectively by fluid overload and stump breakdown.