Commentary
POSTOPERATIVE BEDSIDE CRITICAL
CARE OF THORACIC SURGERY PATIENTS
By Jennifer Grondell, BSN, RN, Charlotte Holleran, BSN, RN, Esther Mintz, NP, RNFA, and
Ory Wiesel, MD
P
atients undergoing major thoracic surgi-
cal procedures are generally a high-risk,
specialty patient population. After under-
going a major surgical procedure such as
an esophagectomy, a pneumonectomy,
a pleurectomy, or a lung transplant, patients require
admission to an intensive care unit (ICU) for advanced
monitoring and a broad range of procedures per-
formed by members of the thoracic surgery and
critical care teams. The care of such complicated
patients requires critical care nursing considerations
that vary and necessitates guidelines that are tailored
to the specific patient and procedure. Currently, a
gap exists in the literature regarding standardized
nursing care of these patients in the initial postop-
erative period in the ICU.
In this article, we describe the role of the criti-
cal care nurse in the management of thoracic surgery
patients, in an effort to establish protocol-driven care
guidelines. Our experience is based on a 10-bed
thoracic surgery ICU in a teaching hospital, with
emphasis on a multidisciplinary approach.
Preparing for a Patient’s Arrival
When the need for an ICU bed is anticipated for
postoperative recovery, the need is communicated to
the ICU team preoperatively, so that staffing and bed
availability can be arranged in advance. Typically,
new admissions to the thoracic surgery ICU require
a 1:1 nurse to patient ratio for a minimum of 2 hours.
Higher-acuity patients, such as those after lung trans-
plant, require a 2:1 nurse to patient ratio in the ini-
tial recovery phase. In order to maintain adequate
staffing for patient acuity, a charge nurse handoff
occurs at the beginning of each shift and is focused
on patient acuity, surgical schedule, timing of the
cases, and staffing needs.
To facilitate a smooth transition from the oper-
ating room (OR) to the ICU, the thoracic surgical
©2018 American Association of Critical-Care Nurses
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patients are admitted directly to the ICU from the
OR, bypassing the postanesthesia care unit.
Communication between the OR nurse and the
ICU nurse is essential for continuity of care as well
as for proper setup of the ICU room. Two phone
calls take place between the OR nurse and the ICU
nurse. The first call occurs approximately 1 hour
before the anticipated transfer and is an opportunity
for the OR nurse to give a formal report that includes
a brief medical history of the patient, the procedure
performed, perioperative clinical issues, intraopera-
tive events, placement of tubes and drains, and plans
for anticipated extubation versus the need for a ven-
tilator setup. This conversation allows the receiving
nurse enough time to prepare the room for the
patient’s arrival. The second call, made just before
transfer, notifies the ICU team of the anticipated
arrival time as well as any updates on clinical acuity
and last-minute changes.
Patient’s Transfer and Arrival
During transfer from the OR to the ICU, thoracic
surgery patients are accompanied by the thoracic
surgery team, an attending anesthesiologist, an
anesthesia resident, an OR nurse, and when the
patient is intubated, a respiratory therapist. Upon
arrival in the ICU, a team approach is used to admit
the patient. A second critical care nurse and the
ICU patient care assistant join the primary nurse
and help with tasks such as connecting the cardiac
monitor, emptying and marking drains, activating
postoperative orders, updating the chart, collecting
samples for laboratory tests, and obtaining a post-
operative electrocardiogram. This team approach
allows the primary nurse to perform an initial
assessment of the patient, including the patient's
hemodynamic status, and participate in the “post-
operative huddle” along with the OR team.
The postoperative huddle is a multidisciplinary
handoff of the patient from the OR team to the
ICU team. The huddle begins by reviewing in detail
the patient’s medical history and the procedure
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 “ Each of these surgical procedures requires
a different, protocol-driven postoperative
care plan that uses specific order sets.
performed. Next, the anesthesia team reviews intra-
operative medications, current infusions, net fluid
balance, blood products, and intraoperative com-
plications encountered by the anesthesia team such
as hypotension, cardiac arrhythmias, and ventila-
tion difficulties. The thoracic fellow then outlines
the surgical procedure performed, intraoperative
complications, patient-specific considerations or
issues of concern, and any monitoring required
outside the usual protocols. Finally, the ICU team
reviews the postoperative plan of care and orders
and addresses any discrepancies.
Postoperative Care of Thoracic Surgical
Patients
The major thoracic surgery procedures after which
patients are admitted to the ICU include esophagecto-
mies, pneumonectomies, pleurectomies, and lung
transplants. Each of these surgical procedures requires
a different, protocol-driven postoperative care plan
that uses specific order sets. The following sections
provide some insight into the care of these patients
in the immediate postoperative period in the ICU.
Esophagectomy
Esophagectomies, both open and minimally inva-
sive procedures, are performed for the management
of esophageal cancer and to treat benign esophageal
diseases such as end-stage achalasia, esophageal
strictures, and esophageal perforation.
After an elective esophagectomy, patients typically
arrive in the ICU extubated and hemodynamically
stable. Special considerations for the critical care
nurse include hemodynamic monitoring, ensuring
proper functioning of the nasogastric tube (Salem
sump), maintenance of adequate pain control, and
prevention of aspiration.
About the Authors
Jennifer Grondell is nurse in charge and Charlotte Holle-
ran is a staff nurse in the thoracic surgical intensive care
unit, Brigham and Women’s Hospital, Harvard Medical
School, Boston, Massachusetts. Esther Mintz is a nurse
practitioner and first assistant and Ory Wiesel is a tho-
racic surgeon, Division of Thoracic Surgery, Maimonides
Medical Center, Brooklyn, New York.
Corresponding author: Ory Wiesel, MD, Division of Thoracic
Surgery, Maimonides Medical Center, 4802 Tenth Ave,
Brooklyn, NY 11219 (email: orywiesel@gmail.com).
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”
Inadequate perfusion after an esophagectomy
can lead to conduit necrosis and alteration in anas-
tomotic healing. When hemodynamic stability is
of concern, an arterial catheter is used to ensure ade-
quate monitoring. The goal is to maintain a mean
arterial pressure greater than 65 mm Hg, ideally with
maintenance intravenous fluids and boluses of lac-
tated Ringer solution or 5% albumin as needed. While
fluid replacements (fluid resuscitation) are being
provided, efforts should be made to prevent fluid
overload, which can contribute to postoperative
respiratory complications.1 Vasoactive medications
cause vasoconstriction and should be avoided when
possible. Conduit or anastomotic vasoconstriction
may lead to ischemia, which might contribute to com-
plications such as acute conduit necrosis, anastomotic
leak, or late anastomotic strictures. It is the role of the
critical care nurse to monitor the patient’s hemody-
namic status closely, ensure adequate urine output,
and maintain electrolyte balances. Constant commu-
nication with the ICU and surgical teams is essential
to maintain hemodynamic stability and prevent hypo-
tension, cardiac arrhythmia, and fluid overload.2
In order to prevent distention of the conduit,
a nasogastric Salem sump is placed during surgery.
The tip of the nasogastric tube sits distal to the anas-
tomosis site, and its position should be marked. Rou-
tine care of the nasogastric tube includes flushing
with 20 to 30 mL of normal saline to prevent clog-
ging every 8 hours and constant monitoring to ensure
that the tube is sumping adequately. Change in the
nasogastric output and/or content, malfunction,
inadequate sumping, or dislodgment of the tube
should be addressed immediately to avoid compli-
cations such as dehiscence of the anastomosis. Dis-
lodged nasogastric tubes should never be blindly
advanced or manipulated, as doing so can damage
the anastomosis. Interventions that can cause conduit
distention, such as bilevel or continuous positive
airway pressure, should be avoided. If intubation is
necessary, it should be done under direct visualiza-
tion to avoid injury of a high-riding neck anastomo-
sis, and prolonged use of the bag valve mask should
be avoided to prevent conduit distention.3
Other nursing considerations after esophagec-
tomy include ensuring adequate pain control, aspi-
ration precautions, monitoring of the respiratory
status, encouraging early ambulation, and early
329
 nutrition. Loss of the lower esophageal sphincter and
presence of a nasogastric tube puts the postesophagec-
tomy patient at an increased risk for aspiration. The
head of the bed should always be kept above a 30º
angle, and all aspiration precautions should be
strictly observed. Adequate pain control is import-
ant to facilitate coughing, deep breathing, and early
ambulation. Ambulation and moving out of bed to
chair are initiated on postoperative day 1 when tol-
erated, and fluid resuscitation is continued as needed.
Postoperative days 2 through 6 are focused on
ambulating at least 3 times per day, diuresis as
needed, and once evidence of bowel function is
apparent, the start of enteral feedings through the
jejunostomy tube. When hemodynamically stable,
with adequate urine output and stable respiratory
status, patients are transferred to the step-down unit.
Throughout the rest of the hospitalization, strict
aspiration precautions should be maintained,
enteral feedings should be advanced and opti-
mized, and ambulation should be encouraged.
Pneumonectomy
Pneumonectomy is usually performed for a
central tumor or hilar lung mass that mandates
resection of the main bronchus or a proximal pul-
monary artery or vein. Patients undergoing pneu-
monectomy are at very high risk for postoperative
complications and are very sensitive to slight increases
in pulmonary artery pressure (pulmonary hyper-
tension) and right-sided heart failure. Additional
complications, such as hemodynamic alterations,
atrial fibrillation, fluid shifts, and aspiration are
common in patients after pneumonectomy and
should be monitored carefully. Early signs of com-
plications should be addressed urgently as these
patients have limited reserve with only 1 lung.4
After pneumonectomy, patients usually arrive
from the OR extubated, with a central catheter, arte-
rial catheter, nasogastric tube, urinary catheter, and
chest drain. Chest drain management after pneumo-
nectomy differs from chest drain management after
other lung resection. In addition to its use for assess-
ing for air leak and bleeding, the chest drain is
imperative for assessing and ensuring mediastinal
stability after pneumonectomy. The chest drain
should be placed to water seal and never to suction
because use of suction may cause a mediastinal shift
and devastating consequences. Some surgeons prefer
to use a red rubber tube (Rob-Nel catheter, Dover-
Covidien) instead of a chest tube and connect it to a
transducer to monitor changes in intrathoracic pres-
sure. An increase or decrease in pressure can be a
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sign of mediastinal shift and should be reported to
the ICU and thoracic surgery team immediately and
prompt an urgent chest radiograph for assessment.
Fluid or air can be drawn off from the chest in a
sterile fashion by the surgeon if necessary via the
drain. Other signs of a potential mediastinal shift in
these patients include hypotension, arrhythmias,
and dyspnea. Over time, fluid will accumulate to fill
the postpneumonectomy space, and the contralat-
eral lung may expand to accommodate. Shift of the
mediastinum toward the side of the pneumonec-
tomy is expected over time; however, abrupt shift of
the mediastinum can cause significant complica-
tions. If the mediastinum is stable, the chest tube is
typically removed on postoperative day 1 or 2 to
prevent an infection in the pneumonectomy space.
Postpneumonectomy patients have an increased
risk of development of pulmonary artery hypertension
and postoperative right-sided heart failure. The bed-
side ICU nurse should closely monitor these patients
for persistent hypotension, increased shortness of
breath, and decreased urine output and quickly report
these findings to the ICU and surgical team as these
can be early signs of worsening right-sided heart fail-
ure.5 Strict fluid intake and output should be assessed
hourly. Fluid restriction in the early postoperative days
is usually practiced to prevent pulmonary congestion.
Pain management for pneumonectomies is of utmost
importance to allow deep breathing and prevent atel-
ectasis of the remaining lung. It typically includes a
combination of an epidural infusion, patient-
controlled analgesia, acetaminophen suppositories,
and lidocaine patches. Patients usually tolerate sips of
clear liquids on postoperative day 1 if they show evi-
dence of bowel function, which allows medications to
be switched to the oral route as quickly as tolerated.6
Aspiration and pneumonias can lead to signifi-
cant morbidity and mortality after pneumonectomy,
because the pulmonary reserve is limited and no
second lung is present to compensate. Strict aspira-
tion precautions should be maintained at all times,
including elevating the head of the bed to greater
than 30º and having the patient move out of bed to
chair for all meals and remain upright after all oral
intake. Chest physiotherapy, coughing and deep
breathing, ambulation, and use of incentive spirom-
etry should be encouraged to prevent atelectasis and
pneumonia. A special thoracic walker was developed
for postoperative ambulation (see Figure). These
walkers are designed for optimal recruitment of lung
volume as well as ease of ambulation with chest tubes.
Other postoperative nursing considerations for
patients after pneumonectomy include early and
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frequent ambulation, close monitoring of telemetry
data and electrolyte levels because these patients
have an increased risk of atrial fibrillation, and
monitoring of fluid balance to prevent fluid over-
load. Patients are typically stable enough for transfer
to the step-down unit by postoperative day 2.

Pleurectomy
A pleurectomy, with or without the instillation
of intraoperative heated chemotherapy, is most com-
monly performed for the treatment of mesothelioma.
Preoperatively, these patients are admitted the night
before surgery to receive intravenous hydration and a
bowel preparation. During pleurectomy, the surgeon
strips and decorticates the parietal and visceral pleura
and resects the diaphragm and part of the pericardium.
Often, this surgical procedure also includes lung
resections and even pneumonectomy. Intraoperative
heated chemotherapy is given during pleurectomy
in most cases. This procedure is very morbid, involving
bleeding and administration of multiple blood
products, hypotension from sympathectomy done
during the process of pleurectomy, hemodynamic
changes, and fluid shifts. Postoperatively, these
patients tend to have multiple complications as a
result of hemodynamic alterations, bleeding, hypoxia,
acute renal failure, prolonged air leak, ileus, and pain.4
The postoperative huddle should address intra-
operative blood loss/transfusions, postoperative risk Figure Thoracic walker enables early ambulation for patients.
of bleeding, use of vasoactive medications, intraop- These unique walkers allow the patient to ambulate with chest
erative heated chemotherapy administration, and tubes to suction. The walkers are designed for erect posture,
whether the pericardium or diaphragm was resected which recruits lung tissue and thus helps to improve postopera-
tive ventilation.
and reconstructed. Procedure-specific postoperative
considerations for critical care nursing include hemo-
dynamic monitoring, fluid replacement protocols for Removing the pleura from the surface of the
renal protection, adequate pain control, and chest lung can cause a continuous air leak and bleeding
tube management. from the lung surface. Therefore, after pleurectomy,
Hypotension and bleeding are common after patients usually remain intubated overnight with 10
pleurectomy. Vasopressors, blood products, and/or cm H2O of positive end-expiratory pressure. This
fluid boluses are often needed to keep the mean intervention promotes apposition of the lung to the
arterial pressure greater than 65 mm Hg and urine chest wall, which will decrease bleeding from the
output greater than 30 mL/h. Patients are also at lung and chest wall surfaces and decrease the air
risk for cardiac arrhythmias, such as atrial fibrilla- leak. Chest tube output and air leaks should be
tion, especially after manipulation or resection of monitored closely and all chest tubes should be
the pericardium. Electrolytes are monitored closely stripped and “milked” hourly to ensure patency.
and replaced as needed. If intraoperative heated Pleurectomy is done through a large postero-
chemotherapy is used, there is a risk of acute renal lateral thoracotomy, and multiple chest tubes are
failure, and a fluid replacement protocol is initiated placed postoperatively. The chest tubes often
for renal protection. Chemotherapy causes a brisk remain in place for a prolonged period because of
diuresis postoperatively and urine output requires air leak from the visceral pleurectomy. Adequate
1:1 replacement with intravenous fluids to prevent pain control may be difficult to achieve and gener-
acute renal failure. This 1:1 fluid replacement is ally requires a combination of epidural, narcotic
maintained for the first 12 hours postoperatively or patient-controlled analgesia, lidocaine patches,
until urine output decreases to less than 100 mL/h.7 acetaminophen, and frequent repositioning.

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Table 1
Key points in managing postoperative thoracic
surgery patients in the intensive care unit
Surgery Key points of management
Esophagectomy Keep mean arterial pressure >65 mm Hg
Ensure that nasogastric and J tubes remain patent
Avoid use of vasopressors as possible
Encourage early and frequent ambulation
Maintain adequate pain control
Take precautions to avoid aspiration
Pneumonectomy Monitor hemodynamic status closely
Check for mediastinal shift
Place chest tube to water seal, never to suction
Restrict fluids
Ensure adequate pain control
Encourage early and frequent ambulation
Take precautions to avoid aspiration
Pleurectomy Bleeding risk: ensure chest tubes are patent and
monitor output hourly
Keep intubated overnight on postoperative day 0
Keep mean arterial pressure >65 mm Hg
Follow fluid replacement guidelines for kidney protection
Encourage early and frequent ambulation
Maintain adequate pain control
Take precautions to avoid aspiration
Perform pulmonary hygiene
Prevent thromboembolism
Lung transplant Maintain normothermia after bypass
Extubate early if possible
Ensure chest tubes are patent and monitor output hourly
Keep mean arterial pressure >65 mm Hg
Implement sternal precautions
Ensure adequate pain control
Encourage early and frequent mobilization
Reinforce guidelines for immunosuppression and
infection control
Take precautions to avoid aspiration
Standard postoperative considerations should
also be implemented, for example, frequent ambu-
lation, aspiration precautions, and frequent chest
physiotherapy including coughing and deep breath-
ing. Deep vein thrombosis and pulmonary embolism
are common in pleurectomy patients and should be
prevented and assessed on daily basis.
Lung Transplants
Single and double lung transplants are most
often performed for patients with end-stage lung
disease such as cystic fibrosis and idiopathic pulmo-
nary fibrosis. The transplant team typically consists
of pulmonologists, thoracic surgeons, transplant
pharmacists, nurse coordinators, and transplant
social workers. Postoperative care for transplant
patients is complicated, and nurses in the thoracic
surgery ICU must complete an annual assessment
of competency to care for patients after transplant.
Scheduling of lung transplant is usually unpredict-
able because it is dependent on availability and
332 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2018, Volume 27, No. 4
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condition of the donor lung at the time of procure-
ment. Once the transplant procedure is scheduled,
the need for ICU nursing staff is anticipated for
approximately 6 hours after incision. Specific critical
care nursing considerations include close monitor-
ing of hemodynamic status, electrolyte levels, signs
of right-sided heart failure, respiratory complica-
tions, hypothermia, and bleeding.
After lung transplant, patients arrive in the ICU
intubated, with multiple chest tubes and drains,
and often require multiple vasoactive medications,
blood products, and collection of blood samples
for laboratory tests. Because of the high acuity of
care, a 2:1 nurse to patient ratio is maintained for a
minimum of 8 hours. After the initial 8 hours, patient
acuity is readdressed and staffing is assigned accord-
ingly. Patients typically arrive in the ICU intubated
and receiving epoprostenol for right-sided heart sup-
port. The goal is to wean patients off the ventilator
and extubate as soon as possible. Up to 5 chest tubes
may be left in place after transplant, depending on
whether a single or double lung transplant was per-
formed. Chest tubes are put to -20 cm H2O suction
to help expand the lung, and the tubes should be
stripped and milked hourly to ensure patency. Chest
tube output should be monitored hourly to assess
for bleeding. Lung transplants are performed through
thoracotomy, clamshell incision or median sternot-
omy. If performed through a sternotomy, sternal pre-
cautions are implemented to protect the incision.
Hypothermia is common after lung transplant because
of the cardiopulmonary bypass during transplant, and
warming blankets should be used postoperatively to
maintain normothermia.8 Frequently blood samples
must be collected to monitor the hematocrit and to
ensure that electrolyte replacement is adequate. The
critical care nurse also initiates the postoperative teach-
ing with lung transplant patients and their families.
Transplant patients are heavily immunosuppressed,
and adequate precautions should be practiced. Mul-
tiple visitors should be limited; strict infection con-
trol precautions should be reinforced; gloves, gowns,
and masks should be used per institutional protocols;
and early signs and symptoms of infection should
be addressed as soon as identified.
Conclusion
Bedside critical care nurses play an important
role in the care of patients after major thoracic sur-
gery. As these surgeries have a unique profile of com-
plications, many interventions vary by patient and
procedure (see Table). Appropriate nursing training,
continued education, knowledge of the unique com-
plication profile of each surgical procedure, and
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postoperative guidelines that are tailored to individ-
ual procedures can help prevent adverse events and
postoperative complications in these high-risk patients.
ACKNOWLEDGMENTS
Jennifer Grondell and Charlotte Holleran are both first
authors of this commentary.
FINANCIAL DISCLOSURES
None reported.
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To purchase electronic or print reprints, contact American
Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo,
CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532);
fax, (949) 362-2049; e-mail, reprints@aacn.org.
333
Postoperative Bedside Critical Care of Thoracic Surgery Patients
Jennifer Grondell, Charlotte Holleran, Esther Mintz and Ory Wiesel
Am J Crit Care 2018;27 328-333 10.4037/ajcc2018107
©2018 American Association of Critical-Care Nurses
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