Admission
4D-Lobectomy/wedge/decortication/pleurodesis
ICU-Pneumonectomy/Esophagectomy
IV
LR 75-100 cc/hr
Diet
Robotic/VATS/chest wall: Clear liquid diet overnight, POD #1 adv to Regular Diet
Esophageal: NPO
Medications – IV
Ketamine drip (hold if >75hrs old)
Robaxin 750mg IV q8hr for pts NPO
Medications – Scheduled
Tylenol 650mg q6 hrs
Gabapentin 300mg q8 hrs (hold if >75 y/o, or CrCl <30)
Robaxin 750mg q 8 hrs
Oxycodone 5mg q6hrs PRN mild pain
Oxycodone 7.5mg q6hrs PRN moderate pain
Oxycodone 10mg q6hrs PRN severe pain
Heparin 5000 subcutaneous every 8-12 hours
Protonix 40mg q24hrs
Medications – PRN
Dilaudid 0.5mg q2hrs prn breakthrough pain
Zofran 4mg IV/SL q6hrs prn
Chest Tube Management
Lobectomy/Wedge
-20 suction in PACU, water seal if no pneumothorax and small/no air leak
Removal-no air leak, output<200, serous drainage
Decortication
-20 suction for 3 days
Removal-usually remove first CT on POD3, the lowest output first
Pleurodesis
-20 suction for 3 days
Removal-start removing CT’s one each day if no air leak, CXR stable, and output low (<100cc/24hrs)
Marking Pleurevac Canisters
Green marker, at 24hr intervals
Chest Tube Dressings
4×4 gauze, Tegaderm or Medipore tape – changed daily and prn
No Vaseline gauze
Chest Tube Removal
Vaseline gauze, 4X4 gauze, tegaderm or medipore tape
Place chest tube and canister in red bag
Post chest tube removal CXR – as directed by attending
Clamping Chest Tubes
Only by direction from attending physician
Slide the blue clip to the closed position
Nursing will place tape on the blue clip with date/time/initials
Nursing will monitor for symptoms
Place order for the chest tube to be clamped
CXR 2 hrs post clamping, then in AM
Foley
Remove POD1
Imaging
PCXR in PACU
PCXR qAM – Place order for ‘Timed’ at 0400, (not Routine)
PCXR 2-3hrs post CT removal as directed by attending (Erwin no post removal CXR)
Labs
CBC/BMP in AM x3 days, then PRN
Discharge Orders
Follow up with surgeon 2-3 weeks after discharge
Remove chest tube site dressing after 48hrs then ok to shower, no need to replace dressing. No bath/pool/jacuzzi
No heavy lifting or straining for 4 weeks limit 10 lbs
No driving until seen by Dr. in office
Pain medications: typically give: gabapentin, robaxin, tylenol, oxycodone (administer #40)
Endoluminal VAC Orders
Wound Vac order set: Wound Vac Settings => see screenshot
“Comments” use the dot phrase => .ENDOVAC
Ordering Esophagram
Order Fluoro Esophagram as Stat on the morning test is needed
Free text: Evaluate for leak and for gastric conduit emptying/transit time
Doxycycline Pleurodesis
Doxycycline 100mg in 100cc
Fever
Most common is atelectasis in first 48hrs
Typical work up: CXR, UA, sputum culture, evaluate CT output for purulence
Discuss with attending before ordering blood cultures
Blood Patch
https://pmc.ncbi.nlm.nih.gov/articles/PMC8264717/
Place Picc line or large gauge midline
10 x 10cc syringes
For an IR drain: Add a three-way stopcock between the tube and adapter for injection of the blood.
For a standard chest tube: Prep tubing at site of injection
Chyle Leak
Send pleural fluid for Triglycerides (do not order serum TG)
NPO
PICC line/TPN
Octreotide 50mcg SQ q8hrs
Pleurx TPA
Empyema Order set-TPA 10mg/30mls
Instill through Pleurx with 20 gauge gelco – catheter only, needle removed
Clamp for 1 hr
Website
http://www.rapidtrainer.org
password: thoracic