MANAGEMENT OF

CHEST INFECTIONS
IN THORACIC SURGERY
BY

DR. ANIMESH ARYA

CONSULTANT RESPIRATORY PHYSICIAN

CHAIRMAN HOSPITAL INFECTION CONTROL COMMITTEE
SHRI BALAJI ACTION MEDICAL INSTITUTE
NEW DELHI

MAX HOSPITAL PITAM PURA

NEW DELHI
THORACIC SURGERY
Cardiac Surgery
General Thoracic Surgery
• Pulmonary
Acquired
• Chest
Congenital
Wall
• Mediastinal
Vascular Surgery
•• Pleural
aneurysms
•• Pericardial
aortic dissection
• Neural Surgery
Esophageal
THORACIC SURGERY:
PULMONARY SURGERY
Infections
Emphysema
• TB
Neoplasms
•• Lung Abscess CA
Bronchogenic
•• Empyema
Other malignant tumors
•• Bronchiectasis
Lung Metastasis
•• Fungi
Benign tumors
• Parasitic
Palliative
Trauma
• pleural-pericardial effusion
•• blunt
airwayvs. penetrating
obstruction
Congenital
• cystic fibrosis
INCIDENCE
POST OP COMPL AFTER THOEACIC SURGERIES -19-59%

UPPER ABDOMEN -16-17%

LOWER ABDOMEN-0-5%
TYPE OF POST OP
INFECTIONS
• POST OP WOUND INFECTIONS

• EMPYEMA

• POST OP PNEUMONIA

INCIDENCE 5-24 %- RESPOSIBLE FOR INCREASE

MORTALITY UPTO 19%
INCIDENCE VARIES GPS -39% GN-56% FUNGI 7%
ANAEROBES ALSO OCCUR
SURGICAL
PROPHYLAXIS
• THERE ARE GUIDELINES ONE MUST
FOLLOW
• AND THESE ARE USUALLY TO PREVENT
SSI
• BUT THESE ARE TO BE STRICTLY
FOLLWED BASED ON CLINICAL
STUATION IN TOUR HOSPITAL
Trial (year) Surgical Field Antibiotic Regimen Antibiotic Control Group
Group Infection Infection Rate
Rate
Bernard et Gastrointestinal Penicillin 8% (5/66 27% (21/79
al4 (1964 surgery G/Methcillin/Chloram patients) patients)
phenicol vs. placebo
(given pre-, intra-,
and post-op)

Brown et al5 Gastrointestinal, Cephaloridine vs. 6.7% (6/90 22.8% (21/92

(1969 head and neck, placebo (given pre- patients) patients)
hernias, skin and op then every 8
soft tissue hours for 5-10
surgery doses)

Allen et al6 Gynecologic Cephalothin vs. 14.1% (12/85 41.0% (34/83

(1972) procedures placebo (given pre-, patients) patients)
intra-, and post-op
for 5 days)

Boyd et al7 Hip fractures Nafcillin vs. placebo 0.8% (1/135 4.8% (7/145
(1973) (given pre-, intra-, patients) patients)
and post-op)
PREOP FACTORS

PATIENT
1. AGE
2. SMOKING
3. PREOP STRUCTURAL LUNG DISEASE
4. PREOP PERFORMANCE STATUS
5. PREOP LUNG FUNCTION
6. COPD
7. CONCOMITANT CARDIOVASCULAR DISEASE
DISEASE
1. EMPYEMA
2. RESECTION
3.LUNG ABSCESS
4.CARCINOMA
A COMMENT ON
PREOP PREPARATION
Due to the nature of the disease and it’s presentation, these patients
are usually quite fragile pre-operatively.  the absolute importance of
early and aggressive pre-operative optimization and nutritional
rehabilitation in these patients.  particularly large surgeries such as
this for what it really is – a profound, manmade injury.
The benefits only come later – if your patient survives the initial injury
and recovers and if you knew now that you were going to be in a
horrible but completely unavoidable car accident in a few weeks
-you’d do things differently, wouldn’t you?
You’d make sure to be in a car with the maximum amount of safety
features (we’d all be in Volvos) with 6 air bags, automatic assisted
braking, five point seatbelts and helmets. You’d do all of this, to
ensure your survival. You wouldn’t just hop into a alto and drive off to
work
Pre-optimization is giving your patient a helmet, a seatbelt, and array
of airbags, and understanding that they could be in a difficult situation
 

This pre-operative training/ planning, in

my experience is the one crucial
factor; (more than surgical technique,
surgeon* or hospital facility) in
ultimately determining outcomes.
K. Eckland, ACNP
HOW TO SUSPECT INFECTIONS
EARLY
1. FEVER
2. RAISED TLC
3. CRP
4. PROCALCITONIN
5. SYSTEMIC SYMPTOMS
6. OVERALL ASSEESSMENT
POINTS NOT TO BE IGNORED

1. ANY CHANGE IN PATIENT LOOK

2. EARLY SIGNS OF SEPSIS – CONFUSION DROWSINESS,
INCREASED FIO2, TACHYPNOEA.
3. FRESH CHANGE IN XRAY CHEST
4. DISTINGUISH BETWEEEN ATELECTASIS AND
PNEUMONIA
5. ARDS, PULMONARY EDEMA, TRALI ,AKI, UTI
WHAT INFECTIONS DO WE
SEE

1. IMMEDIATE AND LATE

2. SITE INFECTIONS
3. POST OP BSI
4. POST OP CASI
5. INFECTIVE TRACHEOBRONCHITIS
6. VAP
INVESTIGATIONAL
NEED
USUAL TO SEND ALL CULTURES AND CBC
BUT MOST IMPORTANT ARE SIGNS TO FORM A STRATEGY
BRONCHOSCOPY REMAINS A VERY IMPORTANT TOOL
AND EARLIER THE BETTER
NOW WE HAVE A PCR BASED TEST TO IDENTIFY
ORGANISMS IN SHORT TIME AND CHANGE ANTIBIOTICS
CTSCAN CHEST A VERY VALUABLE TOOL IN DIFF FROM
ATELECTASIS, PNEMONIA AND EFFUSION MIMICING THESE
WITH RAISED DIAPHRAGM
ULTRASONOGRAPHY OF CHEST FOR NEW SHADOW AND
ASPIRATE AND SEND FOR INV
TREATMENT

OPTIONS ARE TO CORRECT THE COMPLICATION LEADING

TO AN EVENT
WHEN TO CHANGE ANTIBIOTICS \
NO GUIDELINES EXIST
BUST BASED ON YOUE HOSPITAL ANTIBIOGRAM AND
PROBABLE ORGA.NISM
INTIALLY THESE ARE GP ORG AND LATER NOSOCOMIAL
INF3ECTIONS
HOWVER AT TIMES THE TIMING AND CHOICE IS CRUCIAL
TO SUCCEES SOF A CRITICALLY ILL PATIENT
SUMMARY AND
CONCLUSIONS

CHOOSING THE PATIENT WISELY

PREOP PREPARATION –PHYSIO DEEP INHALATION
TECHNIQUE
HUFF ANF PUFF TECH
NUTRIONALLY BUILDING UP
PREOP PROPHYLAXIS AS PER GUIDELINES
EARLY WARNING SIGNS NOT TO BE MISSED IN POST OP
PERIOD AND PREVENT SEPSIS
SEPSIS NEED TO BE AGGRESSIVELY MANAGED
SOMETIMES REOPENING OF CONTAMINATED
SECCRETIONS IS NEEDED
COMPONENTS OF “MODERN”
THORACIC SURGERY=
SEVEN COMMANDMENTS
• Anatomic-Pathologic Diagnosis
• Endotracheal intubation and positive
pressure ventilation
• Anatomic dissection and individual ligation
• Secure bronchial closure
• Closed pleural suction drainage
• Respiratory therapy and ventilatory support
• Antibiotic therapy
THANK YOU