Preemptive gastrointestinal tract management reduces aspiration and respiratory failure after thoracic operations

Objectives: Respiratory failure is the major mode of death after general th oracic operations. However respiratory failure may develop from two very di fferent mechanisms: aspiration, often caused by ileus, and pneumonia, which often results from poor pain control. Epidural catheters help control pain and prevent pneumonia but contribute to ileus and may increase aspiration, We report a decrease in the incidence of aspiration after changing postope rative care to include gastrointestinal tract management. Methods: All pati ents undergoing elective thoracotomy by a single surgeon mere evaluated for hospital mortality and morbidity, For the first 21 months, patients did no t receive an intraoperative nasogastric tube and were prescribed an "advanc e as tolerated" diet after the operation (n = 125), For the second period, nasogastric tubes were placed intraoperatively and patients received nothin g by mouth the day of operation, clear liquids the first day, and a regular diet the second day (n = 153), Pneumonia was considered to have developed if infiltrates developed in a single lobe or two adjoining lobes and cultur e of the sputa grew a dominant organism, Patients were considered to have a spirated if diffuse infiltrates developed or cultures grew multiple organis ms. Significance of results was determined by chi(2) testing. Results: A to tal of 278 patients underwent elective lung resection over a 3 1/2-year per iod, 125 with ad libitum dietary management and 153 with intensive manageme nt of the gastrointestinal tract. Six patients (4.84%) aspirated before the institution of gastrointestinal tract management, whereas none (0.0%) aspi rated after the change. This difference was significant (P =.01), Respirato ry mortality was eliminated in the group with gastrointestinal tract manage ment (P =.04). Conclusions: Aspiration and its subsequent respiratory failu re and mortality can be decreased with preemptive gastrointestinal tract ma nagement.