Optimizing LOS after Lobectomy

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Optimizing Length of Stay after Lobectomy

Authors: Najib Safieddine, Sean McFadden

 

Summary of Recommendations

  • Preop
    1. Patient education that includes family members and social supports
    2. Council re smoking cessation and refer to smoking cessation clinic
    3. Clearly set expectations re hospital stay and pain
  • Peri/Intra op
    1. Minimize airleak (refer to recommendation on post-op airleak)
    2. Regional pain control measures (intercostal blocks) and no epidural if VATS
    3. Single c-tube
  • Post-op
    1. Avoid use of IV anesthesia whenever possible esp. for VATS
    2. Avoid routine suction on chest tubes and remove if < 450ml
    3. Impower nursing and physician allies to remove chest tubes
  • Adopt a standardized postoperative care pathways

 

Introduction

We examine length of stay (LOS) after lung resection not as an end in and of itself and not as a cost saving metric but rather as a secondary outcome of best perioperative approaches to management of chest tubes, pain control, and surgical technique (among others) that allows for safe and timely discharge without increased readmission. The recommendations below reflect practice consensus and not guidelines whereby adjustment for local needs organizational considerations can occur. Our hope is that particularly in thoracic units where perioperative practice has not yet adopted a common “standardized” approach, these recommendations can serve as a starting point for discussion and implementation.

 

MIS Lobectomy

PREOP PERI/INTRA OP POST-OP
Patient education, counseling and setting of expectations is paramount:

·       Use of educational material

·       Detailed overview of hospital course

·      Include family members, partners and/or supports in the discussion whenever possible

 No indication for routine use of epidural analgesia Chest Tube

o Remove chest tubes if- no air leak, drainage < 450ml and fluid color not concerning

oAvoid routine use of suction post-operatively

oRoutine use of tube removal protocols for unit nurses
Counsel patients regarding smoking cessation and exercise pre-operatively

·    Refer to smoking cessation clinic if available

 Local anesthetic regional block such as intercostal block or serratus block Selective use of chest x-rays post-op

Avoid use of chest x-ray post tube removal
Specifically advise patients they will go home POD 1 or 2 (occasionally with a  chest tube) unless there is a medical reason to delay discharge Routine use of 1 chest tube (smaller 24 Fr. preferrable) Avoid routine use of IV PCA analgesia for routine VATS lobectomy
Counsel patients RE pain related expectations.

·    Level of function and limitation drives pain assessment and opioid use

 Refer to recommendations RE airleak for technical suggestions to minimize prolonged airleak CATS standard for opioid use and prescription at discharge

Open Lobectomy

  • Patients undergoing thoracotomy and lobectomy, given the widespread adoption of VATS, likely represent a group of patients with more complex and potentially advanced disease. Nonetheless, the principles guiding the recommendations for outlines above for VATS patients apply with few exceptions notably:
    • Routine use of epidural analgesia

Selected Reading

  1. Recommendations primarily based on consensus statements adopted following Canadian national Positive Deviance Seminars involving multiple high volume thoracic units.
  2. Philip A. Linden, Yaron Perry, Stephanie Worrell, Amelia Wallace, Luis Argote-Greene, Vanessa P. Ho, Christopher W. Towe. Postoperative day 1 discharge after anatomic lung resection: A Society of Thoracic Surgeons database analysis. J Thorac Cardiovasc Surg. 2020 Feb; 159(2): 667–678.e2.
  3. Christopher W Towe, Dylan P Thibault, Stephanie G Worrell, Katelynn C Bachman, Yaron Perry Philip A Linden. Factors Associated With Successful Postoperative Day One Discharge After Anatomic Lung Resection. Ann Thorac Surg. 2021 Jul;112(1):221-227
  4. Greg P. Giambrone, Matthew C. Smith, Xian Wu, Licia K. Gaber-Baylis, Akshay U. Bhat, Ramin Zabih, Nasser K. Altorki, Peter M. Fleischut, Brendon M. Stiles. Variability in length of stay after uncomplicated pulmonary lobectomy: is length of stay a quality metric or a patient metric? Eur J Cardiothorac Surg.2016 Apr; 49(4): e65–e71