Guidelines for Enhanced Recovery After Lung Surgery (ERAS)

Guidelines for Enhanced Recovery After Lung Surgery (ERAS)

Armen Parajian1

1 Department of Thoracic Surgery, Lakeridge Health Oshawa and The Durham Regional Cancer Center, Oshawa ON, Canada


Background

Enhanced Recovery After Surgery, or ERAS, can be considered an evidence-based treatment paradigm for all surgical patients. It’s fundamental tenets are the development and systematic implementation of evidence-based perioperative care protocols. The goal of which is to optimize patient outcomes, decreased morbidity and decrease length of stay. There has been considerable interest in the development of these protocols for nearly two decades with Colorectal Surgery being one of the original champions of the paradigm. There is an abundance of data linking ERAS protocols with improved patient outcomes. This is borne out in many meta-analyses albeit with a significant amount of heterogeneity in the data. “Fast Track” protocols in lung surgery have been described by many authors and more recently a large review by the ESTS and ERAS societies synthesized some of this data into a highly-effective and streamlined recommendations. Continued efforts are needed to generate high level data examining each facet of perioperative care, to solidify any lessons derived there-from.

Aim

The following are evidence-based perioperative care recommendations endorsed by the CATS best practice committee for an Enhanced Recovery After Surgery (ERAS) pathway in patients undergoing major pulmonary resection. These recommendations are in line with the recommendations described by the ESTS and ERAS societies however recommendations for which data was less clear, or not relevant in the Canadian clinical context, were modified or excluded. Where possible the data were independently reviewed for quality and relevance, particularly in areas known to have a paucity of quality data. As this document in itself is not based on an exhaustive systematic review of the literature therefore the strength of evidence and grades of recommendation will not be mentioned.

Preoperative phase

Perioperative nutrition

  • Patients should be screened preoperatively for nutritional status and weight loss
  • Oral nutritional supplements should be given to malnourished patients

Smoking cessation

  • Smoking cessation should strongly be encouraged including the use of smoking cessation programs
  • Cessation greater than 4 weeks pre-op is associated lower post operative pulmonary complications

Alcohol dependency management

  • Alcohol consumption (in alcohol abusers) should be avoided for at least 4 weeks before surgery

Pulmonary ‘prehabilitation’

  • Patients with COPD should have their pulmonary function medically optimized by a multidisciplinary team that includes a respirologist

Admission

Preoperative fasting and carbohydrate treatment

  • Clear fluids should be allowed up until 2 h before the induction of anaesthesia and solids until 6 h before induction of anaesthesia
  • Oral carbohydrate loading reduces postoperative insulin resistance and can be considered (data is extrapolated from abdominal surgery population)

Preanaesthetic medication

  • Routine administration of sedatives to reduce anxiety preoperatively should be avoided

Perioperative phase

Venous thromboembolism prophylaxis

  • Patients undergoing major lung resection should be treated with pharmacological and mechanical VTE prophylaxis
  • Patients at high risk of VTE may be considered for extended prophylaxis with LMWH for up to 4 weeks although data are lacking in the Thoracic patient population and trials are forthcoming

Antibiotic prophylaxis and skin preparation

  • Routine intravenous antibiotics should be administered within 60 min of, but prior to, the skin incision
  • Hair clipping is recommended if hair removal is required
  • Chlorhexidine–alcohol is preferred to povidone-iodine solution for skin preparation

Preventing intraoperative hypothermia

  • Maintenance of normothermia with convective active warming devices should be used perioperatively
  • Continuous measurement of core temperature for efficacy and compliance is recommended

Standard anaesthetic protocol

  • Lung-protective strategies should be used during one-lung ventilation
  • A combination of regional and general anaesthetic techniques should be used
  • Short-acting volatile or intravenous anaesthetics, or their combination, are equivalent choices

PONV control

  • A multimodal pharmacological approach for PONV prophylaxis is indicated in patients at moderate risk or high risk

Regional anaesthesia and pain  relief

  • Regional anaesthesia (ie intercostal nerve block, paravertebral block or pleural catheter) is recommended with the aim of reducing postoperative opioid use
  • Paravertebral blockade provides equivalent analgesia to epidural anaesthesia
  • A combination of acetaminophen and NSAIDs should be administered regularly to all patients unless contraindications exist
  • Ketamine should be considered for patients with pre-existing chronic pain
  • Dexamethasone may be administered to prevent PONV and reduce pain

Perioperative fluid management

  • Very restrictive or liberal fluid regimes should be avoided in favour of euvolemia
  • Balanced crystalloids are the intravenous fluid of choice and are preferred to 0.9% saline High Strong
  • Intravenous fluids should be discontinued as soon as possible and replaced with oral fluids and diet

Atrial fibrillation prevention

  • Patients taking b-blockers preoperatively should continue to take them in the postoperative period
  • Magnesium supplementation may be considered in magnesium deplete patients

Surgical technique: thoracotomy

  • If a thoracotomy is required, a muscle-sparing technique should be performed
  • Intercostal muscle- and nerve-sparing techniques are recommended
  • Reapproximation of the ribs during thoracotomy closure should spare the inferior intercostal nerve

Surgical technique: minimally invasive surgery

  • A VATS approach for lung resection is recommended for early-stage lung cancer
  • Minimally invasive techniques are feasible in more advanced disease (post-neoadjuvant, sleeve resections) but their use should be limited to surgeons with experience in such techniques

Postoperative phase

Chest drain management

  • The routine application of external suction should be avoided Low Strong
  • Chest tubes should be removed even if the daily serous effusion is of high volume (up to 450 ml/24 h)
  • A single tube should be used instead of 2 after anatomical lung resection

Urinary drainage

  • In patients with normal preoperative renal function, a transurethral catheter should not be routinely placed for the sole purpose of monitoring urine output
  • It is reasonable to place a transurethral catheter in patients with thoracic epidural anaesthesia

Early mobilization and adjuncts to physiotherapy

  • Patients should be mobilized within 24 h of surgery Low Strong

Selected References

  • Rogers LJ, Bleetman D, Messenger DE, Joshi NA, Wood L, Rasburn NJ et al. The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. J Thorac Cardiovasc Surg 2018;155:1843–52.
  • Cerfolio RJ, Pickens A, Bass C, Katholi C. Fast-tracking pulmonary resec- tions. J Thorac Cardiovasc Surg 2001;122:318–24.
  • Das-Neves-Pereira JC, Bagan P, Coimbra-Israel AP, Grimaillof-Junior A, Cesar-Lopez G, Milanez-de-Campos JR et al. Fast-track rehabilitation for lung cancer lobectomy: a five-year experience. Eur J Cardiothorac Surg 2009;36:383–91; discussion 391.
  • Muehling BM, Halter GL, Schelzig H, Meierhenrich R, Steffen P, Sunder- Plassmann L et al. Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway. Eur J Cardiothorac Surg 2008;34:174–80.
  • Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008;248:189–98
  • Navarro LH, Bloomstone JA, Auler JO, Cannesson M, Rocca GD, Gan TJ et al. Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med 2015;4:3.
  • Fiore JF, Bejjani J, Conrad K, Niculiseanu P, Landry T, Lee L et al. Systematic review of the influence of enhanced recovery pathways in elective lung resection. J Thorac Cardiovasc Surg 2016;151:708–15.e6.
  • Bjerregaard LS, Jensen K, Petersen RH, Hansen HJ. Early chest tube re- moval after video-assisted thoracic surgery lobectomy with serous fluid production up to 500 ml/day. Eur J Cardiothorac Surg 2014;45:241–6.
  • Frendl G, Sodickson AC, Chung MK, Waldo AL, Gersh BJ, Tisdale JE et al. 2014 AATS guidelines for the prevention and management of periopera- tive atrial fibrillation and flutter for thoracic surgical procedures. J Thorac Cardiovasc Surg 2014;148:e153–93.
  • Li S, Zhou K, Che G, Yang M, Su J, Shen C et al. Enhanced recovery pro- grams in lung cancer surgery: systematic review and meta-analysis of randomized controlled trials. Cancer Manag Res 2017;9:657–70
  • Zaouter C, Ouattara A. How long is a transurethral catheter necessary in patients undergoing thoracotomy and receiving thoracic epidural analgesia? Literature review. J Cardiothorac Vasc Anesth 2015;29: 496–501.
  • Allen MS, Blackmon SH, Nichols FC, Cassivi SD, Harmsen WS, Lechtenberg B et al. Optimal timing of urinary catheter removal after thoracic operations: a randomized controlled study. Ann Thorac Surg 2016;102:925–30.

Preoperative Physiologic Assessment Prior to Pulmonary Resection

Simon Turner1, Serena Shum2, Tim van Haaften2

1Thoracic Surgery, University of Alberta

2Anesthesiology, University of Alberta


Background

Anatomic lung resection is the gold standard treatment for early stage lung cancer but may be associated with significant risks of postoperative morbidity and mortality. To reduce the incidence of adverse events, patients should be carefully evaluated prior to any anatomic lung resection. This evaluation should take into account the extent of the planned resection, the patient’s baseline pulmonary and cardiac function as well as any other comorbidities, including factors such as frailty and sarcopenia. Modifiable risk factors, such as coronary artery disease, may be amenable to intervention to allow resection with improved outcomes.

Recommendations

  1. All patients prior to anatomic lung resection should undergo pulmonary function testing with spirometry and diffusion capacity.
    • Patients with predicted post-operative FEV1 and/or DLCO below 40% predicted should be considered above average risk for postoperative complications and death. Post-operative FEV1 and/or DLCO below 30% should be considered exceptionally high risk, and either below 20% considered prohibitive risk.
    • High risk patients may still be candidates for resection with acceptable outcomes, but consideration should be given to further stratification of such patients with testing such as low-tech exercise testing (e.g. shuttle walk test, stair climb), cardiopulomary exercise testing (CPET aka VO2 max) and/or quantitative VQ scan (Fig. 1).

    • Low tech exercise testing such as stair climb, shuttle walk test and 6-minute walk test may be useful to supplement clinical decision making, especially in circumstances where CPET is not readily available. Correlation of these tests with more accurate measures of pulmonary function may vary, especially when performed in non-standardized settings.
    • Patients who may require a pneumonectomy are subject to more significant physiologic impacts of surgery and should undergo more thorough testing than other patients. An echocardiogram to rule out pulmonary hypertension and cardiac dysfunction should be considered. A quantitative VQ scan can give a better estimate of post-operative pulmonary function than predictions based on the number of bronchopulmonary segments being resected.

2. All patients prior to anatomic lung resection should be assessed clinically for cardiac risk factors.

    • The use of a standardized risk score such as the Thoracic Revised Cardiac Risk Index is recommended (Table 1). A ThRCRI score of 2 or greater should be considered high risk.
    • ThRCRI Risk Factor Weighted Score
      Renal failure* 1
      Ischemic heart disease 1.5
      Cerebrovascular disease 1.5
      Pneumonectomy 1.5

      Table 1. Thoracic Revised Cardiac Risk Index (ThRCRI). *serum creatinine >177umol/L

    • Patients at high risk for cardiac complications, especially those undergoing major resections such as pneumonectomy, should have more formal cardiac testing, including echocardiography or be referred to a cardiologist for consideration of angiography or cardiac stress testing.
    • Patients should be assessed for their risk of post-operative atrial fibrillation and managed accordingly. The question of atrial fibrillation prophylaxis is beyond the scope of this review.
    • The role of prehabilitation for patients deemed at high risk of post-operative complications is beyond the scope of this review.

3. Age is a marker of potential increased risk but should not be the only reason a patient is denied potentially curative surgery.

    • Healthy patients at advanced age may be candidates for anatomic lung resection.
    • All patients should have their comorbidities assessed, ideally including the use of a standardized scale such as the Charlson Comorbidity Index.
    • Other measures of increased operative risk, such as frailty and sarcopenia should be taken into consideration.

4. Quality of life (current and expected short- and long-term post-operative) should be considered when discussing risks and benefits of surgery compared to other treatment options.

5. The smoking status of all patients undergoing lung surgery should be assessed, and recommendations made to assist patients in smoking cessation. See the CATS recommendation on this topic for more detail.

6. All patients with questionable operability and/or resectability should be reviewed by a dedicated multidisciplinary oncology team.

7. All patients prior to anatomic lung resection should be assessed by an anesthesiologist for further risk stratification and preoperative optimization.

Key References

  1. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery. Diagnosis and Management of Lung Cancer, 3rd Ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 2013;143:e166s-e190s.
  2. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy). European Respiratory Journal, 2009;34:17-41.
  3. British Thoracic Society guidelines on the radical management of patients with lung cancer. Assessment of the risks of surgery. Thorax, 2010;65(Suppl III):iii11-iii15.

Recommendations from a Review and Analysis of Strategies for Prediction, Prevention and Management of Post-operative Atrial Fibrillation after Non-cardiac Thoracic Surgery.


Background:

Atrial fibrillation (AF) is the most commonly sustained arrhythmia after non-cardiac thoracic surgery, occurring between 12%-44% of pulmonary and esophageal resections, and is associated with a significant increase in post-operative morbidity, length of stay (LOS), intensive care unit (ICU) admission and mortality ([i],[ii]). Patients who develop postoperative atrial fibrillation (POAF) often experience an increased LOS of 2 to 14 days ([iii]). If sustained, it can increase the patient’s risk of thromboembolic events ([iv]). As an independent risk factor of stroke in the 30 days following development of new sustained AF ([v]), anticoagulation is critical ([vi]). AF is associated with increased mortality risk after esophagectomy (mortality increase from 4.8 to 8.1%, p=0.04) ([vii]) and decreased long-term survival after lobectomy (HR 3.75; 95% CI 1.44 to 9.08) (1). AF is both common and impactful, efforts to effectively and optimally predict, prevent and manage POAF is critical to improving quality of thoracic surgical care.

Our review and analysis aimed to provide a practical, feasible and clinically applicable strategy for the prediction, prevention and management of POAF in patients undergoing non-cardiac thoracic surgery. Below are the recommendations developed from our review and analysis, as well as an algorithm to guide individualized evidence-based management of POAF.

Recommendation

  1. Multiple existing predictive models are capable of identifying patients at increased risk for POAF; however clinical application of these risk models first requires external validation, followed by ongoing evaluation and improvement over time.
  2. Prophylactic therapy with beta-blocker agents, amiodarone, calcium-channel blockers (CCB) and magnesium may be considered to reduce the risk of POAF; however, providing prophylaxis to all patients is not recommended because the exposure of all patients to the risk of adverse events outweighs the benefit experienced by only a few patients in preventing POAF. The approach of implementing prophylaxis only in high-risk patients only to reduce incidence and severity of POAF is promising yet unproven, and requires further study to evaluate safety and effectiveness.
  3. For patients with new onset POAF who develop acute hemodynamic instability, immediate synchronized electrocardioversion is recommended and consideration of echocardiogram.
  4. Hemodynamically stable patients with POAF should receive incremental dosing of rate control therapy with continuous cardiac monitoring until a heart rate of <110 BPM is achieved. If the patient has known decompensated heart failure or ejection fraction <35%, consider the least negatively inotropic agent, namely amiodarone. If no decompensated heart failure, initial trial of low trial dose of beta-blocker (e.g. 2 mg metoprolol IV push) should be given followed by repeat dosing if beneficial effect witnessed (e.g. lowering HR) and no adverse events (e.g. hypotension, bronchospasm, bradycardia) until desired effect; or if no effect observed on heart rate or blood pressure, consider CCB (e.g. 5 mg diltiazem IV push), with repeat dosing if beneficial effect and no adverse events to achieve rate control.
  5. To augment effect of either beta-blocker or CCB, consider digoxin to further augment effectiveness of rate control and minimize adverse events.
  6. Early assessment and correction of underlying POAF triggers may help facilitate early return to sinus rhythm (such as pneumothorax, pneumonia, pulmonary embolism, infection, bleeding or electrolyte abnormalities).
  7. Cardioversion should be reserved for patients who cannot tolerate rate control agents or who, after 48h, continue to have POAF despite rate control.
  8. The choice of antiarrhythmic agent should be selected in accordance with the patient’s comorbidities and the agents side effect profile.
  9. Further formal evaluations of standardized protocols to predict, prevent and manage POAF are warranted to evaluate impact on incidence, duration and severity of POAF.
  10. Antithrombotic therapy to reduce the risk of stroke in patients with persistent AF should be considered if POAF persists >48h, and should be individualized based on patient’s risk factors for thromboembolic event (congestive heart failure, hypertension, diabetes, previous thromboembolic event, peripheral vascular disease) and post-operative bleeding risk.

Abbreviations: POAF, post-operative atrial fibrillation; CCB, calcium channel blocker; BPM, beats per minute.

Abbreviations: IV, intravenous; O2, oxygen; ECG, electrocardiogram; CBC, complete blood count; LOC, level of consciousness; HR, heart rate; HF, heart failure; EF, ejection fraction, CHF, congestive heart failure; HTN, hypertension; DM, diabetes mellitus; TIA, transient ischemic attack, CXR, chest x-ray; TEE, trans-esophageal echocardiogram; LMWH, low molecular weight heparin; ASA, acetylsalicylic acid.

References

[i] Imperatori, A., Mariscalco, G., Riganti, G., et al. (2012b). Atrial fibrillation after pulmonary lobectomy for lung cancer affects long-term survival in a prospective single-center study. Journal of Cardiothoracic Surgery, 7, 4. https://doi.org/10.1186 /1749-8090-7-4

[ii] Amar D, Zhang H, Shi W, et al. Brain natriuretic peptide and risk of atrial fibrillation after thoracic surgery. The Journal of Thoracic and Cardiovascular Surgery. 2012 Nov 1;144(5):1249–53.

[iii] Polanczyk, C.A., Goldman, L., Marcantonio, E.R., et al. Supraventricular arrhythmia in patients having non cardiac surgery: clinical correlates and effect on length of stay. The Annals of Internal Medicine. 1998; 129: 279–285

[iv] Investigators, T. A. F. F. I. of R. M. (AFFIRM). (2002). A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation. New England Journal of Medicine, 347(23), 1825–1833. https://doi.org/10.1056/NEJMoa021328

[v]  Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. The Lancet. 2008 May 31;371(9627):1839–47.

[vi]  Camm, A.J., Lip G.Y.H, De Caterina R., et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation An update of the 2010 ESC Guidelines for the management of atrial fibrillation Developed with the special contribution of the European Heart Rhythm Association. Europace. 2012 Oct 1;14(10):1385–413.

[vii] Rao, V. P., Addae-Boateng, E., Barua, A., et al. (2012). Age and neo-adjuvant chemotherapy increase the risk of atrial fibrillation following oesophagectomy. European Journal of Cardio-Thoracic Surgery, 42(3), 438–443. https://doi.org/10.1093/ejcts /ezs085


Authors:
H Smith, MD ; C, Yeung, MD2; S Gowing, MD2; MM Sadek, MD, FRCPC3; DE Maziak, MD, FRCSC2; S Gilbert, MD, FRCSC2; FM Shamji MD, FRCSC2; PJ Villeneuve, MD, FRCSC2; RS Sundaresan MD FRCSC2, AJE Seely MD, PhD, FRCSC
[1] Division of General Surgery, The Ottawa Hospital, University of Ottawa
[2] Division of Thoracic Surgery, The Ottawa Hospital, University of Ottawa
[3] Division of Cardiology, The Ottawa Hospital, University of Ottawa

Correspondence to:
Heather Smith
Department of Surgery, Division of General Surgery, The Ottawa Hospital
501 Smyth Rd, Ottawa, ON K1H 8L6
Email: hesmith@toh.ca
Telephone: (613) 789-5555

Author’s Contribution:
(II) Administrative support: HS
(III) Provision of study materials or patients: NA
(IV) Collection and assembly of data: HS, AS, MS, FS, DM, SS, AS
(V) Data analysis and interpretation: HS, AS, MS, FS, DM, SS, AS
(VI) Manuscript writing: All authors
(VII) Final approval of manuscript: All authors


Surgical Wait-Times for Resectable Lung Cancer.


Background:

Timely care is a fundamental component of quality. Although what constitutes timely care in lung cancer remains a subject of debate, many international/national/regional bodies have set consensus targets for wait times. Given the lack of level I evidence, the committee reviewed various recommendations and adopted one best supported by the available evidence for a Canadian context.

CATS recognizes all too well that thoracic surgeons are only able to achieve timely care if adequate resources (e.g. OR time, CT guided biopsies, imaging resources including PET scans to mention a few) are made available in a timely fashion. CATS also recognizes that local/provincial factors and limitations vary. CATS hopes that adopting such recommendations based on best available evidence helps empower surgeons and care providers to demand the resources they need to deliver quality care.

Recommendation

  • For patients with lung cancer whose primary treatment modality is surgical resection, time from referral* for initial consultation to resection should not exceed 6 weeks**.

* We purposefully avoided specifying time from referral to consultation as centres may have different preferences about performing certain investigations prior to consultation or starting with a consultation

** We believe that in the majority of cases, surgeons do have an understanding early on as to which patients will likely be operable and so diagnostic, staging and physiologic investigations can be arranged in parallel making 6 weeks a realistic goal.

Summary of Literature

Several guidelines highlighting recommended wait times based on different time intervals in the treatment pathway have been published. The table below highlights some of these guidelines.  Two main areas of debate in the wait-times literature persist: 1) the effect of timely care on survival and 2) the ability of healthcare providers to meet established (recommended) wait time guidelines.

No strong association between earlier initiation of anticancer treatment and improved survival has been reported. In addition, recent publication out of McGill University, demonstrated that roughly 60% of patients met the target of first contact, and only 62% of cases were operated on within the recommended time frame (28 days) after being initially seen by a surgeon. Interventions that are associated with improved timeliness include: nurse-led care coordination, access to multidisplinary meetings and a standardized diagnostic process.

References

Olson JK, Shultz EM, Gould MK. Timeless of care in patient with lung caner: a systematic review. Thorax 2009. Sep; 64(9): 749-56.

Kasymjanova G, Small D. Cohen V.  et al. Lung Cancer care trajectory at a Canadian center: an evaluation of how wait times affect clinical outcomes. Curr Oncol. 2017 October 24(5): 302-309

Time Interval Recommended wait time (days)
  British Thoracic Society UK National Health Service RAND Corporation American College of Chest Physician Cancer Care Ontario
Referral → Lung cancer specialist 7 14
Lung cancer speciality → Diagnosis 30 35
Referral → 1st Treatment 62 62 60
Lung specialist → Surgery 56 104 68
Diagnosis → Surgery Consult 60
Surgery Consult → Surgery 28 14-84
Surgery → Adjuvant Chemotherapy 120 120
Diagnosis → 1st Treatment 30 31 42 35 52
Diagnosis → Chemotherapy 28 30 42 39
Diagnosis → Radiotherapy 42
Decision to treat → Non-surgical treatment 7-28
Ready to treat → Radiation 28

Adapted from: Curr Oncol. 2017 October 24(5): 302-309

 


Recommendation for Thoracic Surgery Perioperative VTE Prophylaxis.


Background:

It is now widely accepted that the true incidence of post-op VTE following lung and esophageal resection is largely under-reported. A large range of incidence has been reported, with variations mainly related to different detection methods, type and duration of prophylaxis, and the subclinical nature of a significant proportion of VTE occurrence. Thoracic surgery poses an increased risk of postop VTE given the high prevalence of oncologic surgery, the protracted post-operative recovery, and the direct manipulation of the lung and pulmonary vascular anatomy.

CATS Recommendations

CATS members continue to be involved in research evaluating the optimal method and duration for post-thoracic surgery VTE prophylaxis. The committee recognizes however the paucity of high-level evidence in this field. As higher level evidence emerges, CATS hopes that a unified approach to postop VTE prophylaxis can serve as a starting point to adopt new guidelines for in-hospital and post discharge care.

  1. Post Thoracic surgery in-hospital prophylaxis = LMWH or LDUH +/- mechanical compression
  2. No recommendation for extended prophylaxis = use at surgeon’s discretion
  3. Symptomatic postop VTE = Thrombosis referral + therapeutic anticoagulation

Summary of the Evidence

  • Most data is based on retrospective single-institution cohort studies.
    • Results are challenged by the retrospective nature of the studies, dependence on symptomatic diagnosis and not asymptomatic screening, and lack of recognition of de novo PE without DVT
    • Estimates of postop incidence: 5-15.2%
  • More recent research has evaluated prevalence of post-lung resection VTE using screening strategies in a prospective fashion
    • Prospective screening studies
      • CTPA 7-15 days postop = prevalence of 14%
      • B/L Doppler U/S + CTPA @ 30-days postop = prevalence 12.1%
    • 23% of VTE occur post-discharge & Post-pneumonectomy peak incidence à >7 days postop
    • Cohort of 2,373 cancer patients identified that 40% of VTE occurred >21 days post discharge
  • Canadian Delphi Survey including CATS members (Journal Thorac Dis. 2017 Jan; 9(1)80-87)
    • Strong agreement in identifying risk factors for VTE, and which of those factors may potentially influence the decision for extended post-hospital discharge prophylaxis.
    • Limited agreement on the type of prophylaxis (pharmacological, mechanical and/or both), as well as the initiation and duration of thromboprophylaxis—indicating high degree of variability
    • The only reliable factor of agreement was the use of LMWH in hospital

ACCP 9th Edition Guidelines for Thoracic Surgery

  • Moderate risk for VTE + not high bleeding risk à LDUH or LMWH (Grade 2B), or MCS (Grade 2c)
  • High risk for VTE + not high bleeding risk à LDUH or LMWH (Grade 1B) + MCS (Grade 2C)
  • High risk for Major bleeding à MCS with optimally applied IPC (Grade 2C)
  • No recommendation for extended post-discharge prophylaxis.