Analysis of surgical results leads to improved post-operative algorithms and fast-tracking of high risk patients after pulmonary resection
Ayesha Bryant, Robert J. Cerfolio; Surgery, Univer of Alabama at Birmingham, Birmingham, AL
Comment on this Abstract
Objective: To identify our results with changes to our fast-tracking protocol in selected high-risk patients.
Methods: A retrospective study of a prospective database. Using multi-variate regression we identified several patient characteristic that predicted failure to fast-track secondary to increased morbidity. We modified our fast-tracking algorithm: in the elderly (>70 years) by substituting pain pumps for epidurals and avoiding narcotics. Patients with a BMI >40 had increased aspiration precautions. Patients with poor pulmonary function (FEV1% <45%) underwent increased respiratory treatments and more aggressive ambulation. Outcomes were compared.
Results: There were 2,895 patients who underwent elective pulmonary resection before the algorithm modification (1/1997-12/2001) and 3252 patients after (1/2002-7/2007). The length of stay was reduced by the protocol changes from 6.7 to 4.9 days (p=0.024) in the elderly, from 5.7 to 4.8 days in the obese and from 6.2 to 4.3 days (p = 0.008) in those with FEV1<45%. The morbidity was reduced from 26% to 17% in the elderly (p=0.046), from 29% to 20% (p=0.027) in the obese and from 45% to 23% in those with a FEV 1 <45%. Overall mortality was also reduced 4.0% to 2.1% (p = 0.014).
Conclusion: Critical review of surgical results can lead to improve patient care. High risk patients such as the elderly, the obese and those with poor pulmonary function can safely undergo pulmonary resection and a short hospital stay. Further identification of other specific modifications in other groups of patients is needed to continue to decrease surgical morbidity and mortality and maximizing patient and family satisfaction.
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