Cerfolio R J, Pickens A, Bass C, Katholi C
Division of Cardiothoracic Surgery and the Department of Biostatistics, University of Alabama at Birmingham, 35294, USA.
J Thorac Cardiovasc Surg. 2001 Aug;122(2):318-24. doi: 10.1067/mtc.2001.114352.
We streamlined our care after pulmonary resection for quality and cost-effectiveness.
A single surgeon performed 500 consecutive pulmonary resections through a thoracotomy over a 2(3/4)-year period in a university setting. Patients were extubated in the operating room and sent directly to their hospital room. Chest tubes were placed to water seal and removed on postoperative day 2 if there was no air leak and drainage was less then 400 mL/d. Epidural catheters were used and removed by postoperative day 2. The plan for each day and discharge on postoperative day 3 or 4 was reviewed with the patients and families daily during rounds. The patient went home the day the last chest tube was removed. Persistent air leaks were treated with Heimlich valves.
There were 500 patients (338 men), with a median age of 58 years (range, 3-87 years). Of these patients, 293 had pre-existing conditions. Seventy-three (15%) patients had been denied operations by at least one other surgeon. Four hundred nineteen (84%) patients had successful placement of a functioning preoperative epidural catheter. Pneumonectomy was performed in 32 (6%) patients, segmentectomy was performed in 16 (3%) patients, and lobectomy, sleeve lobectomy, and/or bilobectomy was performed in 194 (39%) patients. Nonanatomic resections were performed for metastasectomy. This included a single wedge resection in 161 (32%) patients and multiple wedge resections in 97 (19%) patients. A total of 482 (96%) patients were extubated in the operating room, and 380 (76%) patients were sent to their hospital room. The remaining 120 patients went to the intensive care unit for a median of 1 day (range, 1-41 days). Complications occurred in 107 (21%) patients, and operative mortality was 2.0%. Median day of discharge was postoperative day 4 (range, 2-119 days). A total of 327 (65%) patients left the hospital on postoperative day 4 or sooner. By survey, 97% of patients had excellent or good satisfaction with their care at hospital discharge, and 91% were extremely happy or satisfied at the 2-week follow-up contact.
Most patients who undergo elective pulmonary resection can be extubated immediately after the operation, go directly to their room and avoid the intensive care unit, be discharged on postoperative day 3 or 4, and have minimal morbidity and mortality with high satisfaction both at discharge and at the 2-week follow-up contact. Techniques that seem to accomplish this include the following: the use of a water seal, removal of epidural catheters on postoperative day 2, early chest tube management, treatment of persistent air leaks with Heimlich valves, and daily reinforcement of the planned events for each day, as well as on the date of discharge with the patients and their families.
为了提高质量和成本效益，我们简化了肺切除术后的护理流程。
在一所大学附属医院，一名外科医生在2（3/4）年的时间里连续进行了500例开胸肺切除术。患者在手术室拔管后直接送回病房。放置胸腔引流管并接水封瓶，若术后无漏气且引流量小于400 mL/d，则在术后第2天拔除。使用硬膜外导管，并在术后第2天拔除。每天查房时与患者及其家属回顾术后每天的计划及术后第3或4天出院的计划。最后一根胸腔引流管拔除当天患者即可出院。持续性漏气采用海姆利希单向阀治疗。
共500例患者（338例男性），中位年龄58岁（范围3 - 87岁）。其中293例患者有基础疾病。73例（15%）患者至少被一名其他外科医生拒绝手术。419例（84%）患者成功置入了术前有效的硬膜外导管。32例（6%）患者行全肺切除术，16例（3%）患者行肺段切除术，194例（39%）患者行肺叶切除术、袖状肺叶切除术和/或双肺叶切除术。为行转移瘤切除术进行了非解剖性切除。其中161例（32%）患者行单楔形切除术，97例（19%）患者行多楔形切除术。共有482例（96%）患者在手术室拔管，380例（76%）患者被送回病房。其余120例患者入住重症监护病房，中位时间为1天（范围1 - 41天）。107例（21%）患者发生并发症，手术死亡率为2.0%。中位出院时间为术后第4天（范围2 - 119天）。共有327例（65%）患者在术后第4天或更早出院。通过调查，97%的患者对出院时的护理评价为优秀或良好，91%的患者在术后2周随访时非常满意。
大多数接受择期肺切除术的患者术后可立即拔管，直接返回病房，避免入住重症监护病房，术后第3或4天出院，发病率和死亡率极低，出院时及术后2周随访时满意度高。实现这一目标的技术包括：使用水封瓶、术后第2天拔除硬膜外导管、早期胸腔引流管管理、用海姆利希单向阀治疗持续性漏气、每天向患者及其家属强化每天的计划安排以及出院当天的计划安排。
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