Enhanced Recovery After Surgery (ERAS) Andperioperative Management Of Routine Thoracoscopic Surgery

Part I: The application of enhanced recovery after surgery(ERAS)in routine thoracoscopic pulmonary surgeryObjective: To explore the rationality of the expected goals of ERAS,evaluate the main causes and risk factors of delayed extubation and discharge,and further improve the current ERAS pathway.Methods: Design the ERAS pathway and set the expected goal of extubation and discharge time.Implement the ERAS pathway for 278 patients who received routine thoracoscopic pulmonary surgery in our medical group between February 2019 and January 2020,and collect the basic information of patients,preoperative examination,operation related information and postoperative complications.Then evaluate the completion and rationality of the expected goals in the study.Evaluate the main causes and related risk factors of delayed extubation and discharge.Observe the extubation and discharge ahead of schedule in different surgical methods,and evaluate the possibility of improving the expected goals.Results: In 57 patients with wedge resection,only 1(1.8%)patient was delayed in extubation according to the expected goal(POD1),and 4(7.0%)patients were delayed in discharge according to the expected goal(POD2).In 89 patients with segmentectomy,16(18.0%)patients were delayed in extubation according to the expected goal(POD2).The main reason of delayed extubation was poor postoperative pulmonary relaxation(P<0.05).According to the expected goal of discharge(POD3),33(37.1%)patients were delayed,The main reason of delayed extubation was delayed in extubation and fever after extubation(P<0.05).Patients’ compliance was an independent risk factor for delayed discharge(OR= 0.236;95% CI: 0.105-0.530;P= 0.000).Patients’ compliance was an independent risk factor for delayed extubation(OR = 0.146;95% CI: 0.057-0.375;P = 0.000).No risk factor was found for fever after extubation.The main reason of early discharge was early extubation(P<0.05),and advantaged segmentectomy(L/RS6,Ls4+5)(P=0.015)was the independent advantage factor for early extubation.In 132 patients with lobectomy,34(25.8%)patients were delayed in extubation according to the expected goal of extubation(POD2).The main causes of delayed extubation were air leakage and excessive thoracic drainage(P<0.05).Patients’ compliance(OR = 0.234;95% CI: 0.132-0.417;P = 0.000)and smoking history(OR = 0.331;95% CI: 0.113-0.966;P = 0.043)were independent risk factors for delayed discharge.Patients’ compliance(OR = 0.232;95% CI;0.134-0.404;P = 0.000)and smoking history(OR = 0.199;95% CI: 0.067-0.597;P = 0.004)were independent risk factors for delayed extubation.And patients’ compliance(P<0.05)was independent risk factor for fever after extubation.The main reason of early discharge was early extubation(P<0.05),and the independent advantage factor of early extubation was advantaged lobectomy(RM)(P = 0.000).The average body temperature,WBC and neutrophil percentage of the patients that got fever after extubation were(38.2 ± 0.2)℃,(9.6 ± 1.9 * 10^9)and(80.0 ± 4.7)%,respectively.Conclusion: The expected goal of ERAS pathway is reasonable in general.There were no patients with wedge resection discharged ahead of schedule.It’s feasible to discharge them on the day of extubation in future clinical work.In segmentectomy,patients’ compliance was an independent risk factor for delayed extubation and delayed discharge.The independent favorable factor for early extubation is advantaged segmentectomy(L / RS6,Ls4 + 5).The target extubation time of advantaged segmentectomy can be advanced(POD1).In lobectomy,the patient’s compliance and smoking history are the independent risk factors for delayed extubation and delayed discharge.The independent risk factor for fever after extubation is the patient’s compliance.The independent favorable factor for early extubation is advantaged lobectomy(RM),of which the target extubation time could be advanced(POD1).Fever after extubation is one of the main reasons for delayed discharge of segmentectomy and lobectomy.It can be considered that the discharge standard should be changed to the temperature below 38.5 ℃,and the blood routine should be normal or close to normal.The comparison of multiple segmentectomy and lobectomy could be one of the research directions in the future.Part II:Study on the application of enhanced recovery after surgery(ERAS)in routine thoracoscopic mediastinal tumor surgeryObjective: To explore the rationality of the expected goals of ERAS.To evaluate the main causes of delayed extubation and delayed discharge and further improve the current eras pathway.Methods: Design ERAS pathway and set expected goals of extubation and discharge time.Implement ERAS pathway on 107 patients who received routine mediastinal tumor surgery in our medical group from February 2019 to January 2020.Collect the basic information of patients,preoperative examination,operation related data and postoperative complications.Then evaluate the completion and rationality of the expected goals in the study.Evaluate the main causes and related risk factors of delayed extubation and discharge.Observe the extubation and discharge ahead of schedule in different surgical methods,and evaluate the possibility of improving the expected goals.Results: According to the expected goal of extubation(POD1),98(91.6%)patients were extubated on time and 9(8.4%)patients were delayed in extubation.The main causes were excessive drainage of thoracic cavity(5 cases),other causes included hemorrhagic thoracic fluid(2 cases)and chylothorax(2 cases).According to the expected discharge target(POD2),82(76.6%)patients were discharged on time,25(23.4%)patients were delayed,and no patients were discharged ahead of schedule.The main causes of delayed discharge were fever after extubation(15 cases)and delayed extubation.Smoking history was an independent risk factor for delayed extubation(P = 0.008).No independent risk factor for fever after extubation was found in the results,which may be related to individual differences of patients.The average body temperature of 15 febrile patients was(38.1 ± 0.1)℃,the average WBC was(9.4 ± 1.5 * 10 ^ 9),and the average percentage of neutrophils was(79.6 ± 4.6)%,which were slightly higher than the discharge standard.Thymoma combined with thymectomy was an independent risk factor for delayed discharge(P = 0.047).19(76.0%)of 25 patients were delayed in discharge.Conclusion: 91.6% and 76.6% of the patients completed the expected goal of extubation and discharge respectively,which proved the rationality of the preset standard and goal.The main causes of delayed discharge were delayed extubation and fever after extubation.Thymoma combined with thymectomy was an independent risk factor for delayed discharge(P = 0.047).The main reason for delayed extubation was excessive thoracic drainage,and smoking history was an independent risk factor for delayed extubation(P = 0.008).No independent risk factors for fever after extubation were found,which may be related to individual differences of patients.The body temperature and blood routine of patients with fever were only slightly higher than the discharge standard,and the temperature in the discharge standard could be changed to below 38.5 ℃.The next improvement direction of ERAS is to set the off-bed time on the day of operation and discharge from hospital on the day of extubation.Part III: Application of autologous blood pleurodesis(ABP)in persistent air leakage(PAL)after pulmonary surgeryObjective: To evaluate the safety and efficacy of ABP in the treatment of PAL.To explore the risk factors of complications of ABP and analyze and discuss the problems in clinical application,so as to improve the standardization and safety of ABP in the treatment of PAL.Methods: 78 patients with PAL and ABP treatment were selected from 4500 lung surgery patients in our research group from 2014 to 2019.The basic information of patients was collected,including sex,age,smoking history,Charlson’s complication index,ipsilateral operation history.Information related with operation,PAL and ABP treatment were also recorded.The patients with complications and non-complications after ABP were compared to find the differences between them.Results: 78 patients were included in the study and received ABP treatment.The total incidence of serious air leakage was 1.7%.The median time of the first ABP was 5 days,the median time of ABP was 3 times.77 patients stopped air leakage after treatment.The effective rate of treatment was 98.7%.The median time of hospitalization after the first ABP was 8 days,and the median time of hospitalization was 13 days.Among the 77 patients with ABP,6(7.8%)had complications after ABP.All of the complications came out fever after ABP,and all of the patients received lobectomy.The number of ABP more than 3 times was an independent risk factor for fever after ABP(P= 0.006).The range of operation(lobectomy,sleeve resection,double lobectomy)was an independent risk factor for the increase of ABP times(P= 0.003).In this study,there was a death case with serious complications,which reflected that ABP had a certain risk of infection,especially in the case of bronchopleural fistula,it might even be fatal.Conclusion: In this study,the effective rate of using ABP to treat PAL patients after pulmonary surgery is 98.7%.In 77 patients with ABP,6(7.8%)had fever after the injection of autologous blood.The independent risk factor of fever after ABP was that the number of times of ABP was more than 3(P= 0.006).The independent risk factor for the increase of ABP times(> 3 times)was the operation range(lobectomy,sleeve resection,double lobectomy).One case of death warned us that patients with severe air leakage must be examined by electronic bronchoscopy before ABP to eliminate bronchopleural fistula.