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S. Schermer

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    O07 - Supportive and Surgical Care (ID 136)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Surgery
    • Presentations: 1
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      O07.06 - Early Post-Operative Ambulation is Feasible and Safe (ID 2893)

      10:30 - 12:00  |  Author(s): S. Schermer

      • Abstract
      • Presentation
      • Slides

      The goal of any intervention in medicine is to return the patient to the “pre-clinical state”. Thoracic surgical intervention remains the most effective way to manage early stage lung cancer. Minimally invasive techniques have substantially reduced the morbidity associated with traditional open procedures and have returned patients to health faster. This has been achieved without compromising the oncologic validity of the operation and when done appropriately, has even proved superior. Our health system instituted a minimally invasive thoracic surgical program 5 years ago to realize these benefits. This was accomplished through the recruitment of minimally invasive trained, dedicated thoracic surgeons; service line focused team development; rigorous training of the team; systematic community awareness; and investment in technology and equipment. Seeing tremendous success in volumetric growth with our minimally invasive program, we began to focus on strategies to return patients to their pre-operative functional state more swiftly. We believed inherently that early post-operative ambulation had several clear benefits: 1) clearance of pulmonary secretions and reduction of atelectasis thereby preventing pneumonia, 2) avoidance of deep venous thromboses and subsequent pulmonary emboli, 3) reduced third space fluid shifts therefore reducing the risk of atrial fibrillation and myocardial infarction, 4) better pain control without narcotics, and 5) a general sense of well being. Therefore, we hypothesized that prompt initiation of ambulation should reduce morbidity and return patients to the pre-operative state expeditiously and with greater predictability.

      Our limitations were pain, nursing motivation and culture. Pain is substantially reduced in minimally invasive approaches. Ambulation inherently reduces pain as the upright position takes tension off the intercostal spaces. Nursing motivation and culture proved to be a bigger challenge given limitations in the time available for “bedside nursing”. However, perhaps more relevant was the skepticism related to the safety of this endeavor. Given these realities, we created an environment to test our hypothesis seeking first to demonstrate safety and feasibility of an endeavor that we believed to be so pivotal. In July of 2010, with the support of nursing leadership, administration and our thoracic oncology team, we began a program of aggressive post-operative ambulation with one simple mandate: every patient must walk 250 feet within 1 hour of extubation.

      For this analysis we included all patients recovered in our dedicated unit after VATS, thoracotomy, robotic or laparoscopic interventions. We excluded patients undergoing bronchoscopy or mediastinoscopy as they were routinely discharged within two hours of extubation. From July 2010 through May 2013, a total of 720 patients were recovered in our unit. 553 (77%) were able to walk 250 feet or more. Of these, 328 (59%) were successful within 1 hour of extubation. 74 patients (10%) were unable to ambulate largely due to weakness and hypotension. There have been no adverse events since implementation (0% complication rate).

      We conclude that early post-operative ambulation is feasible and safe. We have observed favorable responses from patients and families and have enjoyed a considerable decrement in our overall post-operative length of stay. Further investigation will be necessary to quantify these endpoints.

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