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J Thorac Cardiovasc Surg 2009;137:1173-1179
© 2009 The American Association for Thoracic Surgery

General Thoracic Surgery

The analysis of a prospective surgical database improves postoperative fast-tracking algorithms after pulmonary resection

^a Department of Thoracic Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Ala. Assistant Professor, Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham
^b Department of Thoracic Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Ala. Professor of Surgery, Chief of Section of Thoracic Surgery at University of Alabama at Birmingham Division of Cardio-Thoracic Surgery, Department of Surgery

Received for publication May 6, 2008; revisions received October 28, 2008; accepted for publication December 21, 2008.

^_* Address for reprints: Robert J. Cerfolio, MD, FACS, FCCP, Professor of Surgery, Chief of Thoracic Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, 703 19^th St S, ZRB 739, Birmingham, AL 35294. (Email: Robert.cerfolio{at}ccc.uab.edu).

Objective: We evaluated our results from our prospective database to identify possible modifications that may improve our fast-tracking protocols in selected high-risk patients.

Methods: We conducted a retrospective study of a prospective database. Using multivariable regression, we identified several patient characteristic that predicted failure to fast-track owing to increased morbidity. We modified our fast-tracking algorithm by substituting pain pumps for epidurals in elderly patients (>70 years). In addition, patients with a body mass index greater than 35 had increased aspiration precautions. Patients with poor pulmonary function (ratio of forced expiratory volume in 1 second to forced vital capacity and/or diffusing capacity/alveolar volume < 45%) underwent increased respiratory treatments and more aggressive ambulation. Differences in outcomes between groups were compared after adjusting for differing baseline patient characteristics, including use of a propensity score.

Results: A total of 2895 patients underwent elective pulmonary resection before the algorithm modifications (January 1997–December 2001) and 3252 patients afterward (January 2002–July 2007) by one surgeon. The length of stay was reduced by the protocol changes from 6.7 to 4.9 days (P = .024) in elderly patients, from 5.7 to 4.8 days in obese patients, and from 6.2 to 4.3 days (P = .008) in those with poor pulmonary function. Morbidity was reduced from 26% to 17% in elderly patients (P = .046), from 29% to 20% (P = .027) in obese patients, and from 45% to 23% in those with poor pulmonary function. Overall mortality was also reduced 4.0% to 2.1% (P = .014).

Conclusion: A prospective database provides important information that can lead to improvement in patient care by identifying specific complications. High-risk patients such as the elderly, the obese, and those with poor pulmonary function can safely undergo pulmonary resection and have a shorter hospital stay.