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Lung Volume Reduction Surgery Background • • • The Ohio State University W exner Medical Center (OSUW MC) has been re-certified by The Joint Commission as one of the locations in the United States able to provide lung volume reduction surgery (LVRS). This surgery reduces the size of the lungs damaged by emphysema by removing some of the most diseased parts of the lungs. o Having LVRS will allow the remaining lung to function more normally. OSUW MC was one of 17 centers nationwide that participated in the National Emphysema Treatment Trial (NETT) study which examined the risks, benefits and appropriate selection criteria for the lung volume reduction surgery. Selection Criteria • Effective for services performed on or after January 1, 2004 Medicare will only consider LVRS reasonable and necessary when all of the following requirements are met. o Click here for LVRS patient selection criteria. Labs and Imaging Typical post-operative LVRS orders include the following laboratory and imaging orders: Order Extubation within 4 hours of surgery Early ambulation Effective pain management Infection prevention Air Leak prevention Length of stay goal 6-10 days Consults • • • • • Pulmonology Pulmonary rehabilitation Infectious disease, as needed Respiratory therapy Physical therapy Notify Physician Notify the House Officer for the following: • SBP > 180 mmHg or < 90 mmHg • DBP > 90 mmHg or < 60 mmHg • HR > 120 bpm or < 60 bpm • RR > 24 or < 8 • Temperature > 101.5°F (38.6°C) • Oxygen saturation < 88% at rest or with increased oxygen requirement • pO 2 < 60, or if pCO 2 is > 55 • Chest tube output > 100 ml/hr • Urinary output < 30 mL/hour or < 240 mL/8 hour Timing Arterial Blood Gas Call results to physician on call for Thoracic Surgery In Recovery, STAT one time, 6 hours after initial blood gas in Recovery CBC, EDIFF, Platelet, Chem7 Every morning Chest X-Ray STAT Post-op, every morning and prior to discharge Activity • • Key Aspects of Care • • • • • • 1 Patient should be out of bed to chair 4 hours after surgery unless patient remains intubated. o If patient remains intubated, request Physical Therapy consult. Beginning POD 1, the patient should be out of bed during the day and ambulate in hallway or on treadmill with both nursing and pulmonary rehab staff four times a day. o The patient should be ambulating 3-10 minutes at each outing. Medications and IV Fluids • • • Reconcile medications at each transition of care (e.g., admission and discharge). Continue home medications and inhalers. Typical post-operative LVRS orders include the following medications and IV fluids: Pain management Epidural and other as ordered VTE prophylaxis Pharmacological or mechanical if drug therapy is contraindicated Maintenance IV solutions As ordered – convert to IV lock when tolerating oral diet Post-op antibiotics (2 doses) Cefazolin if no PCN allergy Clindamycin if PCN allergy Antiemetic As needed (no phenergan) GI related Stool softener and laxative as needed 2 Care and Assessment • Typical post-operative LVRS orders include the following nursing care and assessments: • Vital signs As ordered and PRN Pulse oximetry Continuous, at least until weaned down to 2 l/m or RA and then every 4 hours Cardiac monitoring Continuous Weigh patient Every morning Pain management Goal < 5 (scale 1-10) Intake and output Every hour for 4 occurrences Every 4 hours for 6 occurrences Every 8 hours, ongoing Assess degree of dyspnea with activity Continuous Air leak grading Every 8 hours, record air leak grading as +1 to +7 Subcutaneous emphysema Upon arrival to the floor and with each set of vital signs Chest tube Tube care per Chest Drainage System protocol Indwelling Foley catheter tube care Remove Foley catheter by postop day one or LIP to document reason for continuing Notify respiratory therapy evaluator Notify respiratory therapy evaluator upon patient arrival to floor (page 0813) Incentive spirometry encourage deep breathing and coughing Every hour while awake Oxygen RT continuous Wean to room air as tolerated Apply nasal cannula PRN to keep O2 sat > 88% Patient Education • • • • • • Arrange home health care if indicated and if Mini Sahara in place Arrange home oxygen if room air O2 sat < 88% (at rest or with exertion) Complete and call Continuity of Care if needed Schedule follow-up appointment with surgeon in 2 weeks with chest x-ray prior to appointment T/S: Post-Op LVRS References • • • • Provide and explain information to educate the patient and family about the following items: o Educate about equipment and unit rules o Review activity progression and energy conservation o Explain medications o Provide emotional support o Educate about cough and deep breathing o Review proper breathing techniques o Review pain management and narcotic use and side effects o Explain wound care o Review signs and symptoms of infection o Explain when to contact physician o Reinforce activity progressions and limitations o Explain oxygen use (arrange for home oxygen if indicated) o Instruction on Mini Sahara care if indicated Provide and explain Patient Education Materials: o Your Home Care after Lung Volume Reduction Surgery o Caring for Your Chest Tube at Home Order Set • Discharge Planning Schedule follow-up appointment with OSUW MC pulmonologist as needed Pulmonary rehab will contact the patient to resume outpatient therapy as soon as patient is ready after discharge Centers for Medicare & Medicaid Services. NCD for Lung Volume Reduction Surgery (Reduction Pneumoplasty). (240.1). Effective November 17, 2005. Accessed October 2011. Winifred S. Hayes, Inc. 2010 Med tech review. Lung Volume Reduction Surgery for Chronic Obstructive Pulmonary Disease. Updated December 9, 2003. Archived November 12, 2008. Accessed October 2011. Medicare National Coverage Determinations Manual. Chapter 1, Part 4. Section 240.1 Lung Volume Reduction Surgery (Reduction Pneumoplasty). National Emphysema Treatment Trail Research Group. (2003). A randomized trial comparing lung –volume reduction surgery with medical therapy for severe emphysema. The New England Journal of Medicine, 2059-2073. 3 Quality Measures • • • • Improvement in dyspnea associated ADL Post-operative complication rate 90-day mortality rates Patient Satisfaction – overall satisfaction 9 or 10 Guideline Authors • • • • • Susan Moffatt-Bruce, MD, PhD Phillip Diaz, MD Mahasti Rittinger, RRT, BS Scott Cackler, PA Karen Prenger, RN MS, CNS, CPHQ Guideline Approved August 31, 2016. Fourth Edition. Disclaimer: Clinical practice guidelines and algorithms at The Ohio State University Wexner Medical Center (OSUWMC) are standards that are intended to provide general guidance to clinicians. Patient choice and clinician judgment must remain central to the selection of diagnostic tests and therapy. OSUWMC’s guidelines and algorithms are reviewed periodically for consistency with new evidence; however, new developments may not be represented. Copyright © 2016. The Ohio State University Wexner Medical Center. All rights reserved. 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