A review of enhanced recovery for thoracic anaesthesia and surgery

A review of enhanced recovery for thoracic anaesthesia andsurgery N. L. Jones,1 L. Edmonds,2 S. Ghosh1 and A. A. Klein1 1 Consultant, Anaesthesia and Intensive Care, 2 Library and Knowledge Services Manager, Papworth Hospital,Cambridge, UK SummaryDuring the past decade, there has been a dramatic increase in the number of thoracic surgical procedures carried outin the UK. The current financial climate dictates that more efficient use of resources is necessary to meet escalatingdemands on healthcare. One potential means to achieve this is through the introduction of enhanced recovery proto-cols, designed to produce productivity savings by driving reduction in length of stay. These have been promoted bygovernment bodies in a number of surgical specialties, including colorectal, gynaecological and orthopaedic surgery.
This review focuses on aspects of peri-operative care that might be incorporated into such a programme for thoracicanaesthesia, for which an enhanced recovery programme has not yet been introduced in the UK, and a review of theliterature specific to this area of practice has not been published before. We performed a comprehensive search forpublished work relating to the peri-operative management and optimisation of patients undergoing thoracic surgery,and divided these into appropriate areas of practice. We have reviewed the specific interventions that may beincluded in an enhanced recovery programme, including: pre-optimisation; minimising fasting time; thrombo-embolic prophylaxis; choice of anaesthetic and analgesic technique and surgical approach; postoperative rehabilita-tion; and chest drain management. Using the currently available evidence, the design and implementation of anenhanced recovery programme based on this review in selected patients as a package of care may reduce morbidityand length of hospital stay, thus maximising utilisation of available resources.
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Correspondence to: A. A. KleinEmail: andrew.klein@papworth.nhs.ukAccepted: 30 September 2012 Thoracic anaesthesia and surgery is an expanding spe- Department of Health show that surgery for all forms cialty due to the increasing prevalence of lung cancer of cancer now accounts for nearly a quarter of the and the development of new surgical procedures. Mor- national cancer budget [4]; if projections for a sus- tality from lung cancer remains high; one person in tained increase in demand for cancer services are to be the UK dies as a result every 15 min [1]. In the major- met, more efficient utilisation of resources will be ity of instances, surgical resection remains the best needed in the current era of financial austerity. Mini- hope for cure [2]. Over the last decade, the number of mising length of hospital admission has been identified pulmonary resections performed for lung cancer has as a key means to increase capacity whilst reducing risen from 3112 in 2001–2002 to 5265 in 2009–2010, costs, and is a major objective of the Cancer Reform an increase of almost 60% [3]. Figures from the Strategy [4]. A growing body of evidence suggests that Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland Jones et al. | Enhanced recovery in thoracic anaesthesia inpatient stay after elective surgery can be reduced by 2000 to 2012. To achieve maximum sensitivity of the the introduction of an enhanced recovery programme search and indentify relevant studies, the following (ERP) [5], which is a series of evidence-based prac- thesaurus terms were applied: ‘pulmonary surgical tices, serving to optimise the patient before surgery, procedures’; ‘early ambulation’; ‘thorax surgery’; and minimise the physical and psychological stress associ- ‘perioperative period’. Free‐text items searched for ated with the procedure and promote restoration of were: ‘enhanced recovery’; ‘patient recovery’; ‘fasting’; function [6]. Numerous studies demonstrate the value ‘risk factors’; ‘medical optimisation’; ‘day of surgery of enhanced recovery programmes in the surgical admission’; ‘length of stay’; ‘suction’; ‘early ambula- management of colorectal [7], breast [8], pancreatic tion’; ‘mobilisation’; ‘discharge’; ‘quality indicators’; [9] and urological [10] malignancies; however, there is ‘healthcare’; ‘pre-admission’; and ‘pain relief’. The a relative paucity of work in thoracic surgery in gen- search results were limited to English language stud- eral and lung cancer in particular. The National ies. A total of 813 studies were initially identified, and Institute for Health and Clinical Excellence (NICE) has two authors (NJ and AK) selected 95 articles for more recently recommended that further work should be detailed study based on their relevance to the topic of undertaken into the benefits of an ERP in this group of patients [11]. This article reviews the evidence for surgery. Each article was examined and recommenda- individual peri-operative interventions in patients pre- tions were made based on the best level of evidence senting for thoracic surgery, and may be used to form the basis of local enhanced recovery programmes.
A comprehensive literature search was performed on It is a basic tenet of enhanced recovery that patients both MEDLINE and Embase using the National should be in the best possible condition for surgery, Health Service health database advanced search inter- modifiable risk factors should be addressed and co- face, which includes the Cumulative Index to Nursing morbidities optimised before surgery. Ideally, this is and Allied Health Plus (CINAHL), the British Nurs- undertaken by the general practitioner in the period ing Index (BNI) and the Allied and Complementary following diagnosis whilst awaiting treatment, or, at Medicine Database (AMED), accessing articles from the latest, at pre-operative assessment. Table 1 summa- Table 1 Recommendations for pre-operative care as part of an enhanced recovery programme after thoracic surgery.
Investigated and treated before surgery if possible [13–19] Screening for malnutrition and nutritional support given to risk patients [20–23] Advised to stop smoking before surgery and given appropriate support [23–27] Medical therapy should be optimised before surgery [28–30] Pulmonary rehabilitation considered before surgery to improve exercise Detailed assessment carried out to facilitate same-day admission and reduce Used to facilitate informed consent and appropriate resource allocation [36, 37] Patients and their families should receive detailed oral and written information about hospital stay, the recovery process and discharge [38–40] Releases bed capacity and minimises hospital stay [41] Anxiolytic premedication can be given without delaying recovery, but use with Minimise ‘nil-by-mouth’ and consider carbohydrate beverage 2 h preoperatively All patients should be assessed and anti-embolism stockings or mechanical Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland Jones et al. | Enhanced recovery in thoracic anaesthesia rises the key aspects of pre-optimisation included in resulted in a significant reduction in intensive care and hospital stay. These findings require confirma- Anaemia is a common incidental pre-operative finding and is associated with increased morbidity and Smokers are more likely to die following surgery mortality in the peri-operative setting [13]. It should and have significantly greater odds of experiencing seri- be investigated and treated before surgery if time per- ous postoperative complications [24]. In patients with mits. Peri-operative blood transfusion is the commonest lung cancer undergoing pulmonary resection, smoking method of raising haemoglobin concentration in anae- cessation reduces postoperative mortality and morbid- mic surgical patients, but it is associated with the risk of ity [25]. No evidence of a paradoxical increase in pul- acute transfusion reactions, immunosuppression, post- monary complications among those who quit smoking operative infection and longer hospital stay [14, 15].
within two months of undergoing thoracotomy has Alternative strategies to correct even minor degrees of been demonstrated [26]. The NICE guidelines on the anaemia (haemoglobin concentration < 12 g.lÀ1 in diagnosis and treatment of lung cancer [11] recom- females, < 13 g.lÀ1 in males) before surgery, which have mend that all patients should be advised to stop smok- been noted to be highly prevalent in recent studies [16], ing as soon as the diagnosis of lung cancer is suspected; can significantly reduce the need for transfusion and the however, surgery should not be postponed to allow this.
resultant increase in morbidity and mortality [17].
All patients should be offered nicotine replacement and Although studies have examined the utility of iron sup- other therapies to help stop smoking [27].
plementation and erythropoietin in the context of Chronic obstructive pulmonary disease (COPD) is patients with lung cancer undergoing adjuvant treat- very common in patients with lung cancer, and is a ment with chemo- or radiotherapy, none have investi- risk factor for peri-operative pulmonary complications.
gated their use before surgery [18, 19].
Whilst intuitively one would expect that pharmacologi- Malnutrition is another common finding in cal treatment would improve outcome, there are few patients with cancer and is associated with impaired data in patients with either newly diagnosed or estab- lished COPD undergoing lung resection to substantiate muscle fatigue and tissue wasting following surgery.
this. Data that exist suggest that commencing a long- This results in delayed recovery and prolonged acting bronchodilator in patients with untreated COPD length of stay [20]. The European Society for Nutri- significantly improves respiratory symptoms and pul- tion and Metabolism Guidelines [21] recommend monary function [28]. The addition of inhaled steroid that all patients should be screened for malnutrition, may also reduce postoperative complications [29].
and those with severe increased risk (weight loss 10– Intensive pre-operative respiratory physiotherapy com- 15% within 6 months, BMI < 18.5 kg.mÀ2, Subjective bined with optimised drug treatment (inhaled bron- Global Assessment Grade C, or serum albumin chodilators or corticosteroids) in patients considered < 30 g.lÀ1) should receive nutritional support for 10– unfit for surgical resection can result in significant 14 days before major surgery. Up to 28% of patients improvements in lung function to the extent that they with operable lung cancer are reported to be at can be reconsidered as surgical candidates [30]. Pre- severe nutritional risk [22]. To date, no studies have specifically examined the impact of pre-operative cor- employed for selected patients with COPD and lung rection of malnutrition in patients with lung cancer.
cancer to improve exercise capacity [31, 32].
One small prospective randomised trial has investi-gated the effect of micronutrient supplementation in patients with non-small cell lung cancer and a nor- mal body mass index for 10 days before lung resec- undergo pre-operative assessment [33] to establish that tion [23]. The combination of a-ketoglutaric acid the patient is fit for the proposed surgery and anaes- and 5-hydroxymethylfurfural not only improved exer- thetic. There is some evidence that pre-operative cise capacity and reduced oxidative stress but also assessment may facilitate same-day admission, reduce Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland Jones et al. | Enhanced recovery in thoracic anaesthesia unnecessary cancellations and increase patient satisfac- expectations in the pre-assessment clinic may improve tion [34]. Assessments of exercise capacity such as outcome [38, 39]. Detailed explanation of the intended shuttle walk tests and stair climbing, together with for- peri-operative pathway has also been shown to reduce mal measurements of cardiopulmonary function, may patient anxiety, pain and length of hospitalisation [40].
help decision-making in patients at high risk of post-operative dyspnoea [35].
Accurate prediction of peri-operative risk is funda- Effective pre-assessment means that hospitalisation for mental to the process of informed consent. It also a day before surgery is unnecessary (Table 1). Same- serves to identify those patients at higher risk, who day admission for patients undergoing surgery for lung may derive greater benefit from pre-optimisation and cancer is practised in a number of institutions within require more intensive postoperative care. The most the UK [41]. The administration of routine anxiolytic widely used clinical tool for predicting in-hospital premedication has declined in recent years because of mortality after general thoracic surgery is the Thoracic concerns regarding delayed recovery. However, a Surgery Scoring System (Thoracoscore). This system Cochrane review of 17 randomised clinical trials consists of nine variables, with a correlation between (RCTs) comparing anxiolytic premedication (benzo- observed and expected mortality of 0.99 [36]. Other diazepines, opioids and beta-blockers) with placebo well-recognised risk factors for postoperative morbidity found no impediment to recovery [42]. Unfortunately, and prolonged length of stay include age, obesity, poor this review did not include patients undergoing tho- pre-operative lung function (FEV1 or TLCO < 40%), racic surgery, many of whom have impaired respira- impaired functional capacity (VO2 max < 15 ml.kgÀ1.
tory function and in whom the use of sedatives could minÀ1), ASA physical status, continued smoking, insu- be hazardous. Thus, premedication can be employed lin-dependent diabetes, chronic renal failure and regu- in selected patients, but should be used with caution lar pre-operative analgesic use [37]. Patients with and increased vigilance. Same-day admission may lead multiple risk factors may require more intensive use of to the use of premedication becoming rarer, and many resources, such as high dependency postoperative care institutions may choose to omit it altogether from or prolonged hospital stay, and may need to be man- aged outside of the enhanced recovery programme. It Pre-operative fasting causes metabolic and psycho- is important that such patients are identified pre-oper- logical stress. ‘Fasting from midnight’ has been com- atively and appropriate arrangements are made. At the mon practice in the past to reduce the risk of same time, there is evidence that exploring patients’ pulmonary aspiration during anaesthesia and the Table 2 Recommendations for intra-operative care as part of an enhanced recovery programme after thoracicsurgery.
In accordance with local policies and with knowledge of the patient’s colonisation and resistance patterns [46, 47] Use short-acting agents that facilitate early recovery; inhalational anaesthesia may have advantages over intravenous techniques [49–54] Lungs should be ventilated using a protective strategy with limited tidal Prophylaxis should be considered in at-risk patients [64–68] Patients’ tracheas should be extubated at the end of surgery if possible [73] Minimally invasive, provided it does not compromise the curative intent of the One chest drain should be used in preference to two [71] Paravertebral analgesia should be used in preference to thoracic epidural [74] Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland Jones et al. | Enhanced recovery in thoracic anaesthesia immediate postoperative period. However, a review of The use of short-acting anaesthetic agents seems the evidence demonstrates that the pre-operative fast- rational to facilitate early recovery. Inhalational anaes- ing period for clear fluids can be reduced to 2 h with- thesia has the theoretical disadvantage of inhibiting out increasing complications [43], although specific hypoxic pulmonary vasoconstriction; however, in clini- data from patients of ASA status 3–4, such as many cally relevant concentrations, it has no significant effect thoracic surgical candidates, are lacking. There is some on shunt fraction [49, 50] or arterial oxygen content evidence that carbohydrate loading is associated with during one-lung ventilation [51]. One randomised faster recovery and shorter hospital stay [44].
study found that cerebral oxygen balance during lung Thoracic surgery patients should be regarded as surgery is less impaired under sevoflurane-based anaes- high risk for postoperative venous thromboembolism thesia compared with propofol; however, the clinical (VTE). Recent NICE guidelines recommend that implications of this finding need to be determined mechanical VTE prophylaxis (anti-embolism stock- [52]. Various reports have cited the relative benefits of ings, intermittent pneumatic compression devices or sevoflurane [53] or propofol [54] on peri-operative foot impulse devices) should be commenced at admis- cytokine balance in patients undergoing one-lung sion [45]. Pharmacological VTE prophylaxis should ventilation, but the results are conflicting and no firm be added in patients who have a low risk of major recommendations on choice of agent or technique can bleeding, with either low molecular weight heparin or unfractionated heparin for patients with renal failure.
One-lung ventilation induces cytokine release and Prophylaxis should be continued until the patient no activation of the pulmonary inflammatory response longer has significantly reduced mobility. Care must [55, 56]. Use of large tidal volumes can exacerbate be taken in the timing of administration of pharma- lung injury and is associated with an increased risk of cological prophylaxis in patients who may receive respiratory failure after pneumonectomy. Protective regional anaesthetic blocks for their surgical proce- mechanical ventilation, using low tidal volumes (5 ml.
kgÀ1), has been shown to reduce serum inflammatorymarkers and the incidence of postoperative pulmonary dysfunction, such as relative hypoxia or newly devel- There are a number of areas of intra-operative practice oped lung infiltrates or atelectasis [57]. The effect of that may be considered for inclusion in an enhanced positive end-expiratory pressure on postoperative recovery programme (Table 2). Prophylactic antibiotics outcomes remains unclear [58]. Limited data suggest have been shown to reduce infectious complications that pressure-controlled ventilation may be associated after thoracic surgery [46]. However, the current evi- dence on what constitutes the most appropriate antibi- reduced mean airway pressure [59] compared with otic prophylaxis for this group of patients is poor, and volume control. However, a recent review concluded no guidelines exist. Importantly, these patients will that the evidence for an effect on postoperative oxy- often have suffered multiple episodes of respiratory tract infection, and received numerous courses of anti- Sodium and fluid overload are associated with biotics before their surgery. Airway colonisation with increased postoperative complications and prolonged pathogens is a risk factor for the development of post- hospitalisation. In patients undergoing lung surgery, operative pulmonary infectious complications [47].
intra-operative fluids are frequently restricted as posi- When selecting suitable prophylaxis, changes in the tive fluid balance is one of the strongest risk factors usual pattern of flora as a result of chronic colonisa- for the development of postresection acute lung injury tion and the potential development of antibiotic resis- [61]. In addition, or as an alternative, to conventional tance should be considered. Antibiotics should be measurement of central venous pressure, several given 60 min or less before ‘knife to skin’ in accor- devices have been shown to predict fluid responsive- dance with the World Health Organization (WHO) ness in mechanically ventilated patients. In the main, these devices rely on measurement of the cyclical vari- Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland Jones et al. | Enhanced recovery in thoracic anaesthesia ations in stroke volume or pulse pressure induced by require shorter hospital stay than those undergoing mechanical ventilation, but conditions during thoracic conventional surgery [70]. However, this is a techni- surgery (such as open chest, shunt during one-lung cally demanding procedure and may require signifi- ventilation) may limit their usefulness. In practice, it has been shown that pulse pressure variation and therefore, many surgeons perform limited open thora- stroke volume variation may predict fluid responsive- cotomy, which may be preferable from the standpoint ness under certain circumstances [62, 63], but further of safety and prognosis. Video-assisted thoracoscopic research specific to thoracic surgery is needed before surgical resection, undertaken by an appropriately widespread use for goal-directed fluid therapy can be skilled surgeon, should be offered to selected patients with clinical stage-one lung cancer (no evidence of Atrial fibrillation occurs relatively commonly after tumour spread) where appropriate skill exists, and it is pulmonary resection (12–30% after lobectomy), and is likely that increasing familiarity with the technique associated with significant morbidity and increased and improved training, along with the publication of length of stay and hospital costs [64]. An analysis of ongoing research in this field, will lead to increased the Society of Thoracic Surgeons database has identi- use of such minimally invasive techniques.
fied five variables that predict postoperative atrial Chest drains impede mobilisation and exacerbate fibrillation: advancing age; increasing extent of opera- pain in patients after thoracic surgery. There is some tion; male sex; non-black race; and more advanced or evidence from a recently published review that the use large tumours [65]. No standard regimen has been of one drain, as opposed to two or more, is associated recommended to decrease the incidence of atrial fibril- with reduced postoperative pain scores [71], and when lation; however, evidence from prospective RCTs no definite surgical requirement exists the use of one supports the use of beta-blockers, diltiazem, intrave- drain alone should be considered. Postoperative air nous magnesium or amiodarone for the prevention of leak is a frequent complication after pulmonary resec- atrial fibrillation after pulmonary resection [66, 67].
tion for lung cancer. Air leak may prolong the need The use of amiodarone in this setting is controversial for chest drainage and delay discharge. Different types due to the risk of acute lung injury; however, studies of surgical sealants have been developed in an effort to attest to the safety of this drug if the cumulative dose try to prevent or reduce postoperative air leak; how- ever, they are expensive and their efficacy is controver-sial. A systematic review found that although surgical sealants do reduce postoperative air leak and the time The traditional approach to pulmonary resection is a to chest drain removal, this is not always associated postero-lateral thoracotomy as this provides excellent with a reduction in length of postoperative hospital surgical access. However, this technique involves tran- stay [72]. Until further research is available, the section of a large muscle group, and it is believed that routine use of sealants cannot be recommended.
this contributes to postoperative pain, reduced inspira-tory effort and impairment of arm movement.
Attempts have been made to decrease complications Immediate tracheal extubation favours recovery by by performing muscle-sparing limited thoracotomy allowing early initiation of rehabilitation and re-intro- using an antero-axillary or anterolateral approach, or, duction of oral hydration and nutrition. Furthermore, most recently, using video-assisted thoracoscopic surgi- prolonged mechanical ventilation increases the risk of cal (VATS) techniques. Such approaches are associated acute lung injury, pulmonary infection, bronchial with significantly less impairment of postoperative vital stump disruption, bronchopleural fistula and persistent capacity and improved exercise capacity compared air leakage [73]. Predictors of prolonged postoperative with postero-lateral thoracotomy [69]. In early-stage intubation in patients undergoing thoracotomy for lung cancer, evidence is accumulating that patients lung resection include: intra-operative red blood cell undergoing VATS may experience reduced pain and transfusion; high pre-operative serum creatinine level; Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland Jones et al. | Enhanced recovery in thoracic anaesthesia more extensive surgical resection; and poor pre-opera- may be preferable to use paravertebral blockade, in tive lung function. Despite this, immediate tracheal ex- association with multimodal analgesia as first-line tubation should be planned in all patients unless analgesia, and reserve epidural analgesia for high-risk significant complications preclude such a strategy.
patients not expected to follow an enhanced recovery Postoperative care in general and pain manage- programme. These may include patients undergoing ment and early mobilisation in particular are vital chest wall resection or pneumonectomy. There is still components of any enhanced recovery programme controversy over the best method for insertion of the (Table 3). Acute pain after thoracotomy prevents mo- bilisation and causes patients distress, and is associated regarding ultrasound-guided percutaneous injection vs with an increased incidence of cardiopulmonary com- surgical insertion; further studies in this area are plications, including atelectasis, pneumonia, atrial fibrillation and myocardial ischaemia. Persistent pain Bed-rest is associated with deleterious conse- is a frequent cause of delayed discharge and is associ- ated with the development of chronic pain syndromes.
reduction in muscle mass and increased risk of VTE. It Epidural analgesia is a core component of many is possible to mobilise patients safely as early as 4 h enhanced recovery programmes as it provides excellent after lung resection surgery, with a positive benefit on pain relief, attenuates the stress response to surgery the requirement for supplemental oxygen and psycho- and accelerates restoration of pulmonary and gastro- logical recovery [76]. Incentive spirometry causes gen- intestinal function. Furthermore, epidural analgesia avoids the use of systemic opiods and their associated transpulmonary pressure, with consequent expansion side-effects. Thoracic epidurals are widely used in of collapsed alveolar units, and has been used widely to patients undergoing thoracotomy and are regarded by prevent or treat postoperative pulmonary complica- many as the ‘gold standard’ for pain relief following tions. However, a systematic review of incentive spi- pulmonary resection. However, their use is associated with a number of complications including hypoten- procedures found no evidence to support its use and it sion, urinary retention and motor weakness; these can cannot be recommended at present [77]. In contrast, lead to inappropriate fluid loading, urinary catheterisa- implementation of intensive chest physiotherapy in the tion and delayed mobilisation, all contrary to the ethos peri-operative period has been shown in to reduce the of an enhanced recovery programme. This can be risk of pulmonary complications and resultant hospital overcome in patients undergoing thoracic surgery by length of stay and costs of care after major lung resec- using paravertebral regional blockade, which produces tion [78]. However, the only randomised trial to inves- only unilateral sympathetic blockade. A recent meta- tigate the impact of physiotherapy after pulmonary analysis [74] has confirmed that paravertebral block resection concluded that there was no benefit over stan- can produce comparable analgesia to an epidural, but dard care [79]. Non-invasive ventilation has been rec- with a lower incidence of side effects. Adjuncts includ- ommended for the prophylaxis of postoperative ing ketamine have also proven to be beneficial [75]. It respiratory failure in patients who have undergone Table 3 Recommendations for postoperative care as part of an enhanced recovery programme after thoracic surgery.
Pharmacological agents should be used in patients who have a low risk of Suction is not routinely required and may prolong hospital stay [84] A low threshold for drain removal should be used [83] Mobilise as soon as possible after surgery [76] Should be used to reduce complications and length of stay [48, 78] Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland Jones et al. | Enhanced recovery in thoracic anaesthesia major surgery or who are at high risk of pulmonary ery programme into surgical and anaesthetic practice complications. It has been associated with improve- has been slow [86]. However, there is no doubt that ment in gas exchange [80] and reduced hospital stay pressure will continue to be exerted to reduce hospital [81], but may increase complications [82].
stay and costs [87], and that, for the moment at least, Early removal of chest drains reduces pain, facilities enhanced recovery programmes are here to stay.
mobilisation and accelerates recovery following thora- Patient selection and safety are paramount, and it is cotomy [83]. Drain management is not standardised likely that a number of thoracic surgery patients will and there are wide variations in practice, for example be considered to be too high-risk to go through such a whether to use a simple under-water seal or to apply protocol. Patients undergoing certain procedures such active suction. Some surgeons believe that suction as pneumonectomy or chest wall resection should not favours the apposition of parietal and visceral pleura, be included in such a protocol. A graded implementa- thus promoting the sealing of air leaks, whereas others tion process may be considered, starting with relatively believe that it increases the volume of air leaks and hin- low-risk procedures and patients (ASA physical status ders healing. A recent meta-analysis of six RCTs con- 1–2), progressing to selected higher-risk patients and cluded that it is not necessary to use suction in the expanding to include lobectomy and other longer absence of a clinically important postoperative space, procedures. Multidisciplinary involvement is vital and and that earlier drain removal could result in shorter surgical, nursing and physiotherapy input will be hospital stays [84]. The majority of thoracic surgeons required. This review of the literature may be used to leave the chest drain in place until fluid output is less form the basis for developing a local enhanced recov- than 250 ml per day and the air leak has resolved. Hos- ery programme in thoracic anaesthesia and surgery pital length of stay is often prolonged because drainage that may potentially lead to reduced hospital stay and is too high or the air leak persists despite the patient being otherwise ready for discharge. A number of stud-ies have demonstrated that a low threshold for drain removal can be used safely, and that Heimlich valves or No external funding or competing interests declared.
portable drainage systems can facilitate discharge in the AAK is an Editor of Anaesthesia and this article has presence of persistent air leak or effusion.
undergone an additional external review as a result.
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Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland

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