Operative and Perioperative Events : Best Ways to Avoid and H ow to Handle Difficult Ones

1. Operative and Perioperative Events: Best Ways to Avoid and How to Handle Difficult Ones Vanderbilt-Ingram Cancer Center Joe B. Putnam, Jr., MD, FACS Professor and Chairman Department of Thoracic Surgery Ingram Professor of Cancer Research Professor of Biomedical Informatics

2. Good judgment comes from experience.Experience comes from poor judgment.Learn from others; life isn’t long enough for you to make all the mistakes yourself.

3. Outline • Preoperative preparation • Conduct of operation and management of catastrophes • Strategies to avoid intraoperative and postoperative events • Practice based learning and disciplined (e.g. consistent) practice

4. The Battle of 73 Easting, Persian Gulf February 26, 1991 4:20 pm • Eagle Troop, 2nd Armored Cavalry Regiment • A group of 9 U.S. tanks speeding across a flat featureless desert • Sandstorm – common for the desert • Imperceptibly traveling up a very slight rise in the terrain….. • Lead tank reaches the crest , and surprises 90 Iraqi tanks dug into defensive positions

5. The Battle of 73 Easting, Persian Gulf February 26, 1991 4:20 pm • Eagle Troop, 2nd Armored Cavalry Regiment • A group of 9 U.S. tanks speeding across a flat featureless desert • Sandstorm – common for the desert • Imperceptibly traveling up a very slight rise in the terrain….. • Lead tank reaches the crest , and surprises 90 Iraqi tanks dug into defensive positions • No air support secondary to sandstorm • Both sides surprised….. • “He realized at once …to attack quickly and attempt to catch the Iraqis off balance”

6. Factors which contributed to E Troop success: • “Quick thinking” • Training and preparation • Technology • Integrated team • “Flexibility” – ability to grasp the entirety of the situation nearly instantaneously and apply the correct action

7. Proper prior preoperative planning prevents poor performance • Risk assessment by the patient and the surgeon • Surgeon skill / experience • Institutional infrastructure • Tumor biology: response to therapy • Goals of the procedure • Cure / local control / relief of symptoms • Improved quality of life / other • “Surprises” more likely with ‘simple’ operations

8. Engage your team • Multidisciplinary evaluation prior to the operation.. • Thoracic Surgery/ Med Onc / Rad Onc / Pulm Med / Cards • Anesthesiology – OK to talk to the anesthesiologist prior to the OR! • Have your primary OR team in place • Multispecialty care during the operation… • Drive out fear; Collect and review your • Intraop and post op events routinely; • Debrief quickly • Use patient care pathways, and protocols • of care from evidence based medicine Fadel E. et al.; Ann Thorac Surg 2011;92:1024-1030

9. Tumor Maximally Invasive Surgery mediastinum heart lungs great vessels esophagus vertebrae carina vs. Minimally Invasive Surgery More ‘local’ disease – intraparenchymal, etc. Different instruments Different intraop events

10. Conduct of the operation and intraoperative events

11. Adjuncts to resection • Preop “Huddle” / Communicate your plans / Listen to reason • Invasive monitoring • Anesthesia team adept at physiologic/pharmacologic support • Blood conservation yet blood products available • Intrapericardial approach for control of vessels; airway • Choice of primary and secondary incision(s) • Vascular and cardiac surgery techniques • Cardiopulmonary bypass support • Bring in your partner – get some advice…having two brains are better having only two hands • “Fail quickly” - Decide to stop before a problem occurs

12. Tangential superior vena cava (SVC) resection with primary repair Garcia A, Flores RN Surgical management of tumors invading the superior vena cava. Ann Thorac Surg 2008;85:2144–6.)

13. NSCLC with invasion onto descending aorta

14. Primary Surgery for T4 NSCLC over a 25 year period • Retrospective review 271 ptSwith T4 NSCLC (1981-2006) • 126 superiorsulcus tumors • 92 carinal involvement • 39 superiorvena cava replacement • 14 othermediastinal structure invasion • Complete resection achieved in 249 (92%)pts • Operative mortality 4% • Operative morbidity 35% Yildizeli B. et al.; Ann Thorac Surg 2008;86:1065-1075

15. Types of resection and mortality in T4 tumors Yildizeli B. et al.; Ann Thorac Surg 2008;86:1065-1075

16. 5-year survival following resection of T4 NSCLC Subclavian artery invasion Complete vs. Incomplete N0/N1 vs. N2/N3 vs. no invasion 43% 41.7% 40.4% p=0.003 p=0.01 p=0.01 24.9 % 17.7 % 15.9% Yildizeli B. et al.; Ann Thorac Surg 2008;86:1065-1075

17. Some examples of intraoperative catastrophes… • Cervical mediastinoscopy • hmmm…he seems to be pulling a bit…. • “That node sure is hard…” • Inadvertent extubation while in the lateral decubitus position • Exsanguinating hemorrhage during placement of endoscopic stapler during VATS upper lobectomy • Exsanguinating hemorrhage during “simple” LEFT lower lobe • CPR after intraop chest tube placed by another service -> bleeding

18. Postoperative Protocols and Pathways

19. Patient Education

20. Practice Based Learning and Improvement:The role of clinical data • Can’t collect all data • Collect the clinical data as decision is made • Enter data at that timeby the ‘decision maker’ / the ‘decider’ • “Point-of-decision” model • Defined “decision points”

21. “Points of Decision” data collection MODULE AREA • Clinic / “preop” Clinic • Operation OR • Post operative events Ward • Pathology / Staging Office • Follow-up Clinic

24. QI Report for 11/1/2011 – 11/30/2011 Hospital Events

25. QI Report for 11/1/2011 – 11/30/2011 Hospital Events

26. Summary • Avoiding intraoperative and perioperative events is preferred to treatment. This strategy requires careful patient selection and preparation of the OR team. • Be prepared in the OR – almost anything can happen. • Disciplined practice with confirmation by prospective quality improvement efforts will be successful over time. • Engage all members of the team including the patient and family to optimize outcomes. Feedback data to your faculty and team frequently. • Two ears / one mouth: listen twice, talk once. • Be safe, make good decisions.