preoperative preparation for thoracic surgery

Preoperative Patient Education

Saneesh P J

in Thoracic Surgery

Introduction

Modern-day health care

Scientifically perfect

Emotionally or psychologically unsatisfied patients

Surgeon

Anesthetist

Physicians

Nurses

Resp Therapist

s

Others

Patient

Coordinated activity

Initial visit•Recommendation for surgery•Sufficient time is allocated•Questions are encouraged

Subsequent visit•Review the planned procedure•Additional questions are answered•Preop anesthesia clinic visit

Content of preoperative teaching

Related to surgery (or thoracic surgery) in general

Issues related to a specific operation

Content of preoperative teachingGeneral preoperative education

Respiratory hygiene

Pain

Smoking cessation

Diet and nutrition

Wound care and drains

Postdischarge social issues

Contact numbers

General preoperative evaluation

Rapport

General preoperative evaluationUnderstanding of the planned procedure

Why it is being recommended

What its risks are

Whether there are alternatives

Role of active patient participation

Respiratory hygiene

Atelectasis

Pneumonia

Pulm embolism

Common complications of thoracic surgeryCan be prevented with active patient involvement

Respiratory hygiene

Coughing

Deep breathing

Using an incentive spirometer

Walking

Sitting to eat

Performing other seemingly minor activities

Decreased incidence of postoperative pneumonia

Respiratory hygiene

Coughing

Deep breathing

Using an incentive spirometer

Walking

Sitting to eat

Performing other seemingly minor activities

• Painful• ? Prevent pneumonia• Expectoration of sputum – desirable

• Teach method of splinting operative site to minimise pain with coughing

Respiratory hygiene

Coughing

Deep breathing

Using an incentive spirometer

Walking

Sitting to eat

Performing other seemingly minor activities

• Can open collapsed alveoli • Prevent overt atelectasis

Respiratory hygiene

Coughing

Deep breathing

Using an incentive spirometer

Walking

Sitting to eat

Performing other seemingly minor activities

• Improved aeration of the lungs • Avoidance of alveolar and segmental collapse

Respiratory hygiene

Coughing

Deep breathing

Using an incentive spirometer

Walking

Sitting to eat

Performing other seemingly minor activities

• Semirecumbent posture predisposes to aspiration and regurgitation

Respiratory hygiene

• Setting expectations is important• Far more effective preoperatively

than postoperatively when breathing is compromised by pain

• Baseline spirometry readings• Easy to convince target values in

postop period

Pain

Loss of personal control

Most frightening concerns by patients

Pain

Can allay these fears

Reduce anxiety

Realistic expectations - postop pain

Effective preoperative teaching

Pain

Discussion of narcotic analgesics, patient- controlled analgesia, nonsteroidal analgesics, and epidural anesthesia (continuous, intermittent, and patient controlled)

Side effects, including nausea, gastrointestinal dysfunction, and the potential for a lack of efficacy

Goal of postoperative analgesia pain control that provides patients with an ability to function and interact with their environment effectively

Goal

OptionsSide effects

Pain

Effective preoperative counseling

Sets the expectationsCan be reinforced in the postopeative period

Smoking cessationThoracic surgery mostly deals with smoking related pathology

May/may not quit smoking• addictive qualities of nicotine outweigh the intellectual

knowledge that smoking is harmful

May use smoking as a method of coping with anxiety and fear

Cigarette smoking impairs the mucociliary clearance mechanisms of the tracheobronchial tree and may predispose to postoperative pulmonary complications.

Smoking cessation

The optimal time for smoking cessation is unclear

Most surgeons encourage patients to stop smoking in preparation for thoracic surgery.

Whether surgery should be denied to patients who continue to smoke is controversial.

Every effort should be made preoperatively to persuade the patient to stop smoking.

Diet and Nutrition

Significant recent weight loss

Preoperative chemotherapy or radiation therapy

Nutritional deficiencies can be expected and consequently preempted.

Patient questions regarding nutritional supplementation to be addressed

Wound care & Drains

Patients often have negative expectations about wound care and often are pleasantly surprised to learn that care is usually minimal. Patients should be taught about the uses and benefits of percutaneous tubes and drains.

Post-discharge social issues

Family involvement in postoperative convalescence

Job-related concerns

Expectations regarding physical limitations, including appetite, sleep irregularity etc

Cultural sensitivity and family dynamics may play crucial roles in effecting a smooth post- operative recovery.

Contact numbers

Provide patients with a reliable method of contacting the surgeon or his or her designee.

Procedure-specific teaching

Pulmonary resection (lobectomy/pneumonectomy) Thoracoscopy Lung volume reduction surgery Esophagectomy Photodynamic therapy Transplantation

postthoracotomy pain – analgesia plans

potential for decreases in pulmonary reserve

Procedure-specific teaching

Pulmonary resection (lobectomy/pneumonectomy) Thoracoscopy Lung volume reduction surgery Esophagectomy Photodynamic therapy Transplantation

Often can be discharged the day after surgery

Presence of a chest tube often dictates an overnight stay

Procedure-specific teaching

Pulmonary resection (lobectomy/pneumonectomy) Thoracoscopy Lung volume reduction surgery Esophagectomy Photodynamic therapy Transplantation

Risk of prolonged air leaks.

Risks of pneumonia

Potential for postoperative mechanical ventilation

Use of one-way valves and the possibility of being discharged home with a chest tube in place can be discussed

Procedure-specific teaching

Pulmonary resection (lobectomy/pneumonectomy) Thoracoscopy Lung volume reduction surgery Esophagectomy Photodynamic therapy Transplantation

Prolonged cutaneous photosensitivity

Procedure-specific teaching

Pulmonary resection (lobectomy/pneumonectomy) Thoracoscopy Lung volume reduction surgery Esophagectomy Photodynamic therapy Transplantation

Lifelong involvement with the transplant center

Ongoing use of multiple medications

Need for periodic physiologic and pathologic assessment

Preoperative assessment frequently involves psychologists (or psychiatrists) and social workers

Preoperative teaching tools

Verbal instructio

n Written

material

Web-based

material

Audiovisual

material

Verbal instructions

Verbal instructi

on Written

material

Web-based material

Audiovisual material

Basic questions that they are reluctant to discuss with the surgeon

Multiple factors, such as language barriers, learning disabilities, and cultural barriers

The cornerstone tool to pre-operative teaching

Written materials / leaflets

Verbal instructio

n Written

material

Web-based material

Audiovisual material

Commercial product-specific patient education packets

“In-house” procedure-specific information booklets

Patient education materials, leaflets

Web-based materials

Verbal instructio

n Written

material

Web-based

material Audiovisual material

Help to choose right, authentic sources

Pharma websites also can help familiarize with specific products or procedures

Websites of authorised organisations can be of great help

Audiovisual materials

Verbal instructio

n

Written materi

al

Web-based materi

al Audiovisual

material

Better attention with patient’s own X ray, CT scan etc

Diagrams- hand-drawn or from books / web

Lung models to explain the disease

Summary

The goal of patient teaching is to improve patients’ understanding of their disease

process and the operation ensure their active participation in the treating

process The additional goal of obtaining informed

consent is an ingrained component to the current physician-patient relationship.

Summary

Team effort

Knowledgeable, Active Participant

Multiple modalities

Thank you