FastTrack Surgery.ppt

Fast-Track Surgery,Maggie Gordon,R2October 2,2007,Fast-Track Surgery,What is fast-track surgery?,Basic Concept,Early recovery of organ functionfor better outcomes,Kehlet H,Wilmore DW.Am J Surg.183:630,2002,Basic Concept,Pre-op patient educationNew techniques:anaesthetic,analgesic,surgicalReduce:stress,pain,discomfortAggressive post-op rehabUse same D/C criteria as traditional care,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Goals,Lower risk,better outcomeAccelerate recoveryReduce morbidity,complications(pulmonary,cardiac,thromboembolic,infectious)Shorten convalescence,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Literature Search,Web of ScienceTopic=fast track AND colon*2002-presentEnglish articles and reviewsFound 35 articles about colon surgery available from McMaster library3 reviews1 consensus statement found in citations,Fast-Track Surgery,What should we do pre-operatively?,Patient Education,Tell patients what to expectImproves patient collaboration with team anxiety analgesia needsTell patients their role in recoveryOptimize patients medicallyIncluding smoking,EtOH cessation,Kehlet H,Wilmore DW.Am J Surg.183:630,2002,Fearon KC,et al.Clin Nutr.24:466,2005,No Pre-Op Bowel Prep,Bowel prep anastomotic dehiscence(Recommendations not clear yet for low anterior resections),Wind J,et al.Br J Surg.93:800,2006,Soop M,et al.Curr Opin Crit Care.12:166,2006,Limited Fasting,Solids until 6 hours before surgeryClear fluids until 2 hours before surgerySafeBeneficialCarbohydrate-loaded liquid pre-op post-op catabolism insulin resistance,hyperglycemia muscle loss,Wind J,et al.Br J Surg.93:800,2006,Soop M,et al.Curr Opin Crit Care.12:166,2006,Fearon KC,et al.Clin Nutr.24:466,2005,Prophylactic Antibiotics,Single dose immediately pre-opAnaerobesAerobes,Kehlet H,Wilmore DW.Am J Surg.183:630,2002,No Routine Pre-medication,Anxiolytics only when absolutely necessaryNo pre-emptive analgesia,Fearon KC,et al.Clin Nutr.24:466,2005,VTE Prophylaxis,Pre-op heparinHeparin q12h until fully mobilizingTEDS,Fearon KC,et al.Clin Nutr.24:466,2005,Fast-Track Surgery,What should we do intra-operatively?,Anaesthesia,Best anaesthetics and opiods:Rapid-onsetShort-actingMaximize use of regional anaesthesiaSpinal/epidural better than general anaestheticPost-op epidural(controversial?),Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Less Invasive Surgery,Smaller incisionsCurved,transverse incisions?Laparoscopic inflammatory response pulmonary function length-of-stay?,Kehlet H,Wilmore DW.Am J Surg.183:630,2002,Fearon KC,et al.Clin Nutr.24:466,2005,Maintain Normothermia,Mild hypothermia wound infection blood loss cardiac eventsCore temperature monitoringBair huggersWarmed IV fluids,Kehlet H,Wilmore DW.Am J Surg.183:630,2002,Fearon KC,et al.Clin Nutr.24:466,2005,Avoid Fluid Overload,Fluid overload ileus“major and minor morbidity”length of stay,Wind J,et al.Br J Surg.93:800,2006,Soop M,et al.Curr Opin Crit Care.12:166,2006,Pharmacologic Intervention,Glucocorticoid inflammation nausea,vomiting painBeta-blockers cardiac morbidityAnabolic agentsStudies inconclusive,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Fast-Track Surgery,What should we do post-operatively?,Avoid Drains,JP drainsDo not use routinely(except post-mastectomy)NG tubesDo not use routinelyFoleysDo not use routinelyD/C after 24h(even with epidural in place),Kehlet H,Wilmore DW.Am J Surg.183:630,2002,Early Activity,muscle loss thromboembolism pulmonary function tissue oxygenation,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Early Activity,Environment should encourage independenceOut of bed x 2h on day of surgeryOut of bed x 6h every day after,Soop M,et al.Curr Opin Crit Care.12:166,2006,Early Feeding,infection,gut permeability hospital stay catabolismNo dehiscence,Kehlet H,Wilmore DW.Am J Surg.183:630,2002,Soop M,et al.Curr Opin Crit Care.12:166,2006,Early Feeding,Start clear fluids 2h post-opAim 800mL fluids on day of surgeryDAT 4h post-opRoutine nutritional supplements IV appropriately,avoid fluid overload,aim D/C IV on POD#1,Kehlet H,Wilmore DW.Am J Surg.183:630,2002,Soop M,et al.Curr Opin Crit Care.12:166,2006,Prevent Nausea and Vomiting,Ondansetron,droperidol,dexamethasoneAnti-emetic polypharmacy?Minimize narcoticsO2 Useless:metoclopramide,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Kehlet H,Wilmore DW.Am J Surg.183:630,2002,Prevent Ileus,ileus with post-op epiduralAvoidNarcoticsFluid overloadMg supplementsControl medically:novel peripherally acting opioid antagonist(alvimopan)Continue feeding,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Soop M,et al.Curr Opin Crit Care.12:166,2006,Routine Laxatives,Pro-kinetics,Suggested in a few studies,Wind J,et al.Br J Surg.93:800,2006,Optimize Analgesia,Critical forMobilizationOral intake stress responseEpidural x 2dMulti-modal:NSAIDs,routine acetaminophenAPS,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Kehlet H,Wilmore DW.Am J Surg.183:630,2002,Soop M,et al.Curr Opin Crit Care.12:166,2006,Routine Oxygen,sats Anaesthetic effectsSupine position pulmonary functionSleep disturbancesRoutine O2 administration nausea,vomiting infection HRconfusion,Kehlet H,Wilmore DW.Am J Surg.183:630,2002,Continue Medications,Continue with patients home meds,Kehlet H,Wilmore DW.Am J Surg.183:630,2002,Nursing,Nurses good resource for psychological supportEarly oral intakeEarly mobilizationSelf-careCare maps with daily goals are useful,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Discharge Planning,Usual criteriaAdequate pain control with oral analgesiaTaking solid foodsNo IV fluidsIndependently mobilePatient willing to go home,Soop M,et al.Curr Opin Crit Care.12:166,2006,Discharge Planning,Goals readmissions patient safety patient satisfactionOutline for patientExpected recovery time courseRecommendationsEncourage oral nutrition,mobilization,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Follow Up,Structured follow-up planPhone call:1-2dOut-patient clinic:7-10dPhone call:30dPathways for prompt readmission when necessarySymptom reliefOvernight stay,Soop M,et al.Curr Opin Crit Care.12:166,2006,Fast-Track Surgery,What are the outcomes?,Interventions,Outcomes,Wind J,et al.Br J Surg.93:800,2006,Primary Hospital Stay,Wind J,et al.Br J Surg.93:800,2006,Readmission,Wind J,et al.Br J Surg.93:800,2006,Morbidity,Wind J,et al.Br J Surg.93:800,2006,Gut Function,Wind J,et al.Br J Surg.93:800,2006,Fast-track NGTFaster BMEarlier DAT,Fast-Track Surgery,What is the punchline?,What is Most Important?,Education,education,educationPatient:pre-and post-opCare teamCollaboration,collaboration,collaborationSurgeonsAnaesthetists,APS team:intra-and post-opNursesPhysiotherapists,Summary,Fast-track surgery,Discussion,Discussion,Article lacking specific definitions“Early”oral intake,mobilizationHard to do randomized trials in ethical mannerCritical pathwaysPart of fast-track surgeryGood enough on their own?Hospital stays decreasing without formal adoption of“fast track”notion,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Discussion,Cost/burden of care-transfer from surgical team to:Emergency departmentFamily physiciansHome care,rehab,etc.Family?,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Early recovery of organ function,Discussion,Do we really need formality of“fast-track surgery”,or are we doing it already?Need evidenceShould we adoptRoutine dexamethasone use?Ondansetron instead of Gravol?Low threshold for beta-blocker use?Pre-op carbohydrates?Routine O2,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Evidence,General Results,hospital stayNo morbidityNo readmissionNo safety patient satisfaction cost,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Specific Studies,Earlier ambulation muscle function oral intake loss of lean mass pulmonary functionEarlier GI motility exercise capacity,cardiovascular function,Kehlet H,Sawyer F.Fast Track Surgery,ACS Surgery:Principles&Practice,Diseases of the Colon&Rectum.47:271-278,2004.,RetrospectiveColonic resectionStomas excludedLAR excludedAcute surgeries excludedTwo hospitalsConventional care(130 patients)With“multimodal rehabilitation”(130 patients),Basse et al.Colonic surgery with accelerated rehabilitation or conventional care.Dis Colon Rectum.47:271-278,2004.,Basse et al.Colonic surgery with accelerated rehabilitation or conventional care.Dis Colon Rectum.47:271-278,2004.,Basse et al.Colonic surgery with accelerated rehabilitation or conventional care.Dis Colon Rectum.47:271-278,2004.,Basse et al.Colonic surgery with accelerated rehabilitation or conventional care.Dis Colon Rectum.47:271-278,2004.,Basse et al.Colonic surgery with accelerated rehabilitation or conventional care.Dis Colon Rectum.47:271-278,2004.,130 patients in each group,All figures significant,Basse et al.Colonic surgery with accelerated rehabilitation or conventional care.Dis Colon Rectum.47:271-278,2004.,