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Fast-Track Surgery. Maggie Gordon, R2 October 2, 2007. Fast-Track Surgery. What is fast-track surgery?. Basic Concept. Early recovery of organ function for better outcomes. Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002. Basic Concept. Pre-op patient education

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fast track surgery

Fast-Track Surgery

Maggie Gordon, R2

October 2, 2007

fast track surgery2

Fast-Track Surgery

What is fast-track surgery?

basic concept
Basic Concept

Early recovery of organ function

for better outcomes

Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002

basic concept4
Basic Concept
  • Pre-op patient education
  • New techniques: anaesthetic, analgesic, surgical
    • Reduce: stress, pain, discomfort
  • Aggressive post-op rehab
  • Use same D/C criteria as traditional care

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

goals
Goals
  • Lower risk, better outcome
  • Accelerate recovery
  • Reduce morbidity, complications (pulmonary, cardiac, thromboembolic, infectious)
  • Shorten convalescence

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

literature search
Literature Search
  • Web of Science
  • Topic = fast track AND colon*
  • 2002-present
  • English articles and reviews
  • Found 35 articles about colon surgery available from McMaster library
  • 3 reviews
  • 1 consensus statement found in citations
fast track surgery7

Fast-Track Surgery

What should we do pre-operatively?

patient education
Patient Education
  • Tell patients what to expect
    • Improves patient collaboration with team
    •  anxiety
    •  analgesia needs
  • Tell patients their role in recovery
  • Optimize patients medically
    • Including smoking, EtOH cessation

Fearon KC, et al. Clin Nutr. 24: 466, 2005

Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002

no pre op bowel prep
No Pre-Op Bowel Prep
  • Bowel prep →  anastomotic dehiscence
  • (Recommendations not clear yet for low anterior resections)

Soop M, et al. Curr Opin Crit Care. 12: 166, 2006

Wind J, et al. Br J Surg. 93: 800, 2006

limited fasting
Limited Fasting
  • Solids until 6 hours before surgery
  • Clear fluids until 2 hours before surgery
    • Safe
    • Beneficial
  • Carbohydrate-loaded liquid pre-op
    •  post-op catabolism
    •  insulin resistance,  hyperglycemia
    •  muscle loss

Fearon KC, et al. Clin Nutr. 24: 466, 2005

Soop M, et al. Curr Opin Crit Care. 12: 166, 2006

Wind J, et al. Br J Surg. 93: 800, 2006

prophylactic antibiotics
Prophylactic Antibiotics
  • Single dose immediately pre-op
    • Anaerobes
    • Aerobes

Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002

no routine pre medication
No Routine Pre-medication
  • Anxiolytics only when absolutely necessary
  • No pre-emptive analgesia

Fearon KC, et al. Clin Nutr. 24: 466, 2005

vte prophylaxis
VTE Prophylaxis
  • Pre-op heparin
  • Heparin q12h until fully mobilizing
  • TEDS

Fearon KC, et al. Clin Nutr. 24: 466, 2005

fast track surgery14

Fast-Track Surgery

What should we do intra-operatively?

anaesthesia
Anaesthesia
  • Best anaesthetics and opiods:
    • Rapid-onset
    • Short-acting
  • Maximize use of regional anaesthesia
    • Spinal / epidural better than general anaesthetic
    • Post-op epidural (controversial?)

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

less invasive surgery
Less Invasive Surgery
  • Smaller incisions
  • Curved, transverse incisions?
  • Laparoscopic
    •  inflammatory response
    •  pulmonary function
    •  length-of-stay?

Fearon KC, et al. Clin Nutr. 24: 466, 2005

Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002

maintain normothermia
Maintain Normothermia
  • Mild hypothermia
    •  wound infection
    •  blood loss
    •  cardiac events
  • Core temperature monitoring
  • Bair huggers
  • Warmed IV fluids

Fearon KC, et al. Clin Nutr. 24: 466, 2005

Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002

avoid fluid overload
Avoid Fluid Overload
  • Fluid overload →
    •  ileus
    • “major and minor morbidity”
    •  length of stay

Soop M, et al. Curr Opin Crit Care. 12: 166, 2006

Wind J, et al. Br J Surg. 93: 800, 2006

pharmacologic intervention
Pharmacologic Intervention
  • Glucocorticoid
    •  inflammation
    •  nausea, vomiting
    •  pain
  • Beta-blockers
    •  cardiac morbidity
  • Anabolic agents
    • Studies inconclusive

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

fast track surgery20

Fast-Track Surgery

What should we do post-operatively?

avoid drains
Avoid Drains
  • JP drains
    • Do not use routinely (except post-mastectomy)
  • NG tubes
    • Do not use routinely
  • Foleys
    • Do not use routinely
    • D/C after 24h (even with epidural in place)

Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002

early activity
Early Activity
  •  muscle loss
  •  thromboembolism
  •  pulmonary function
  •  tissue oxygenation

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

early activity23
Early Activity
  • Environment should encourage independence
  • Out of bed x 2h on day of surgery
  • Out of bed x 6h every day after

Soop M, et al. Curr Opin Crit Care. 12: 166, 2006

early feeding
Early Feeding
  •  infection,  gut permeability
  •  hospital stay
  •  catabolism
  • No  dehiscence

Soop M, et al. Curr Opin Crit Care. 12: 166, 2006

Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002

early feeding25
Early Feeding
  • Start clear fluids 2h post-op
  • Aim > 800mL fluids on day of surgery
  • DAT 4h post-op
  • Routine nutritional supplements
  •  IV appropriately, avoid fluid overload, aim D/C IV on POD#1

Soop M, et al. Curr Opin Crit Care. 12: 166, 2006

Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002

prevent nausea and vomiting
Prevent Nausea and Vomiting
  • Ondansetron, droperidol, dexamethasone
  • Anti-emetic polypharmacy?
  • Minimize narcotics
  • O2
  • Useless: metoclopramide

Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

prevent ileus
Prevent Ileus
  •  ileus with post-op epidural
  • Avoid
    • Narcotics
    • Fluid overload
  • Mg supplements
  • Control medically: novel peripherally acting opioid antagonist (alvimopan)
  • Continue feeding

Soop M, et al. Curr Opin Crit Care. 12: 166, 2006

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

routine laxatives pro kinetics
Routine Laxatives, Pro-kinetics
  • Suggested in a few studies

Wind J, et al. Br J Surg. 93: 800, 2006

optimize analgesia
Optimize Analgesia
  • Critical for
    • Mobilization
    • Oral intake
    •  stress response
  • Epidural x 2d
  • Multi-modal: NSAIDs, routine acetaminophen
  • APS

Soop M, et al. Curr Opin Crit Care. 12: 166, 2006

Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

routine oxygen
Routine Oxygen
  •  sats ←
    • Anaesthetic effects
    • Supine position → pulmonary function
    • Sleep disturbances
  • Routine O2 administration →
    •  nausea, vomiting
    •  infection
    •  HR
    • confusion

Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002

continue medications
Continue Medications
  • Continue with patient’s home meds

Kehlet H, Wilmore DW. Am J Surg. 183: 630, 2002

nursing
Nursing
  • Nurses good resource for psychological support
    • Early oral intake
    • Early mobilization
    • Self-care
  • Care maps with daily goals are useful

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

discharge planning
Discharge Planning
  • Usual criteria
    • Adequate pain control with oral analgesia
    • Taking solid foods
    • No IV fluids
    • Independently mobile
    • Patient willing to go home

Soop M, et al. Curr Opin Crit Care. 12: 166, 2006

discharge planning34
Discharge Planning
  • Goals
    •  readmissions
    •  patient safety
    •  patient satisfaction
  • Outline for patient
    • Expected recovery time course
    • Recommendations
    • Encourage oral nutrition, mobilization

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

follow up
Follow Up
  • Structured follow-up plan
    • Phone call: 1-2d
    • Out-patient clinic: 7-10d
    • Phone call: 30d
  • Pathways for prompt readmission when necessary
    • Symptom relief
    • Overnight stay

Soop M, et al. Curr Opin Crit Care. 12: 166, 2006

fast track surgery36

Fast-Track Surgery

What are the outcomes?

interventions outcomes
Interventions, Outcomes

Wind J, et al. Br J Surg. 93: 800, 2006

primary hospital stay
Primary Hospital Stay

Wind J, et al. Br J Surg. 93: 800, 2006

readmission
Readmission

Wind J, et al. Br J Surg. 93: 800, 2006

morbidity
Morbidity

Wind J, et al. Br J Surg. 93: 800, 2006

gut function
Gut Function
  • Fast-track →
    •  NGT
    • Faster BM
    • Earlier DAT

Wind J, et al. Br J Surg. 93: 800, 2006

fast track surgery43

Fast-Track Surgery

What is the punchline?

what is most important
What is Most Important?
  • Education, education, education
    • Patient: pre- and post-op
    • Care team
  • Collaboration, collaboration, collaboration
    • Surgeons
    • Anaesthetists, APS team: intra- and post-op
    • Nurses
    • Physiotherapists
discussion47
Discussion
  • Article lacking specific definitions
    • “Early” oral intake, mobilization
  • Hard to do randomized trials in ethical manner
  • Critical pathways
    • Part of fast-track surgery
    • Good 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

discussion48
Discussion
  • Cost / burden of care - transfer from surgical team to:
    • Emergency department
    • Family physicians
    • Home care, rehab, etc.
    • Family?

Early recovery of organ function

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

discussion49
Discussion
  • Do we really need formality of “fast-track surgery”, or are we doing it already?
  • Need evidence
  • Should we adopt
    • Routine 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

general results
General Results
  •  hospital stay
  • No  morbidity
  • No  readmission
  • No  safety
  •  patient satisfaction
  •  cost

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

specific studies
Specific Studies
  • Earlier ambulation
  •  muscle function
  •  oral intake
  •  loss of lean mass
  •  pulmonary function
  • Earlier GI motility
  •  exercise capacity, cardiovascular function

Kehlet H, Sawyer F. Fast Track Surgery, ACS Surgery: Principles & Practice

slide54
Retrospective

Colonic resection

Stomas excluded

LAR excluded

Acute surgeries excluded

Two hospitals

Conventional 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.

slide55

Basse et al. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum. 47: 271-278, 2004.

slide56

Basse et al. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum. 47: 271-278, 2004.

slide57

Basse et al. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum. 47: 271-278, 2004.

slide58

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.

slide59

Basse et al. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum. 47: 271-278, 2004.