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What is Fast-Track And Why Bother?. Ian Smith , MD, FRCA Editor , Journal of One-day Surgery Senior Lecturer in Anaesthesia University Hospital of North Staffordshire Stoke-on-Trent. Operating room. Recovery room. Ward area. Overnight stay. HOME. Traditional approach. Operating

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what is fast track and why bother

What is Fast-TrackAnd Why Bother?

Ian Smith, MD, FRCA

Editor, Journal of One-day Surgery

Senior Lecturer in Anaesthesia

University Hospital of North Staffordshire

Stoke-on-Trent

fast track recovery

Operating

room

Recovery

room

Ward

area

Overnight

stay

HOME

Traditional approach

Operating

room

Recovery

room

Ward

area

HOME

Day case surgery

Operating

room

Ward

area

HOME

Fast track approach

Fast Track Recovery
3 stages of recovery
3 Stages of Recovery
  • Early
    • awakening & return of protective reflexes
  • Intermediate
    • recovery to point of discharge
    • still needs support
  • Late
    • recovery to preoperative state
rationale for fast tracking
Rationale for Fast Tracking
  • Early recovery occurs in operating room
  • Patient may meet discharge criteria on arrival
  • Use of recovery room:
    • increases bureaucracy
    • increases cost
    • delays other patients
    • delays discharge
fast track faster discharge
Fast Track = Faster Discharge

*

*

Total recovery time

(min)

*

Song, et al. —Br J Anaesth 93: 768, 2004

* p <0.05, from recovery room group

assessing fast track eligibility
Assessing “Fast-track Eligibility”
  • Clinical
    • awake
    • fully oriented
    • comfortable
    • stable cvs signs
    • stable resp signs
recovery scores
Recovery Scores

Score

Activity:

Respiration:

Circulation:

Consciousness:

Oxygenation:

Moves all 4 limbsMoves 2 limbsNo limb movement

Can deep breathe & coughDyspnoea / limited breathingApnoea

BP ± 20% baselineBP ± 40% baselineBP ± 50% baseline

Fully awakeArousableUnresponsive

SpO2 >92% on airSpO2 >90% onO2SpO2 <90% on O2

210

210

210

210

210

Maximum score 10;need >9

Aldrete —J Clin Anesth 7: 89, 1995

fast track score
“Fast-track” Score
  • Similar to Aldrete +
    • Pain:
      • none or mild discomfort 2
      • controlled moderate–severe pain 1
      • persistent moderate–severe pain 0
    • PONV
      • minimal nausea no vomiting 2
      • controlled transient retching 1
      • persistent PONV 0
  • Maximum 14
    • >12 (no score <1): fast-track eligible
      • White — J Clin Anesth 11: 78, 1998
who can we fast track
Who Can We Fast Track?
  • 13.9 – 42.1% of all ambulatory GA patients met discharge criteria in OR
    • Apfelbaum, et al. — Anesthesiology 87: A32, 1997
  • 75% receiving sevoflurane and90% receiving desflurane for tubal ligation were fast track eligible(only 26% with propofol)
    • Song, et al. — Anesth Analg 86: 267, 1998
success of fast tracking
Success of Fast-tracking
  • 207 patients in RCT
    • 110 fast-track; 97 conventional
  • 81% successfully bypassed PACU
    • arthroscopy 97%
    • hysteroscopy 77%
    • laparoscopy 72%
      • Song, et al. —Br J Anaesth 93: 768, 2004
a question worth asking
A Question Worth Asking?

“Is your journey to the recovery room really necessary?”

Jean Millar — Editorial,Br J Anaesth 93: 756, 2004

do we need the recovery room
Do We Need The Recovery Room?
  • Manage unconscious patient
  • Extubation & airway support
  • Manage complications
  • Administer O2
  • Treat early pain
  • Treat early PONV
the unconscious patient

Propofol-isoflurane

Propofol-desflurane

5.1 ± 2.3

4.4 ± 1.4

6.5 ± 2.5

5.4 ± 1.3

18 ± 10

Ashworth & Smith —Anesth Analg 87: 312, 1998

Propofol-sevoflurane

Sevoflurane (VIMA)

4.6 ± 1.8

3.6 ± 1.8

5.9 ± 1.5

4.4 ± 1.8

22 ± 7

Smith & Johnson —Anesthesiology 89: A39, 1998

Mean ± SD

The Unconscious Patient

Eye opening

(min)

Oriented

(min)

Duration

(min)

Anaesthetic

early awakening
Early Awakening
  • Wound dressing & transfer takes »5 min.
  • Discontinue (/ reduce) anaesthetic towards end
  • Titrate anaesthetic:

“AS DEEP ASNECESSARY,

AS LIGHTAS POSSIBLE”

  • clinical response
  • end-tidal
  • (BIS)
bispectral index
Bispectral Index
  • Processed EEG, index 0–100
    • high awake; low deep
  • Claimed no recall £60
  • May permit dose reduction
  • May improve recovery times
    • Song, et al. — Anesthesiology 87: 842, 1997
  • May predict “fast-track eligibility”
    • Song, et al. — Anesth Analg 87: 1245, 1998
bis fast track recovery

propofol

desflurane

BIS & Fast-Track Recovery

Time tofast-trackeligible(min)

BIS at end of anaesthesia

Song, et al. —Anesth Analg 87: 1245, 1998

bis may not be necessary
BIS May Not be Necessary
  • 99 patients gynae laparoscopy
  • Sevoflurane induction & maintenance
  • BIS 50–60 or BP/HR ± 20%
  • Bypass PACU if Aldrete >9 within 10 min

Clinical group:

90% “Fast-tracked”

BIS titrated:

86% “Fast-tracked”

Ahmad, et al. —Anesthesiology 98: 849, 2003

do we need the recovery room1
Do We Need The Recovery Room?
  • Manage unconscious patientPatients are awake!
  • Extubation & airway support
  • Manage complications
  • Administer O2
  • Treat early pain
  • Treat early PONV
extubation airway support
LMA commonly used

Well tolerated

Complications rare

Removed when awake:

by patient

Extubation & Airway Support

LMA out (min) 3.8 ± 1.8

Eyes open (min) 4.5 ± 1.7

  • Data from 171 pts in ongoing research project
do we need the recovery room2
Do We Need The Recovery Room?
  • Manage unconscious patient
  • Extubation & airway supportLMA!
  • Manage complications
  • Administer O2
  • Treat early pain
  • Treat early PONV
complications in recovery
Complications in Recovery
  • 6,914 Day case GA in 4 Canadian hospitals
  • PONV 7.3%
  • Hypotension 0.23%
  • Hypertension 0.1%
  • Respiratory 0.43%

Duncan, et al. — Can J Anaesth 39: 440, 1992

complications in recovery1
Complications in Recovery
  • 17,638 Day cases at Toronto Western
  • “PACU Incidents” 7.3%
  • Pain 4.7%
  • PONV 2.2%
  • All CVS 0.8%
  • All respiratory 0.6%

Chung, et al. — Br J Anaesth 83: 262, 1999

complications in recovery2
Complications in Recovery
  • CVS events predictable by:
    • CVS disease
    • smoking
    • obesity
  • Respiratory events predictable by:
    • obesity
    • smoking
    • respiratory disease

Chung, et al. — Br J Anaesth 83: 262, 1999

do we need the recovery room3
Do We Need The Recovery Room?
  • Manage unconscious patient
  • Extubation & airway support
  • Manage complicationsComplications are rare
  • Administer O2
  • Treat early pain
  • Treat early PONV
oxygen therapy
Oxygen Therapy

Admission

SpO2

SpO2

<90%

  • 10 / 11 pts with SpO2 <90% had admission value £92%
  • 8 / 282 remaining pts had admission SpO2£92%

Regimen

Number

Nasal O2

Humidified O2

Deep breaths

Nothing

69

72

69

72

96.8 ± 2.3

96.7 ± 2.1

97.1 ± 1.6

97.4 ± 1.4

2 (3%)

2 (3%)

4 (6%)

3 (4%)

Gift, et al. — Anesth Analg 80: 368, 1995

what s the harm of o 2
What’s the Harm of O2?
  • Delay recovery
  • Uncomfortable for patient
  • Fire risk
  • Expense of disposables
  • Waste
do we need the recovery room4
Do We Need The Recovery Room?
  • Manage unconscious patient
  • Extubation & airway support
  • Manage complications
  • Administer O2 Only if SpO2£92%
  • Treat early pain
  • Treat early PONV
optimal pain relief
Optimal Pain Relief
  • NSAID
  • Local anaesthesia
    • infiltration
    • topical
    • block
  • Intraoperative opioids
    • only if needed
pain on awakening
Pain on Awakening
  • Should be minimal with appropriate measures:
  • Severe 1%
  • Mild 15%
  • None 84%
    • Data from 171 pts in ongoing research project
do we need the recovery room5
Do We Need The Recovery Room?
  • Manage unconscious patient
  • Extubation & airway support
  • Manage complications
  • Administer O2
  • Treat early painWhat pain?
  • Treat early PONV
slide33

And

Vomiting

Postoperative

Nausea

risk factors for ponv
Risk Factors For PONV

History of Motion Sickness / PONV

Female

Opioid Therapy

Non-smoker

treatment prevention of ponv
Treatment & Prevention of PONV
  • Consider hydration, analgesia
  • Prophylaxis if high risk
    • dexamethasone 4–5 mg
  • Combination therapy
    • for highest risk
    • different classes
  • AVOID OPIOIDS
nausea on awakening
Nausea on Awakening
  • Should be minimal with appropriate measures:
  • Moderate 2%
  • Mild 2%
  • None 96%
    • Data from 171 pts in ongoing research project
the case for fast tracking
The Case for Fast-tracking
  • Modern anaesthetics allow rapid recovery
    • if carefully titrated
  • Early complications are rare (& predictable)
  • Pain & PONV may be minimised
    • treatment may still be given in ward
  • Recovery room admission may be unnecessary
is there risk
Is There Risk?

“Importantly, this accelerated recovery process was not associated with any increased postoperative side effects or patient discomfort”

Song, et al. —Br J Anaesth 93: 768, 2004

are there benefits
Are There Benefits?
  • No reduced nursing workload
  • No reduced interventions
    • less time measuring vital signs
  • No cost savings
      • Song, et al. —Br J Anaesth 93: 768, 2004
slide40
But...
  • Savings unlikely unless staff reduced
  • Recovery and staff still needed
    • for fast-track failures
benefits may occur
Benefits May Occur...
  • In integrated units with
    • phase I & II recovery close together
    • flexible working
  • In predictable groups with rapid turnover
  • By reducing congestion and theatre delays
patient benefits
Patient Benefits
  • Patients feel good
    • clear-headed recovery
    • no oxygen masks
    • no pain
    • no sickness
  • Earlier return to home