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Enhanced recovery - transferability into acute medicine

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Presentation from the Enhanced Recovery Summit 2012 by Professor Henrik Kehlet …

Presentation from the Enhanced Recovery Summit 2012 by Professor Henrik Kehlet
Enhanced recovery - future developments and transferability into acute medicine

Published in: Health & Medicine

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  • 1. enhanced recovery – future developments and transferability into acute medicine ?
  • 2. improvement of perioperative outcome? • every operation can be ambulatory ? • why is the patient in hospital today ? • what is it that we cannot control ?
  • 3. why is the patient in hospital today ? • organ dysfunction (”surgical stress”) • hypothermia-induced morbidity • pain • PONV / ileus • fluid excess/ hypovolaemia • cognitive dysfunction/sleep disturbances • immobilisation • semi-starvation • fatigue (early/late) • traditions (tubes,drains,restrictions,etc.) Kehlet & Dahl Kehlet & Wilmore Kehlet Lancet 2003; 363: 1921 Ann Surg 2008;248:189 Langenbecks Arch Surg 2011;396:585
  • 4. 1997; 78:606-617 Multimodal approach to control postoperative pathophysiology and rehabiliation H. Kehlet preop optimisation/ information attenuation of stress pain relief exercise oral nutrition enhanced recovery and reduced morbidity Kehlet Langenbecks Arch Surg 2011;396:585
  • 5. Clin Nutri 2010; 29: 434-440 fast-track vs traditional care - morbidity
  • 6. Surgery 2011;149:830-40. ”ERP’s can and should be routinely used in care after colorectal and other major gastrointestinal procedures”
  • 7. Br J Anaesth 2011;106:289-91. established risk indices, but • fast-track methodology not implemented • ”surgical” vs ”medical” morbidity ?
  • 8. enhanced surgical recovery becomes mandatory ! yes ! • process: - read the literature - know your data - multidisciplinary collaboration - monitoring - share the economic benefits Kehlet & Wilmore Colorectal Dis 2010;12:2-4
  • 9. the hip fracture patient a ”medical” patient with a hip fracture
  • 10. mortality analysis in hip fractures 47 perioperative deaths: 12 deaths (25%) unpreventable prefracture terminal disease – 10 refusing postoperative care - 2 21 deaths (45%) potentially preventable active care curtailed before death – 14 death due to pre-fracture acute illness - 7 14 deaths (30%) possibly preventable Foss Br J Anesth 2005
  • 11. enhanced recovery in hip fracture patients • early surgery (< 24 h) • multimodal non-opioid analgesia • oral nutrition • standardized fluid therapy • aggressive transfusion policy • oxygen therapy • immediate mobilisation and physiotherapy • early planning of discharge
  • 12. Anaesthesiologists Geriatricians Orthopaedic surgeons and nurses Physiotherapists Admission to surgery Surgery Specialist involvement in care proposed multidisciplinary hip fracture care Postoperative phase stable organ function Rehabilitation to discharge
  • 13. enhanced recovery programmes • elective surgery • acute surgery (hip fracture) • ”medical” patients
  • 14. JAMA 2011;306:1800-1801. • ”iatrogenic” complications due to • bed rest, inadequate nutritional support, overuse of monitors, urinary cathethers, iv lines, opioid-based analgesia, etc.
  • 15. JAMA 2011;306:1782-1793. • hospitalization-associated disability develops between the onset of the acute illness and discharge from the hospital • at least 30 % of patients > 70 years and hospitalized for a medical illness are discharged with an ADL disability they did not have before becoming acutely ill
  • 16. fast-track acute older medical patients ? secure sufficient assessment of comorbidities, all functional capabilities, nutritional status, pain, etc.  action on identified problem  post-discharge rehabilitation plan  follow-up, re-admissions etc.
  • 17. enhanced recovery in acute older medical patients ? conclusion: • ”medical” patients different from ”surgical” patients: • additional resources required (rehab interventions)
  • 18. enhanced recovery in acute older medical patients ? conclusion: • phase I: prospective hypothesis-generating studies • phase II: large, prospective data (subgroups) incl. economic assessment • phase III: RCT different interventions/subgroups
  • 19. conclusions: enhanced recovery programmes • elective surgery: do it • acute surgery: do it – and research • ”medical” patients: documentation/ research/ monitoring/ care organisation