Basics of fast track surgery- a great read!


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Basics of fast track surgery- a great read!

  1. 1. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 10 Fast Track Surgery — 1 ELEMENTS OF CONTEMPORARY PRACTICE 10 FAST TRACK SURGERY Henrik Kehlet, M.D., Ph.D., F.A.C.S. (Hon.), and Douglas W .Wilmore, M.D., F.A.C.S. Over the past several decades, surgery has undergone revolutionary changes that are leading to improved treatments (involving lower risk and better outcome) for an increasing number of diseases. These salutary developments are the result of more advanced anesthetic techniques, new methods of reducing the perioperative stress response, wider application of minimally invasive techniques, improved understanding of perioperative pathophysiology, and more sophisticated approaches to the prevention of postoperative organ dysfunction. Currently, many operations that once necessitated hospitalization can readily be performed in the outpatient setting; in addition, many major procedures are now associated with a significantly reduced duration of hospitalization and a shorter convalescence. Although these anesthetic and surgical developments are the result of basic scientific and clinical research, they have also been influenced by governmental and managed care policies aimed at encouraging more cost-effective treatments. Such extraclinical influences, coupled with new clinical developments, have resulted in novel approaches designed to enhance the cost-effectiveness of health care, such as so-called fast track surgery, critical pathways, and various types of clinical guidelines. To understand the true potential value of such approaches, it is essential to recognize that their aim is not merely to ensure that fewer health care dollars are spent but, more important, to ensure that better and more efficient health care is delivered. Although these novel approaches may reduce cost, their primary purpose is to improve surgical management by reducing complications and providing better outcomes. In what follows, we outline the basic concept, primary components, and current results of fast track surgery, which is a comprehensive approach to the elective surgical patient that is designed to accelerate recovery, reduce morbidity, and shorten convalescence. Basic Concept Fast track surgery involves a coordinated effort to combine (1) preoperative patient education; (2) newer anesthetic, analgesic, and surgical techniques whose aim is to reduce surgical stress responses, pain, and discomfort; and (3) aggressive postoperative rehabilitation, including early enteral nutrition and ambulation. It also includes an up-to-date approach to general principles of postoperative care (e.g., use of tubes, drains, and catheters; monitoring; and general rehabilitation) that takes into account the revisions to traditional practice mandated by current scientific findings. It is believed that by these means, fast track surgery can shorten the time required for full recovery, reduce the need for hospitalization and convalescence, and lower the incidence of generalized morbidity related to pulmonary, cardiac, thromboembolic, and infectious complications.1-3 For an accelerated recovery program of this type to succeed, proper organization is essential. In general terms, fast track surgery must be based on a process of multidisciplinary collaboration that embraces not only the surgeon, the anesthesiologist, the physiotherapist, and the surgical nurse but also the patient. More specifically, fast track surgery depends on the inclusion and integration of a number of key constituent elements (see below). Constituent Elements EDUCATION OF THE PATIENT To obtain the full advantages of a fast track surgical program, it is essential to provide patients with information about their perioperative care in advance of the procedure. Such educational efforts often serve to reduce patients’ level of anxiety and need for pain relief, thereby providing a rational basis for collaboration with health care personnel, a process that is crucial for enhancing postoperative rehabilitation.1-3 Patients can supplement the information they receive directly from health care providers by accessing reference sources such as aboutbroch.html, a collection of electronic brochures on specific clinical procedures that is provided by the American College of Surgeons. OPTIMIZATION OF ANESTHESIA The introduction of rapid-onset, short-acting volatile anesthetics (e.g., desflurane and sevoflurane), opioids (e.g., remifentanil), and muscle relaxants has enabled earlier recovery from anesthesia and thereby facilitated ambulatory and fast track surgery.4 Although use of these newer general anesthetic agents has resulted in quicker recovery of vital organ function after minor surgical procedures, it has not been shown to decrease stress responses or mitigate organ dysfunction after major procedures. Regional anesthetic techniques (e.g., peripheral nerve blocks and spinal or epidural analgesia), on the other hand, have several advantages in addition to providing anesthesia. Such advantages include improved pulmonary function, decreased cardiovascular demands, reduced ileus, and more effective pain relief. Neural blockade is the most effective technique for providing postoperative pain relief, and it has been shown to reduce endocrine and metabolic responses to surgery [see 1:6 Postoperative Pain]. For a pronounced reduction in perioperative stress after a major operation, continuous epidural analgesia for 24 to 72 hours is necessary.5,6 A meta-analysis of randomized trials evaluating regional anesthesia (primarily involving patients undergoing operations on the lower body) found that morbidity was 30% lower with regional anesthesia than with general anesthesia.7 However, the effect of continuous epidural analgesia on outcome after major abdominal or thoracic procedures has been questioned in the past several years. In three large randomized trials,8-10 no beneficial effect on overall morbidity could be demonstrated, except for a slight improvement in pulmonary outcome, and the duration of hospi-
  2. 2. © 2004 WebMD Inc. All rights reserved. ELEMENTS OF CONTEMPORARY PRACTICE talization was not reduced. It should be remembered, however, that in these studies, either an epidural opioid regimen or a predominantly epidural opioid regimen was employed and that the perioperative care regimens either were not described or were not revised according to current scientific data regarding the use of nasogastric tubes, early oral feeding, mobilization, and other care parameters.3 We believe, therefore, that for further assessment of the role of continuous epidural local analgesic regimens that include local anesthetics in improving outcome, an integrated approach within the context of fast track surgery is required.6 Perioperative measures should also be taken to preserve intraoperative normothermia. Hypothermia may lead to an augmented stress response during rewarming, impaired coagulation and leukocyte function, and increased cardiovascular demands. Preservation of intraoperative and early postoperative normothermia has been shown to decrease surgical site infection, intraoperative blood loss, postoperative cardiac morbidity, and overall catabolism.11 REDUCTION OF SURGICAL STRESS The neuroendocrine and inflammatory stress responses to surgery increase demands on various organs, and this increased demand is thought to contribute to the development of postoperative organ system complications. At present, the most important of the techniques used to reduce the surgical stress response are regional anesthesia, minimally invasive surgery, and pharmacologic intervention (e.g., with steroids, beta blockers, or anabolic agents).12 Neural blockade with local anesthetics reduces endocrine and metabolic (specifically, catabolic) activation and sympathetic stimulation, thereby decreasing the demands placed on organs and reducing loss of muscle tissue; however, regional anesthetic techniques have no relevant effect on inflammatory responses.5,6 Minimally invasive surgical techniques clearly decrease pain and lessen inflammatory responses,13-15 but they appear to have relatively little, if any, effect on endocrine and metabolic responses. Pharmacologic intervention with a single dose of a glucocorticoid (usually dexamethasone, 8 mg) given before a minor procedure has led to reduced nausea, vomiting, and pain, as well as to decreased inflammatory responses (interleukin-6), with no observed side effects.16,17 This intervention may facilitate recovery from minor (i.e., ambulatory) procedures18; however, the data from major procedures are inconclusive.The use of perioperative beta blockade to reduce sympathetic stimulation and thereby attenuate cardiovascular demands has been shown to reduce cardiac morbidity,19 as well as to reduce catabolism in burn patients [see Elements of Contemporary Practice:6 Risk Stratification, Preoperative Testing, and Operative Planning].20,21 Perioperative beta blockade may therefore become an important component of efforts to facilitate recovery in fast track surgical programs. For patients whose nutritional status is normal, oral feeding ad libitum is appropriate in the postoperative period. For patients who are elderly or nutritionally depleted, nutritional supplementation, administration of an anabolic agent (e.g., oxandrolone or another anabolic steroid,22-24 insulin,25 or growth hormone [GH]26,27) to enhance deposition of lean tissue, or both may be beneficial. Most of the studies addressing the use of anabolic agents have focused on critically ill catabolic patients, in whom both indirect effects (e.g., improved nitrogen balance26) and direct effects (e.g., improved wound healing and decreased length of stay with GH in burned children27 and decreased mortality with insulin in critically ill patients25) on outcome have been demonstrated. In a study published in 2000, a group of elderly patients undergoing opera- ACS Surgery: Principles and Practice 10 Fast Track Surgery — 2 tions for hip fracture received either low-dose GH (20 mg/kg/day) or placebo.28 Overall, those in the GH group were able to return to their prefracture living situation earlier than those in the placebo group. A 1999 study reported increased mortality when GH was administered to ICU patients,29 but a 2001 meta-analysis failed to confirm this observation.30 More work is necessary before definitive conclusions can be formed in this regard. Postoperative insulin resistance is an important metabolic factor for catabolism. There is evidence to suggest that preoperative oral or intravenous carbohydrate feeding may reduce postoperative insulin resistance.31 Whether this approach yields clinical benefits in terms of improved recovery remains to be determined,31,32 but its simplicity, its clear pathophysiologic rationale, and its low cost make it a potentially attractive option. CONTROL OF NAUSEA, VOMITING, AND ILEUS The ability to resume a normal diet after a surgical procedure (whether minor or major) is essential to the success of fast track surgery. To this end, postoperative nausea, vomiting, and ileus must be controlled. Principles for rational prophylaxis of nausea and vomiting have been developed on the basis of systematic reviews33: for example, 5-HT3 receptor antagonists, droperidol, and dexamethasone have been shown to be effective in this regard, whereas metoclopramide is ineffective.There is some reason to think that multimodal antiemetic combinations may be superior to single antiemetic agents; unfortunately, the data currently available on combination regimens are relatively sparse. In addition, analgesic regimens in which opioids are cut back or eliminated have been shown to decrease postoperative nausea and vomiting. Paralytic ileus remains a significant cause of delayed recovery from surgery and contributes substantially to postoperative discomfort and pain. Of the various techniques available for managing ileus,34,35 continuous epidural analgesia with local anesthetics is the most effective, besides providing excellent pain relief. Now that cisapride has been taken off the market, no effective antiileus drugs are available. In a 2001 study, however, a peripherally acting mu opioid receptor antagonist significantly reduced nausea, vomiting, and ileus after abdominal procedures, without reducing analgesia.36 If further studies confirm these findings, use of peripherally acting opioid antagonists may become a popular and effective way of improving postoperative recovery; this treatment is simple and apparently has no major side effects. ADEQUATE TREATMENT OF POSTOPERATIVE PAIN Despite ongoing development and documentation of effective postoperative analgesic regimens—such as continuous epidural analgesia in major operations, patient-controlled analgesia (PCA), and multimodal (balanced) analgesia that includes nonsteroidal anti-inflammatory drugs as well as stronger agents37-39 [see 1:6 Postoperative Pain]—postoperative pain still is too often inadequately treated. Improved pain relief, facilitated by an acute pain service,40 is a central component of any fast track surgery program and is a prerequisite for optimal mobilization and oral nutrition, as well as a valuable aid in reducing surgical stress responses.37 APPROPRIATE USE OF TUBES, DRAINS, AND CATHETERS There is substantial support in the literature for the idea that nasogastric tubes should not be used routinely in patients undergoing elective abdominal surgery.1,2 Randomized trials indicated that drains offered little benefit after cholecystectomy, joint replacements, colon resection, thyroidectomy, radical hysterectomy, or
  3. 3. © 2004 WebMD Inc. All rights reserved. ELEMENTS OF CONTEMPORARY PRACTICE pancreatic resection1,3,41 but that they might limit seroma formation after mastectomy.1,3 Such postmastectomy drainage does not necessarily impede hospital discharge, and the patient generally may be treated on an outpatient basis. Urinary catheterization has been routinely performed after many operations, but scientific documentation of the requirement for this measure is often lacking. In general, catheterization beyond 24 hours is not recommended with colorectal procedures, except with the lowest rectal procedures, for which 3 to 4 days of catheterization may be indicated.3 Although tubes, drains, and catheters may lead to morbidity only when used for extended periods, they do tend to hinder mobilization, and they can raise a psychological barrier to the patient’s active participation in postoperative rehabilitation. Therefore, such devices should be used not routinely but selectively, in accordance with the available scientific documentation. NURSING CARE, NUTRITION, AND MOBILIZATION Postoperative nursing care should include psychological support for early rehabilitation, with a particular focus on encouraging the patient to resume a normal diet and become ambulatory as soon as possible. Early resumption of an oral diet is essential for self-care; furthermore, according to a 2001 meta-analysis of controlled trials, it may reduce infectious complications and shorten hospital stay after abdominal procedures, without increasing the risk of anastomotic dehiscence.42 In addition, early resumption of enteral feeding may reduce catabolism and may be facilitated by the methods used to reduce postoperative nausea, vomiting, and ileus (see above). Postoperative bed rest is undesirable because it increases muscle loss, decreases strength, impairs pulmonary function and tissue oxygenation, and predisposes to venous stasis and thromboembolism.3 Accordingly, every effort should be made to enforce postoperative mobilization; adequate pain relief is a key adjuvant measure in this regard. Organization is essential for good postoperative nursing care: a prescheduled care map should be drawn up, with goals for rehabilitation listed for each day. DISCHARGE PLANNING Given that a primary result of fast track surgery is reduced length of hospitalization, discharge planning must be a major consideration in the preoperative patient information program, as well as during hospitalization. Careful, detailed discharge planning is essential for reducing readmissions and increasing patient safety and satisfaction. The discharge plan should include (1) detailed information on the expected time course of recovery, (2) recommendations for convalescence, and (3) encouragement of enteral intake and mobilization. For patients with a significant degree of postoperative disability, various acute care facilities are available after hospital discharge. It should be kept in mind, however, that the integrated care approach fundamental to fast track surgery is specifically intended as a way of limiting or preventing such disability, thereby reducing patients’ need for and dependence on postdischarge care facilities. Reported Results Ongoing efforts to formulate multimodal strategies aimed at improving postoperative outcome have led to the development of a variety of fast track surgical programs [see Table 1]. Most of the studies published to date have been descriptive ones reporting consecutive patient series from single centers, the findings from which have often been confirmed by other groups using the same ACS Surgery: Principles and Practice 10 Fast Track Surgery — 3 or a slightly modified fast track care program. On the whole, the preliminary results from these studies are very positive: fast track surgery is associated with shorter hospital stays, reduced or at least comparable morbidities, and low readmission rates, with no apparent decrease in safety. Studies of fast track surgery in which organ function was assessed postoperatively and compared with organ function after traditional care found fast track surgery to be associated with earlier ambulation,43,44 superior postoperative muscle function,44 improved oral nutritional intake,45 better preservation of lean body mass,43,45 reduced postoperative impairment of pulmonary function,43 earlier recovery of GI motility,46 and mitigation of the decrease in exercise capacity and impairment of cardiovascular response to exercise that are usually expected after an operation.43 The few randomized trials performed to date (mostly involving patients undergoing cholecystectomy, colonic resection, or mastectomy) reported that fast track programs increased or at least maintained patient satisfaction while achieving major cost reductions. Future Developments The initial promising results from the fast track surgical programs studied suggest that such programs can achieve major care improvements in terms of reducing postoperative stay. At present, however, sufficient scientific documentation is lacking for many commonly performed major operations. Thus, there is a need for additional data—in particular, data on the potential positive effects of fast track surgery on postoperative morbidity. The necessary data would probably be best obtained through multicenter trials using identical protocols. Randomized trials within the same unit that allocate some patients to suboptimal care recommendations for pain relief, mobilization, and nutrition would be difficult to perform, if not unethical, though a few such reports have been published on colon surgery patients.44,47 As yet, it has not been conclusively demonstrated that reducing the duration of hospitalization necessarily reduces morbidity,48 though data from studies addressing colonic and vascular procedures suggest that nonsurgical (i.e., cardiopulmonary and thromboembolic) morbidity may be reduced and overall postoperative recovery (assessed in terms of exercise performance and muscle power) enhanced. More study is required in this area. Future trials should also focus on identifying any factors that might be limiting even more aggressive early recovery efforts, so that more effective fast track programs can be designed. Finally, studies are needed to identify potential high-risk patient groups for whom fast track surgery may not be appropriate or who may need to be hospitalized for slightly longer periods to optimize organ function.47 There has been considerable interest in whether the use of critical pathways improves postoperative care. Preliminary studies involving coronary artery bypass grafting, total knee replacement, colectomy, thoracic procedures, and hysterectomy suggested that critical pathways may reduce length of hospital stay, but the reduction is no greater than can be observed in neighboring hospitals that do not use critical pathways.49 Thus, the initial enthusiasm for critical pathways notwithstanding, conclusive evidence that they have a beneficial effect on postoperative care is still lacking.The continuously decreasing length of stay noted in hospitals without fast track programs may be partly attributable to the intense competition within the health care system, which can lead to changes in care principles even without the formal adoption of critical pathways or similar systems.49 All of the studies on the economic implications of fast track surgical programs and critical pathways have documented substantial
  4. 4. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 10 Fast Track Surgery — 4 ELEMENTS OF CONTEMPORARY PRACTICE Table 1 Type of Operation Results from Selected Fast Track Surgical Programs Postoperative Hospital Stay Comments and Other Findings Abdominal procedures Inguinal hernia repair59-61 1.5–6 hr Large consecutive series using local infiltration anesthesia in > 95%, with one series59 using unmonitored anesthesia; documented low morbidity, with no urinary retention; patient satisfaction ~90%, cost reduction > $250 with local anesthesia Cholecystectomy (laparoscopic,62-67 mini-incision68) > 80% discharge on same day Large consecutive series, with documented safety and patient satisfaction > 80%; cost reduction of $750/patient in randomized study64; recovery of organ functions within 2–3 days, with <1 wk convalescence67; similar results with mini-incision in consecutive series68 Fundoplication69,70 > 90% < 23 hr Large consecutive series with documented safety70 Open43,44,46,47,56,71-76 and laparoscopic72,77-79 colorectal procedures 2–4 days Consecutive series including high-risk patients; reduced cardiopulmonary morbidity, readmission rates 0%–15%; no documented advantages of laparoscopy-assisted colonic resection, though costs may be reduced72; ileus reduced to < 48 hr in > 90% of patients,46,56 with improved muscle and pulmonary function in fast track patients and better preservation of postoperative body composition43; one randomized study showed similar morbidity, readmissions, and satisfaction with fast track versus traditional care47 Complex pelvic-colorectal procedures80,81 3–6 days Short stay80 (~4–6 days) even with additional stoma; low readmission rate (7%) Rectal prolapse82 80% < 24 hr Consecutive series (N = 63) with Altemeier repair; 5% readmission rate (nonserious indications) Pancreaticoduodenectomy,83,84 complex biliary tract procedures85 — Hospital stay decreased by implementation of clinical pathway 90% < 1 day Large cumulative series; documented safety and major cost reduction with high patient satisfaction; no increased morbidity with fast track, but less wound pain and improved arm movement and no increase in risk of psychosocial complications Carotid endarterectomy91-94 90% < 1 day Surgery done with local anesthesia; specialized nurses and wards Lower-extremity arterial bypass95 2–3 days Large series (N = 130); documented safety Abdominal aortic aneurysmectomy96,97 ~3 days Preliminary studies (N = 5096 and N = 7797); documented early recovery and safety; one study with epidural analgesia,97 one without96 Radical prostatectomy98 ~75% 1 day Large consecutive series (N = 252); documented safety and patient satisfaction Laparoscopic adrenalectomy99-101 < 1 day Small series; safety and low morbidity suggested Cystectomy102,103 7 days Improved mobilization, bowel function, and sleep recovery with fast track surgery102; low mortality; ileus a problem102,103 Laparoscopic donor nephrectomy104 < 1 day Preliminary study (N = 41); low readmission rate (2%) Open donor nephrectomy105 2 days — ~1 day in some series,106,107 ~4–5 days in others Shortest stay with fast track protocol including revision of drainage principles106,107; safety with very early discharge suggested Craniotomy111 ~40% < 24 hr Large consecutive series (N = 241) including tumor surgery; local anesthesia used; low readmission rate; safety suggested Parathyroid procedures112 ~90% ambulatory Selected consecutive series (N = 100); regional anesthesia and intraoperative adenoma localization employed; documented safety Vaginal procedures113 ~1 day Consecutive series (N = 108); surgery done with local anesthesia Mastectomy86-90 Vascular procedures Urologic procedures Pulmonary procedures106-110 Other procedures cost savings. It should, however, be borne in mind that the last portion of a hospital stay is much less expensive than the initial portion; thus, the cost savings in this area may turn out to be smaller than they would at first appear.50-52 This cavil should not hinder further development and documentation of fast track surgery, because inherent in the concept is the idea that revision and optimization of perioperative care may also reduce morbidity, thereby achieving additional cost savings. As noted, the large-scale data with detailed patient description and stratification that are needed to clarify the improvements achieved by fast track surgery are, unfortunately, lacking at present, but so far, all indications are that postoperative morbidity is comparable or reduced. A commonly expressed concern is that fast track surgery might increase the burden on general practitioners and other parts of the
  5. 5. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 10 Fast Track Surgery — 5 ELEMENTS OF CONTEMPORARY PRACTICE nonhospital care system. The evidence currently available clearly indicates that increased use of ambulatory surgery is safe and is associated with a very low readmission rate.53,54 After major procedures such as colorectal surgery, however, readmissions are often unpredictable, and the readmission rate is not significantly reduced by keeping patients in the hospital for an additional 2 to 3 days.55,56 Moreover, in some studies of patients who have undergone coronary bypass57 and hip replacement,58 earlier discharge and hospital cost savings have been offset by increased use of postacute rehabilitation services. Thus, any assessment of the costs associated with fast track surgery should include the total period during which care (including both hospital care and rehabilitation care) is delivered. Again, however, it should be emphasized that the basic concept of fast track surgery implies control of perioperative pathophysiology with the aim of enhancing recovery and thereby reducing the need for postdischarge care.The relatively few published studies that addressed patient functional status after fast track colonic surgery suggested that muscle function, exercise capacity, and body composition are better preserved with this approach than with traditional care, in which surgical stress, insufficient nutrition, and prolonged immobilization typically lead to significant deterioration of organ function. Accordingly, an optimal fast track surgery regimen should aim at early recovery of organ function, not just early discharge. In summary, the basic concept of fast track surgery, which could be expressed as multimodal control of perioperative pathophysiology, seems to be a highly promising approach to improving surgical outcome. 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