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Simposium Madrid 051108

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    Simposium Madrid 051108 Simposium Madrid 051108 Presentation Transcript

    • Protocol and initial results of the Spanish Multicentric Group of Fast-Track Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • Fast Track protocol Enhanced recovery program Enhanced surgical treatment Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
      • Optimize the perioperative treatment of the patients with the aim to:
      reduce morbidity improve recovery after surgery reduce hospital stay reduce health costs Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • Preoperative Intraoperative Postoperative
      • What changes supposes the management of patients?
      • Information and consent.
      • Adequate nutrition
      • No bowel preparation
      • Beverage intake rich on Carbohydrates pre-op.
      • Avoid drains
      • Avoid NGT
      • Use of de laparoscopic techniques
      • Use of transverse Incisions
      • Epidural Analgesia (Open Surgery).
      • Avoid Hypothermia
      • Use high concentrations of Oxygen
      • Controlled Fluid therapy (“Goal-directed”). CardioQ
      • Early mobilization (same afternoon)
      • Energy intake (same afternoon)
      Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
      • What changes supposes the management of patients?
      Surgeon Anesthesiologist Nurse
      • Information and consent.
      • Adequate nutrition
      • No bowel preparation
      • Beverage intake rich on Carbohydrates pre-op.
      • Avoid drains
      • Avoid NGT
      • Use of de laparoscopic techniques
      • Use of transverse Incisions
      • Epidural Analgesia (Open Surgery).
      • Avoid Hypothermia
      • Use high concentrations of Oxygen
      • Controlled Fluid therapy (“Goal-directed”). CardioQ
      • Early mobilization (same afternoon)
      • Energy intake (same afternoon)
      Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Colorectal Dis. 2008 May 3 "Fast-track"-colonic surgery in Austria and Germany - results from the survey on patterns in current peri -operative practice. T Hasenberg , M Keese , F Längle , B Reibenwein , K Schindler , A Herold , G Beck , S Post , K W Jauch , C Spies , W Schwenk , E Shang Conclusions: Although there is an evident benefit of fast-track management, the survey shows that they are not yet widely used as a routine.
      • Spanish multicenter group of Fast-Track
      • Objectives:
      • What are our results for traditional surgery?
      • Where are the difficulties of implementing a program of Fast-Track?
      • Evidence of a multi-center group using the same protocol for the patients themselves.
      • Are the results extrapolated to any other centers?
      • Permanent audit of the multi-center group results.
      • To collaborate with other national or international centers.
      • To offer the best available information on fast-track to whom it may concern.
      Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
      • MULTI-CENTER STUDY FOR
      • THE INTRODUCTION OF A PROGRAM
      • ON ENHANCED REHABILITATION IN COLORECTAL SURGERY:
        • Inclusion Criteria:
          • Patients older than 18 years, scheduled for surgery intervention for right colon, left and / or rectum due to a malignant or benign cause.
        • Exclusion Criteria:
          • Emergency surgery.
          • ASA IV
          • Patients in need of colostomy or ileostomy.
          • Diabetic patients
          • Patients who have not signed informed consent.
      Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • MULTI-CENTER STUDY FOR THE INTRODUCTION OF A PROGRAM ON ENHANCED REHABILITATION IN COLORECTAL SURGERY: Ethical Aspects : Taking into account that each point of “Fast Track” is a form of treatment fully accepted and supported by the best available scientific evidence. It was not considered necessary by ethics committees and clinical trials to request the approval . However, patients are individually informed orally and in writing on the early rehabilitation program, expecting them to cooperate. Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • Protocol PRE-OPERATIVE - Verbal and written information about the early rehabilitation program and obtain signature for the informed consent. Evaluation of quality of life baseline : SF-36, EuroQoL. - Malnourished patients (>10% weight in < than three months), hyperproteine supplement twice daily, at least the whole week before surgery.
      • DAY -1:
      • Non preparation of the colon. Two Enemas Casen ® at 20.00 hr.
      • Normal intake in the morning. Throughout the afternoon, 4 Nutricia Preop ® bricks of 800 ml (100 mg of carbohydrates).
      • During the afternoon, fluid intake on demand.
      • A drink rich in carbohydrates at 20.00 hr.
      • Not to use pre-medication.
      • Antibiotic prophylaxis as usual.
      • Prophylaxis of pulmonary embolism as usual.
      Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • Protocol
        • DAY 0:
        • Two hours before surgery, intake of drink rich in carbohydrates (Nutricia Preop ®, 2 bricks, 400ml, 50g CHO).
        • Two hours before Casen ® Enema.
        • Not to use pre-medication.
        • Routine Vital Signs surveillance
      • IN THE OPERATING ROOM
        • Surgeons:
          • Not to use drains.
          • Avoid gastric nasal tube.
          • Attempt Laparoscopic intervention. Transverse incision in open surgery.
          • Infiltrate wounds with Bupivacaine 0,25 % (20 ml).
      Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • (*)Grocott MP, Mythen MG, Gan TJ. Anesth Analg. 2005;100:1093–1106. (*)Bundgaard-Nielsen M, Holte K, Secher NH, et al. Acta Anaesthesiol Scand. 2007;51:331–340. Protocol
            • Anesthesiologists:
            • Epidural analgesia. At T9-T10 Bupivacaine 0,25/0,50% with Sulfentanyl/Fentanyl.
          • Maintenance: Oxygen/air with FiO2>80%.
            • Do not use morphine
          • Analgesia with Paracetamol IV in the operating room, Diclofenac IV, unless contraindication or alteration of the renal function.
          • Anti-emetics: Ondansetron IV (Zofran) 4 mg. Do not use Dexamethason.(If necessary use Droperidol 0.625 mg or Haloperidol 1 mg).
          • Monitoring : Routine + esophageal Doppler . Central catheter / arterial catheter if necessary
          • * Goal directed fluid therapy:
          • Optimization according to ejection volume (Stroke Volume) with the esophageal Doppler probe (Reset volume bolus of coloid 250cc depending on the drop in the cardiac output measured by the esophageal Doppler).
      Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • You'll see, something will happen today day ... Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • Protocolo
      • Postoperative :
          • High flow oxygen mask for 2 hours. After nasal mask to keep saturation>95%.
          • In the afternoon mobilize the patient to arm chair (min. 2 hrs)
          • From 18.00 hr, liquid diet (800-1000cc) + 2 units rich in protein and calories.
          • Minimum diuresis (500cc first 24 hrs).
          • Analgesia with 1 gr Paracetamol / 6 hrs + Epidural catheter.
          • Gluco-saline maintenance.
      Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
      • DAY 1:
          • - Liquid diet (min. 2 liters) + 3 energy preps.
          • - Mobilization with armchair 6 hrs. day.
          • - Discontinue fluids IV if tolerated. IV access heparinized.
          • - Maintain epidural pump (if any).
          • - Paracetamol 1 gr / 6 hrs.
          • Lactulose 1 pack / 12 hrs.
          • Evaluate criteria for discharge.
    • Protocolo Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
          • DAY +2:
          • Suspend epidural catheter. Start with NSAIDs.
          • Soft / normal diet.
          • Mobilization on demand.
          • Remove bladder catheter.
          • Evaluate criteria for discharge.
          • DAY +3:
          • - Revision of the patient's general state.
          • - Evaluate criteria for discharge.
          • Evaluate criteria for discharge and take decision over it.
          • DAY +4 and the following: Similar to Day +3.
      • Discharge criteria
      Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
      • Only oral analgesia
      • Mobilization until preoperative level
      • Tolerates solid nutrition
      • Flatulation
      • Absence of nausea
      • Wants to go home
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    • Hospital Do Meixoeiro. Vigo Hospital Fundación de Calahorra Hospital Clínico Universitario. Zaragoza Hospital Mutua de Terrassa. Hospital General Universitario de Valencia Hospital Universitario de Elche Hospital Son Llátzer. Palma de Mallorca Hospital Clínico San Carlos de Madrid Hospital Gregorio Marañón. Madrid Hospital La Paz. Madrid Complejo Hospitalario La Mancha-Centro (A. de San Juan) 1 st of April 1 st of June Participants Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • Participants Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Retrospective study (data Introduction) Prospective study (prepared for the study) June July August September October June July August September October 1 st of April 5 th of November
    • Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Multi-center study to introduce a program of enhanced rehabilitation in colorectal surgery Preliminary results Average age 69,6 years ± Std. Dev. 13,2 (43 - 89 years). Male 61%. 69% 31% Way of Approach Surgical Technique Retrospective study (182 patients)
    • Retrospective study. Initial results (182 pat.) Complications Postoperative TOTAL: 24,82% Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Mean Stay: 12,1 days ± Std. Dev. 13,731 (4-78 days)
    • Retrospective study Initial results (64 pat.) Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
      • Design of the study: Data is analyzed on the principle of “intention to treat”
      • Meets Inclusion Criteria
      • Doesn’t meet Exclusion Criteria
      STUDY PATIENT
      • Objectives:
      • Success of the Program
      • Satisfaction of the Patient
      • Complications
      • Mortality
      • Re-operated
      • Hospital stay
      • Re-admission
      • Total length of stay
      Pre-operatoria information yes / no Preparation intestine yes / no Pre-surgery drink the night before yes / no Sedation yes / no Morning drink yes / no Pre-medication yes / no Epidural anaesthesia yes / no High flow oxygen yes / no Oesophageal Doppler yes / no Thermal blanket yes / no Nasal gastric tube yes / no Drains yes / no Early mobilization yes / no Early oral intake (High calorie drinks) yes / no
    • Retrospective study. Initial results (64 pat.) (*)Implementation of a Fast-Track Perioperative Care Program: What Are the Difficulties? . Sebastiaan W. Polle, Jan Wind, Jan W. Fuhring, Jan Hofland, Dirk J. Gouma, Willem A. Bemelman. Dig Surg 2007;24:441–449 Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Mean Age 63,4 years ± Std. Dev. 10,2 (38-89 years). Male 60%. Degree of compliance 77.1% 63% Pre-operative information 100% 87% Preparation of the intestine 95% 100% Pre-surgery drink the night before 95% 83% Sedation 87% 40% Morning drink 75% 30% Pre-medication 80% 70% Epidural anaesthesia 50% 71% High flow oxygen 70% 67% Oesophageal Doppler 72% Termal blanket 75% 100% Nasal gastric tube 72% Drains 72% Early mobilization 80% 40% Early oral intake ( high calorie drinks ) 56% 13%
    • Surgical Technique Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA 69% 31% Retrospective Retrospective study. Initial results (64 pat.)
    • Complications Post-operative TOTAL: 14,52% Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Retrospective study. Initial results (64 pat.)
    • MEAN Length of stay: 5,43 days (3-18 days) Readmission: 3/64 (4.7%) Mean LOS (including readmission): 6,03 (3-37) Estudio Prospectivo. Resultados iniciales (64 pac.) Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • Medical complications: Nausea. Vomiting. Ileus… Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA
    • Division of Coloproctology SURGERY SERVICE. HCU.ZARAGOZA Retrospective study. Initial results (64 pat.) Success Program Satisfaction Patient. Complications Mortality Recovery Hospital Stay Re-admission Total Length Stay Difficult to Organize and to establish Difficulty to obtain all parameters. We do not have an analysis yet Seems to decrease significantly Similar Similar Seems to be significantly lower <5% 6 days. Seems significantly lower Objetives
    •