Enhanced recovery - transferability into acute medicine

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

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Enhanced recovery - transferability into acute medicine

  1. 1. enhanced recovery – future developments and transferability into acute medicine ?
  2. 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. 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. 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. 5. Clin Nutri 2010; 29: 434-440 fast-track vs traditional care - morbidity
  6. 6. Surgery 2011;149:830-40. ”ERP’s can and should be routinely used in care after colorectal and other major gastrointestinal procedures”
  7. 7. Br J Anaesth 2011;106:289-91. established risk indices, but • fast-track methodology not implemented • ”surgical” vs ”medical” morbidity ?
  8. 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. 9. the hip fracture patient a ”medical” patient with a hip fracture
  10. 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. 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. 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. 13. enhanced recovery programmes • elective surgery • acute surgery (hip fracture) • ”medical” patients
  14. 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. 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. 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. 17. enhanced recovery in acute older medical patients ? conclusion: • ”medical” patients different from ”surgical” patients: • additional resources required (rehab interventions)
  18. 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. 19. conclusions: enhanced recovery programmes • elective surgery: do it • acute surgery: do it – and research • ”medical” patients: documentation/ research/ monitoring/ care organisation

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