FAST TRACKFAST TRACK
Was haben wir in die Routine übernommen? Was haben wir in die Routine übernommen? Ein ZentrumsberichtEin Zentrumsbericht
Cosa abbiamo trasportato nella routine?Cosa abbiamo trasportato nella routine?Un resoconto di centroUn resoconto di centro
Alexander PerathonerAlexander Perathoner
Univ.-Klinik für Viszeral-, Transplantations- und ThoraxchirurgieUniv.-Klinik für Viszeral-, Transplantations- und ThoraxchirurgieMedizinische Universität InnsbruckMedizinische Universität Innsbruck
Jahrestagung der Tirolisch-Venezianisch-Lombardischen ChirurgenvereinigungJahrestagung der Tirolisch-Venezianisch-Lombardischen ChirurgenvereinigungBOZEN, 21. Juni 2008BOZEN, 21. Juni 2008
October 2004INTRODUCTION FAST TRACK colorectal surgery in Innsbruck
concept by H. Kehlet (Hvidovre) and W. Schwenk (Berlin)
1 ward (colorectal surgery)Inclusion criteria: all consecutive elective colorectal resections
EVALUATION after 1 year (82 patients)outcome + feasibility
82 Fast Track Patients-----------------------------------------------------------------------------------------------------------------------------------
SEX male 55 %, female 45 %AGE 60,5 years (32-90)BMI 25,5 kg/m²ASA-Score 2,7
INDICATION 70 % colorectal cancer23 % sigmoid diverticulitis7 % IBD
PROCEDURE 25 % sigmoid resection23 % rectal resection19 % right hemicolectomy15 % left hemicolectomy14 % ileocaecal resection4 % proctocolectomy
47 % laparoscopy
postop. stat. Aufenthalt
0
1
2
3
4
5
6
7
8
9
10
11
Length of hospital stay mean 9 daysmedian 7 daysrange 3 – 60 days
Complications…
Surgical complications 13 %Anastomotic Insufficiency 9Bleeding 1Burst abdomen 1
Morbidity 17 %Urinary tract infection 5Pneumonia 3Wound infection 3Subileus (Fast Track stopped) 3
Mortality 1,2 %
Readmissions 2,4 %Pneumonia 2
October 2004INTRODUCTION FAST TRACK colorectal surgery in Innsbruck
concept H. Kehlet (Hvidovre) and W. Schwenk (Berlin)
1 ward (colorectal surgery)Inclusion criteria: all consecutive elective colorectal resections
EVALUATION after 1 year (82 patients)outcome + feasibility
high patients satisfactionacceptable morbidity
decreased length of hospital stay
October 2005FAST TRACK colorectal surgery in Innsbruck ROUTINE
all patients with elective resection of colon/rectum
CONTRAINDICATIONSemergency surgery
inadequate compliance
AGE, a relative contraindication for Fast Track Surgery?Is it too risky to treat older patients with the Fast Track concept?
INDICATIONINDICATION
… younger patients are best suited for fast track surgery
… older patients profit most!
(adapt Fast Track to age/compliance of older patients)
INDICATIONINDICATION
Age < 65
Hospital stay 6 d
Morbidity 4 %
Age > 65
Hospital stay 7,5 d
Morbidity 20 %
a crucial factor for the success of the Fast Track treatment (motivate to collaborate)
Information about...
• ... Purpose of Fast Track elements/measures• e.g. postoperative mobilisation
• ... Goal of treatment:• not early discharge• reduction of morbidity• acceleration of convalescence
preoperative phasepreoperative phase INFORMATIONINFORMATION
!
Allgemeine Informationen(Fast Track, Narkose,
OP-Vorbereitung,postoperative Therapie…)
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Tagebuch(Schmerz, Stuhlgang, Übelkeit...)
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Verhaltenstipsnach Entlassung
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Krankheitszeichen
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Kontaktinformationen
breathing exercises, breathing technique
(physiotherapy)
preoperative phasepreoperative phase BREATHING THERAPYBREATHING THERAPY
FLOW 600 ml, 900 ml, 1200 ml
DIETICIAN
information about preoperative
and
postoperative
diet
preoperative phasepreoperative phase DIET CONSULTATIONDIET CONSULTATION
NO mechanical bowel preparation
• discomfort
• alterated electrolytes
• hypovolemia
• no advantage in randomised controlled trials
MECHANICAL BOWEL PREPARATIONMECHANICAL BOWEL PREPARATION
Contant CM, et al.Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial.Lancet. 2007 Dec 22;370(9605):2112-7.
Bretagnol F, et al.Rectal cancer surgery without mechanical bowel preparation.Br J Surg. 2007 Oct;94(10):1266-71.
Wille-Jørgensen P, et al.Pre-operative mechanical bowel cleansing or not? an updated metaanalysis.Colorectal Dis. 2005 Jul;7(4):304-10. Review.
but…
2 exceptions:
• Enema (70 ml)– rectal resection– sigmoid resection
• Laxative (Karlsbader salt, laxative tea…)
– protective Loop-Ileostomy (low rectal resection) to evacuate the bowel between ostomy and anastomosis
MECHANICAL BOWEL PREPARATIONMECHANICAL BOWEL PREPARATION
• prevent postoperative postaggression-syndrom = inability to metabolise glucose
• 200 ml drink with high content of carbohydrates 2h before surgery
• malnutrition: 3 x 1 drink, 5 days before surgery
preoperative phasepreoperative phase CARBOLOADINGCARBOLOADING
fettfreimilcheiweißfrei
2 h nach Gabe von 200mlentspricht das Restvolumen
im Magen dem einesnüchternen Menschen
INST (Innsbucker Nutrition Score Tool) 1 2 3 Alter (Jahre) >70 BMI (kg/m2) <18,5 <16 % Gewichtsabnahme in 3 Monaten >5 >10 >15 Nahrungszufuhr in der letzten Woche <75%
INST > 3 = malnutrition
3 x 1 drink with high content of proteins and carbohydratesat least 5 days before surgery
Age (years)BMI (kg/m²)
Weight loss (last 3 months) (%)Oral nutrition (%)
INNSBRUCK NUTRITION SCORE TOOLINNSBRUCK NUTRITION SCORE TOOL
• patients are allowed to drink clear drinks until 2 hours before surgery
• evening before surgery: fluid diet with carbohydrate drink
preoperative phasepreoperative phase SOBRIETYSOBRIETY
Guidelines International Societies of Anaesthesia
no food from midnightno drinking 2h before surgery
= improvement of patient well-being= prevention of hypovolemia
= risk of aspiration not increased
first operation in the morning (makes postoperative mobilisation and nursing easier)
SURGERYSURGERY
• minimal traumatic surgery (minimize surgical complications, reduce postoperative pain, improve postoperative mobilisation)– avoid drainage (remove drains as soon as possible, day 1)
• laparoscopy (intracorporal anastomosis)
• laparotomy: transverse incision– right hemicolectomy– ileocaecal resection– (sigmoid resection)
SURGICAL TECHNIQUESURGICAL TECHNIQUE
transverse laparotomy, ileocaecal resection (colon cancer)
ANAESTHESIAANAESTHESIA
general anaesthesia peridural anaesthesia
avoid/reduce opiate =
improve mobilisation
FLUID THERAPY
restrictive
normovolemia
guideline 10 ml/h/kg
cristalloids and colloids
intraoperative phaseintraoperative phase ANAESTHESIAANAESTHESIA
Gefahr der Hypervolämie/Hyperhydratation
Ödeme (Anastomose!), Ergüsse, resp. Insuffizienz, kardiale Belastung, Elektrolytstörungen, Darmparalyse, Zunahme des intraabd. Drucks, verlängerter
stat. Aufenthalt
„Patients are not able to drink enough after the operation“
0
500
1000
1500
2000
2500
3000
3500
4000
Day 1 post operationem
Oral fluid intake150 – 3500 ml
(mean 1600 ml)
>1000 ml 83 %>2000 ml 40 %
„The urinary excretion goes down with restrictive intravenous fluid therapy.“
Day 1 post operationem
Urinary excretion500 – 5100 ml
(mean 2350 ml)
34 % furosemid (on demand)
1,5 % K+ < 3mmol
0 % renal insufficiency0
1000
2000
3000
4000
5000
6000
fluid managementpreoperative p.o. liberalintraoperative i.v. restrictivepostoperative (day 0,1) i.v. restrictivepostoperative p.o. liberal
MONITORING
Blutdruck, Herzfrequenz, Hautturgor, Atemfrequenz, Sauerstoffsättigung, Schweißsekretion, Harnausscheidung, Hämatokrit,
Nierenfunktionsparameter, Elektrolyte, Körpergewicht, Kolloidosmotischer Druck, Durstgefühl, Harnnatrium (< 20 mmol/l = i.v. Therapie)
Indication for intravenous therapy: urine sodium < 20 mmol/l
postoperative IMCU; transfer to ward, as soon as possible
postoperative phasepostoperative phase DAY 0DAY 0
• Restrictive administration of i.v. fluid (max. 500 ml)
• early prophylaxis/therapy of PONV (Metoclopramid 20 mg i.v., Tropisetron 5 mg i.v.)
• Tea (max. 1500 ml)
• Mobilisation (get out of the bed, attempt at walking)
• Joghurt in the evening (max. 2 portions)
postoperative phasepostoperative phase DAY 0DAY 0
postoperative phasepostoperative phase ANALGETIC THERAPY ANALGETIC THERAPY
• Therapy per os
• Stimulation of bowel motility– Magnesium (3 x 350 mg)– Metoclopramid 20 mg on demand– Chewing gum (gastrocephal reflex!)
• Light food
postoperative phasepostoperative phase DAY 1DAY 1
bowel movement
0
2
4
6
8
10
12
14
Tag 1 Tag 2 Tag 3 Tag 4
STUHLGANG
• remove PDA-catheter, central venous catheter, urinary catheter– removement of urinary catheter about 4 hours after
the PDA-catheter
postoperative phasepostoperative phase DAY 2DAY 2
• Discussion and information about discharge
postoperative phasepostoperative phase DAY 3DAY 3
• Discharge with informational booklet for patient and family doctor
• Out-patient control on day 10 with inspection of the wound, removement of sutures and information about additional therapies (oncological patients, chemotherapy…)
DISCHARGEDISCHARGE
• FAST track = EARLY discharge ?
• Does every patient want to be discharged as soon as possible ?
• Does the hospital want to discharge patients as soon as possible ?
DISCHARGEDISCHARGE
Leistungsorientierte Krankenhausfinanzierungin Österreich (LKF-Punkte)
LKF-Punkte pro Behandlung = Pauschalbehandlung = Pauschalbetrag
längerer stat. Aufenthalt bei gleicher Leistung = weniger LKF-Punkte = weniger Geld
längerer stat. Aufenthalt bei mehr Leistung (Komplikationen) = mehr LKF-Punkte = mehr Geld
short hospital stay = weniger Leistung = weniger LKF-Punkte = less money
• Fast Track concept is feasible and convincing• Patients are satisfied and appreciate the treatment• Low morbidity• Acceleration of convalescence• Extension of Fast Track treatment to whole department
Zentrumsbericht … resocontoZentrumsbericht … resoconto
• Information
• Definition of exact guidelines
• Role of perioperative fluid management?
• Optimization of postoperative diet (functional food…) to reduce risk of postoperative ileus and improve well-being?