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FAST TRACK Was haben wir in die Routine übernommen? Ein Zentrumsbericht Cosa abbiamo trasportato nella routine? Un resoconto di centro Alexander Perathoner.

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Presentation on theme: "FAST TRACK Was haben wir in die Routine übernommen? Ein Zentrumsbericht Cosa abbiamo trasportato nella routine? Un resoconto di centro Alexander Perathoner."— Presentation transcript:

1 FAST TRACK Was haben wir in die Routine übernommen? Ein Zentrumsbericht Cosa abbiamo trasportato nella routine? Un resoconto di centro Alexander Perathoner Univ.-Klinik für Viszeral-, Transplantations- und Thoraxchirurgie Medizinische Universität Innsbruck Jahrestagung der Tirolisch-Venezianisch-Lombardischen Chirurgenvereinigung BOZEN, 21. Juni 2008

2 October 2004 INTRODUCTION 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

3 82 Fast Track Patients ----------------------------------------------------------------------------------------------------------------------------------- SEXmale 55 %, female 45 % AGE60,5 years (32-90) BMI25,5 kg/m² ASA-Score 2,7 INDICATION70 % colorectal cancer 23 % sigmoid diverticulitis 7 % IBD PROCEDURE25 % sigmoid resection 23 % rectal resection 19 % right hemicolectomy 15 % left hemicolectomy 14 % ileocaecal resection 4 % proctocolectomy 47 % laparoscopy

4 Length of hospital stay mean9 days median7 days range3 – 60 days

5 Complications… Surgical complications13 % Anastomotic Insufficiency9 Bleeding1 Burst abdomen1 Morbidity17 % Urinary tract infection5 Pneumonia3 Wound infection3 Subileus (Fast Track stopped)3 Mortality1,2 % Readmissions2,4 % Pneumonia2

6 October 2004 INTRODUCTION 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 satisfaction acceptable morbidity decreased length of hospital stay October 2005 FAST TRACK colorectal surgery in Innsbruck ROUTINE

7 all patients with elective resection of colon/rectum CONTRAINDICATIONS emergency surgery inadequate compliance AGE, a relative contraindication for Fast Track Surgery? Is it too risky to treat older patients with the Fast Track concept? INDICATION

8 … younger patients are best suited for fast track surgery … older patients profit most! (adapt Fast Track to age/compliance of older patients) INDICATION Age < 65 Hospital stay 6 d Morbidity 4 % Age > 65 Hospital stay 7,5 d Morbidity 20 %

9 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 phaseINFORMATION !

10 Allgemeine Informationen (Fast Track, Narkose, OP-Vorbereitung, postoperative Therapie…) *** Tagebuch (Schmerz, Stuhlgang, Übelkeit...) *** Verhaltenstips nach Entlassung *** Krankheitszeichen *** Kontaktinformationen

11 breathing exercises, breathing technique (physiotherapy) preoperative phaseBREATHING THERAPY FLOW 600 ml, 900 ml, 1200 ml

12 DIETICIAN information about preoperative and postoperative diet preoperative phaseDIET CONSULTATION

13 NO mechanical bowel preparation discomfort alterated electrolytes hypovolemia no advantage in randomised controlled trials MECHANICAL 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.

14 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 PREPARATION

15 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 phaseCARBOLOADING fettfrei milcheiweißfrei 2 h nach Gabe von 200ml entspricht das Restvolumen im Magen dem eines nüchternen Menschen

16 INST > 3= malnutrition 3 x 1 drink with high content of proteins and carbohydrates at least 5 days before surgery Age (years) BMI (kg/m²) Weight loss (last 3 months) (%) Oral nutrition (%) INNSBRUCK NUTRITION SCORE TOOL

17 patients are allowed to drink clear drinks until 2 hours before surgery evening before surgery: fluid diet with carbohydrate drink preoperative phaseSOBRIETY Guidelines International Societies of Anaesthesia no food from midnight no drinking 2h before surgery = improvement of patient well-being = prevention of hypovolemia = risk of aspiration not increased

18 first operation in the morning (makes postoperative mobilisation and nursing easier) SURGERY

19 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 TECHNIQUE

20 transverse laparotomy, ileocaecal resection (colon cancer)

21 ANAESTHESIA general anaesthesiaperidural anaesthesia avoid/reduce opiate = improve mobilisation

22 FLUID THERAPY restrictive normovolemia guideline 10 ml/h/kg cristalloids and colloids intraoperative phaseANAESTHESIA Gefahr der Hypervolämie/Hyperhydratation Ödeme (Anastomose!), Ergüsse, resp. Insuffizienz, kardiale Belastung, Elektrolytstörungen, Darmparalyse, Zunahme des intraabd. Drucks, verlängerter stat. Aufenthalt

23 Patients are not able to drink enough after the operation Day 1 post operationem Oral fluid intake 150 – 3500 ml (mean 1600 ml) >1000 ml83 % >2000 ml40 %

24 The urinary excretion goes down with restrictive intravenous fluid therapy. Day 1 post operationem Urinary excretion 500 – 5100 ml (mean 2350 ml) 34 % furosemid (on demand) 1,5 % K + < 3mmol 0 % renal insufficiency

25 fluid management preoperativep.o. liberal intraoperativei.v. restrictive postoperative (day 0,1)i.v. restrictive postoperativep.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

26 postoperative IMCU; transfer to ward, as soon as possible postoperative phase DAY 0

27 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 phase DAY 0

28 postoperative phase ANALGETIC THERAPY

29 Therapy per os Stimulation of bowel motility –Magnesium (3 x 350 mg) –Metoclopramid 20 mg on demand –Chewing gum (gastrocephal reflex!) Light food postoperative phase DAY 1

30 bowel movement

31 remove PDA-catheter, central venous catheter, urinary catheter –removement of urinary catheter about 4 hours after the PDA-catheter postoperative phase DAY 2 Discussion and information about discharge postoperative phase DAY 3

32 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…) DISCHARGE

33 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 ? DISCHARGE Leistungsorientierte Krankenhausfinanzierung in 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

34 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 … 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?


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