fast track was haben wir in die routine übernommen? ein zentrumsbericht cosa abbiamo trasportato...

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…)

***

Tagebuch(Schmerz, Stuhlgang, Übelkeit...)

***

Verhaltenstipsnach Entlassung

***

Krankheitszeichen

***

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 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


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


• Discussion and information about discharge


• 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?

fast track was haben wir in die routine übernommen? ein zentrumsbericht cosa abbiamo trasportato...

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