Fast-track surgery and anaesthesia

Abstract

Major surgery induces profound physiological responses; frequent sequelae include pain, nausea, ileus, increased cardiac demands, and impaired pulmonary function. These complications can lead to delayed mobilization, prolonged hospital stay, and significant postoperative complications. 'Fast-track' surgery was pioneered by Professor Henrik Kehlet in Denmark in the early 1990s. 1,2 The term refers to a multimodal package of techniques which aim to decrease post-surgical organ dysfunction and complications, and hence to improve postoperative recovery. The centres that have pioneered this approach have achieved impressive reductions in hospital stay and surgical morbidity. The core principles of fast-track surgery (or enhanced recovery) programmes, as applied to major abdominal surgery, are reviewed here. Each aspect uses evidence gleaned from the literature on perioperative medicine, and attempts to integrate these ideas into a seamless programme of clinical care. For this to be a success, the multidisciplinary team involved should be fully informed and educated about their roles within the programme. Well-organized prospective audit is an important part of the process. Preoperative management Preoperative assessment Postoperative organ dysfunction and complications are related to preoperative co-morbidity. Preoperative assessment allows estimation of risk and an opportunity to stabilize co-existing disease and optimize organ function before surgery. Preoperative assessment also provides an opportunity for patient education. In fast-track programmes, patients are given information about their anticipated postoperative course, analgesia, mobilization programme, and discharge. Several studies have demonstrated that such information can reduce anxiety, analgesic requirements, and length of hospital stay.

Stress Response to Surgery and Possible Ways of Its Correction

“…Patients are given information about the operation, analgesia, postoperative course, prognosis, etc. (Kitching et al, 2009). Consideration should be directed to appropriate premedication therapy: anxiolytics, such as benzodiazepines, are the most popular medication for reducing fear and anxiety; additionally, painkillers such as COX-2 inhibitors can be used as a preemptive analgesia before surgery to reduce the pain and opioid requirements during the operation (Puura et al, 2006).…”

“…COX-1 inhibitors are less advisable for preemptive analgesia because of antithrombotic effect and irritation of gastric mucosa, which can cause ulceration and bleeding in postoperative period. There is also an increasing interest in using b-blockers; these drugs can suppress the surgical induction of catecholamines and a 2 -agonists (e.g., clonidine), which can have an opioidsparing effect and reduce myocardial ischaemia (Kitching et al, 2009).…”

“…The principle of the multimodal approach is to obtain good analgesic effect from different sources. This practise maximises the analgesic effect and minimises side effects, such as ileus, nausea, and sedation, especially those of opioids (Kitching et al, 2009). There is evidence that postoperative analgesia in combination with local anaesthetics is associated with a faster resolution of postoperative ileus and stimulates bowel motility.…”

“…Additionally, the best option is to use different combinations of local anaesthetics, non-steroidal anti-inflammatory drugs, coanalgesics and opioids. When using such an approach, the need for opioids should be reduced (Rigg et al, 2002;Kitching et al, 2009).…”

“…However, it has since been shown that prompt postoperative enteral feeding in patients undergoing gastrointestinal resection is both effective and well tolerated even when started within 12 hours of surgery. Enteral feeding is also associated with specific clinical benefits such as reduced incidence of postoperative infectious complications and an improved wound healing response (Kitching et al, 2009). Postoperative nausea, vomiting and paralytic ileus should be avoided, and enteral or oral feeding should be used.…”