Achieving 23 hour hospital stay after colorectal resection. Professor Tim Rockall, Guildford, UK

Transcription

1 Achieving 23 hour hospital stay after colorectal resection Professor Tim Rockall, Guildford, UK

2 History Outcomes from open colorectal surgery 10 to 14 days in hospital 10% wound infection 2-10%+ anastomotic leak rate High incidence of DVT / PE / Chest infection Adhesions Incisional hernia HDU utilisation

3 NBOCAP data

4 2009 NBOCAP data

5 Median length of stay for the Excision of rectum in UK Median LOS for Excision of rectum by provider, , ERP providers highlighted Median LOS (days) Uni Hosp Birmingham NHS FT Isle of Wight NHS PCT Imperial College Healthcare Birmingham Heartlands Guy's & St Thomas' NHS FT East Lancashire Hosp NHS Trust Salford Royal NHS FT Plymouth Hosp NHS Trust Barnet & Chase Farm Hosp Good Hope Hospital The Newcastle Upon Tyne Hosp FT York Hosps NHS FT Sherwood Forest Hosp NHS FT Uni College London Hosp NHS FT Brighton & Sussex Uni Hosp Worthing & Southlands Hosp Milton Keynes Hosp NHS FT City Hospital, Birmingham North West London Hosp NHS Trust Wirral Uni Teaching Hosp NHS FT South Devon Healthcare NHS FT St George's Healthcare NHS Trust Yeovil District Hosp NHS FT Scarborough & North East Yorkshire Royal Berkshire NHS FT Northern Devon Healthcare Colchester Hosp Uni NHS FT Southampton Uni Hosp NHS Trust Oxford Radcliffe Hosp NHS Trust Portsmouth Hosp NHS Trust Dorset County Hosp NHS FT Medway NHS FT Whipps Cross Uni Hosp NHS Trust Queen's Medical Centre Royal Surrey County Hosp NHS Trust Salisbury NHS FT Providers (of 10+ operations)

6 Laparoscopic colorectal uptake NBOCAP /07 8.3% 2.5% converted 07/ % 5.3% converted Conversion rate 23%! RSCH % of all colorectal resections < 5% converted

7 Length of hospital stay

8 How we have developed enhanced recovery in colorectal surgery Day case colorectal resection Dis Col Rectum Aug 2009 Levy et al

9 Strategy Pre-operative Intra-operative Post-operative

10 Pre-operative Manage the patients expectation. Plan the discharge If patients think they will be in for two weeks they probably will Patient education Practical issues Dehydration No bowel prep No starvation

11 Intra-operative The anaesthetic is crucial Monitor +++ Very careful fluid management Over transfusion contributes to malaise, nausea, ileus, oedema and exacerbation of cardiac morbidity,? Anastomotic failure? Perform a good minimally invasive operation No big cuts, no blood loss, no drains, no NG

12 Post operative Early mobilisation Early re-establishment of oral intake Early removal of catheters and lines Effective anticipatory analgesia protocols Aim to get your patients tube free, eating and freely mobile on the first postoperative day

13 Colorectal surgery Open Surgery Enhanced recovery programme Laparoscopic Surgery Improved outcome Improved outcome

14 Evidence Laparoscopic surgery versus open surgery within an ERP Small UK study shows benefits persist for laparoscopic group 1 Next step EnROL study 1 King P, Kennedy R et al BJS 2006

15 Questions What aspects of ERP remain important in Laparoscopic surgery? What can we do to improve laparoscopic outcomes even further?

16 ERP criteria Education No bowel prep Carbohydrate load Epidural Warming No drains No NGT <3000mls intraop fluid >800mls oral fluid day 1 Early oral nutrition Terminate IV day 1 Terminate urinary drainage day 2 Solid food day 1 Aperients Mobilisation

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19 Quality of life Laparoscopic (N=77) Open (N=41) laparoscopic (N=65) open (N=35) EQ-5D scores P<0.001 SF-36 total score P= Days post-op Pre-op Days post-op

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21 To achieve rapid recovery Analgesia management Fluid management

22 Analgesia

23 Hospital stay by analgesia technique - medians N = spinal epidur al PCA Analgesia

24 Randomised trial - Spinal versus Epidural versus PCA (In fluid optimised patients undergoing lap colorectal resection) Spinal Epidural PCA Median Mean (sd) 4.3 (5.9) 5.6 (4.5) 2.7 (0.95)

25 Advantages of spinal anaesthesia Higher insertion rate, lower complication rate Does not suffer from unilaterality, displacement, catheter problems Less labour intensive Wears off, patients not limited the following morning? Effective neuro-axial blockade

26 Fluid optimisation

27 Doppler guided fluid optimisation Measure stroke volume 250mls of gelofusin over 2 min 10% fall in stroke volume no Yes Increase in stroke volume is greater than 10% no Measure stroke volume every 10 min

28 Physiology - pneumoperitoneum and steep Trendelenburg Cumulative increase SVRI Decrease in mean cardiac index from 3.3 to 2.8 L/min/m2 MAP initially increases from 74 to 90 mmhg SVRI progressively decreases MAP ultimately collapses requiring vasoconstrictors in 70% of patients Average time to vasoconstrictor support 25 mins (5-40)

29 Intra-operative volume requirement Intra-operative fluid volume in first 440 patients Intra-operative fluid volume in study group using oesophageal doppler Minimum 800 Maximum 4200 Mean 1729 mls Std. Deviation Minimum 350 Maximum 1600 Mean 875 mls Std. Deviation

30 Entry Criteria for 23-hour stay Post op (23 hrs from start of surgery) Informed consent Colonic or high rectal procedure ASA 1 or 2 Age< 75 BMI< 28 Adequate home support Competent adult present post-op 24 hours Telephone line/mobile Home< 15 miles from Hospital Incision< 7 cm Agreement GP Uncomplicated operation Patient motivated

31 Fluid management No bowel prep No prolonged starvation Preload Oesophageal Doppler Use of mixed venous O2 sats. sampling Immediate re-establishment of oral intake No opiates

32 Anaesthetic Standardised GA Spinal Central line Peripheral line Arterial line Oesophageal Doppler Urinary catheter No NG

33 Standardised GA Induction Propofol (2-3mg/kg), Alfentanil 10mcg/kg, Rocuronium 0.6mg /kg. Spinal L2-3 or L mls of 0.5% Bupivacaine with 0.25 mgs of Diamorphine Maintenace Sevoflurane at MAC, O2 enriched air and a Remefentanil infusion titrated to effect. Reversal Neostigmine 2.5 mgs and Glycopyrolate 0.5mg, and all patients received 4mgs of ondansetron.

34 Total IV fluid Oesophageal Doppler directed intraoperative fluid Post-op 1L Hartmann s over 8 hours IL Hartmann s over 12 hours Plus 500mls colloid if mixed venous O2, 60%

35 Post-op analgesia Paracetemal plus NSAID +/- Omeprazole Or Paracetemol plus Tramadol Plus Tramadol for breakthrough Morphine for further breakthrough

36 Time frame of recovery 12:00 hrs Start of operation 15:00 hrs Cup of tea in recovery 16:00 hrs Return to ward Out of bed for >2 hours Walk on spot for 5 minutes Normal dinner 20:00 hrs Mixed venous gas. If mixed venous O2 < 60% given 500ml fluid bolus 24:00 hrs Catheter removed 06:30 hrs All lines removed Breakfast Supervised walk along corridor 11:00 hrs Discharged home

37 Discharge basis Consensus of patient and Medical team Pain controlled Tolerating diet No nausea Unremarkable abdominal findings Normal observations Walking unaided Confident to be at home

38 Results 40 consecutive patients undergoing laparoscopic colorectal resection 10 fulfill criteria (25%) 9 colorectal cancer, 1 Diverticular disease All discharged at 23 hours post surgery No readmissions No complications High patient satisfaction

39 Table 5 Frequency of operation performed Cases

40 Protocol and non protocol patients 23 hour stay Normal pathway (median 3 day stay) Male: female 4:6 17:13 Average (range) age 60 (43-72) 69 (33-91) ASA I:II:III 1:9:0 1:24:5 Mean (range) Possum 24.4 (20-31) 27.3 (18-38) Mean (range) op. time 73 (50-110) 88 (50-160)

41 Why bother? Economics Reduce costs Increase income Patient safety Hospital acquired infection directly related to Time spent in hospital Prolonged catheterisation (IV / urinary / ng) Patient debility DVT and chest infection related to Immobility Fluid overload Analgesia Patient satisfaction

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47 Our philosophy Much of surgical dogma is wrong Patients can be safe at home Patient expectation is paramount Minimally invasive surgery is enabling

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