Chapter 6 Fast-Track Protocols

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1 Chapter 6 Fast-Track Protocols Peter Mattei It is increasingly clear that the application of systematic and evidence-based perioperative protocols can help make patients more comfortable and hasten their recovery. Many also believe that patient care should be straightforward and that patients should not be subjected to the discomfort and indignity of unnecessary procedures, worthless rituals, and therapies that are not supported by scientific evidence. Clinical pathways should address several aspects of postoperative care including: the return of bowel function, increasing activity levels, maximizing patient comfort, and eliminating superfluous maneuvers. Postoperative Ileus Traditional surgical teaching, passed on through generations of surgical residents, emphasized the idea that the postoperative ileus is a mandatory period of bowel inactivity that could not, and should not, be hastened or otherwise modified. This was especially true for patients who had undergone intraabdominal procedures such as bowel surgery. Standard therapy mandated strict bowel rest and gastric decompression. Patients were typically forbidden to eat or drink until they had a bowel movement, which was supposed to signify the return of bowel function. An enlightened few would allow removal of the nasogastric tube and resumption of diet upon the passage of flatus or when the nasogastric tube drainage was no longer green. Regardless, the result of this strategy was that the typical length of time before resumption of regular diet could be anywhere from 3 to 14 days. The postoperative period of paralytic ileus was considered not only mandatory but beneficial. The house officer foolhardy enough to remove a nasogastric tube prematurely, allow the patient to suck on ice chips or sip water, or induce P. Mattei (*) Department of Anesthesia and Critical Care, Children s Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA 19146, USA mattei@ .chop.edu a bowel movement with a laxative or suppository was roundly castigated and accused of placing the patient at risk for such horrible complications as bowel obstruction, anastomotic dehiscence, and peritonitis with sepsis. Finally, a few intrepid pioneers in the late 1980s did the unthinkable and questioned this dogma by doing away with some of these firmly held beliefs. They found that not only did their patients survive but they got better faster, went home sooner, and were more comfortable throughout their postoperative course. Studies throughout the 1990s have confirmed that these fast-track protocols are safe and they have become standard at many forward-thinking surgical services around the world. Strangely, pediatric surgeons seemed initially reticent about adopting similar measures in the care of children. Indications Most likely to benefit from application of a fast-track postoperative program is the healthy child who has undergone an elective and uncomplicated intra-abdominal procedure and who is comfortable, neurologically intact, and spontaneously breathing. The absence of any of these components is not an absolute contraindication to applying the protocol, but the critically ill, comatose, mechanically ventilated patient with severe chemical peritonitis might not the best candidate. Although the patient who has undergone a minimally invasive procedure would naturally be expected to recover more quickly, children who have undergone an extensive operation through a more traditional open incision also appear to benefit from these measures. Safe application of a fast-track protocol involves experience and good judgment. Relative contraindications include: age less than 6 months or weight less than 10 kg, or any infant whose respiratory status might be compromised by a distended abdomen; esophageal, gastric or duodenal procedures; inability to protect the airway in the event of emesis; positive-pressure ventilation, BiPAP, or CPAP; and conditions expected to cause a profound ileus such as high-grade bowel obstruction, fecal contamination of the peritoneum, or P. Mattei (ed.), Fundamentals of Pediatric Surgery, DOI / _6, Springer Science+Business Media, LLC

2 38 P. Mattei massive ascites. On the other hand, we have safely utilized the protocol or a slightly modified version thereof in patients with perforated appendicitis, partial SBO, jejunal resection with primary anastomosis, hepatic resection, Meckel s diverticulitis, retroperitoneal tumor resection, nephrectomy, and many procedures that include creation of an ileostomy. The Protocol The basic tenets of a typical fast-track protocol include: no routine nasogastric tube, early diet advancement, minimization of narcotic analgesics, and early ambulation/physical rehabilitation (Table 6.1). Naturally, the protocol is modified according to the patient population, the procedure, preference of the surgeon, and, sometimes, the biases of the institution, but a common theme is that each component should be supported by the evidence. how well the patient is doing and therefore inherently unpredictable. Some patients having the same operation will go home within a few days while others need more time, and still others will have setbacks that could delay discharge even more. However, families should be given some idea of what an average length of stay is expected to be. We have found it best to err on the side of too few days rather than too many, as parents who are told that their child will stay 5 days will feel like they are being rushed out the door or their care is being compromised if you declare on day 3 that they can are ready to go home. Because we have many patients who are ready for discharge on postoperative day 2 or 3 after laparoscopic-assisted ileocecectomy for ileal Crohn s disease, this is the length of stay we use for this procedure. Other operations have different anticipated lengths of stay. Do not underestimate the importance of the psychology of illness and wellness: in general, patients who think they should be sick for a certain number of days often feel ill for that many days while those who anticipate feeling better sooner often do. Patient Expectations Nasogastric Tubes The first step is to manage expectations by educating patients and their families that the discharge date is determined by Table 6.1 Typical fast-track protocol in pediatric surgery Patient education Anticipate discharge to home by POD 2 3a NO nasogastric tube Except After esophageal, gastric or duodenal surgery Infants <6 months of age or <10 kg body weight Placed postop as needed for comfortb Clear liquid diet immediately (sips at first) Advanced to regular as toleratedc 0.8 of calculated maintenance rated Minimize narcotics Nalbuphine and/or ketorolac If PCA, basal rate infusion should be zero Thoracic epidural delivering local anesthetice Start to ambulate within first h Diet Intravenous fluids Pain management Physical rehabilitation Bisacodyl Start on POD 2 then BID until bowel movement suppository POD postoperative day; PCA patient-controlled analgesia; BID twice daily a This is standard for an uncomplicated bowel resection but will vary depending on the procedure being performed b Intractable emesis, extreme distension, gas bloat c In the absence of symptoms (fullness, nausea, emesis) or abdominal distension d Maximum rate: 84 ml/h (roughly 2 L/day) e Lumbar epidural administration of narcotics are known to prolong postoperative ileus Nasogastric tubes were once thought to improve patient comfort by preventing postoperative emesis and to shorten the postoperative ileus by reducing bowel distension caused by intestinal secretions and swallowed air. However, most patients in fact do not experience severe postoperative bloating or emesis, and it appears that gastric decompression probably prolongs the postoperative ileus rather than shortens it. The reasons for this are unclear but one possibility is that postoperative emesis was much more common and more severe with older anesthetic drug regimens and before the development of modern antiemetics. Also, gastric decompression might prolong ileus by removing stimulants to downstream bowel motility that are normally secreted proximally. The tubes themselves are also known to increase the risk of infectious complications such as sinusitis and aspiration pneumonia. Nasogastric tubes are therefore not routinely needed after most abdominal operations. But we still use them after operations in which gastric distension might disrupt a suture line or be otherwise disastrous, such as those involving the esophagus, stomach, or duodenum. Following small bowel or colorectal surgery, fewer than one in 20 patients will need to have a nasogastric tube placed, and this is usually for patient comfort: intractable emesis, severe distension, or symptomatic gastric gas bloat. We also still use them in small infants because even a moderate amount of gastric or abdominal distension can compromise their respiratory status.

3 6 Fast-Track Protocols Diet There is rarely the need to strictly prohibit oral intake after uncomplicated abdominal or bowel surgery. With or without a nasogastric tube in place, taking sips of clear liquids in the immediate postoperative period is probably harmless as the volume is minuscule compared to the typical volume of saliva, gastric secretions, and pancreaticobiliary effluent that patients generate. Of course, excessive volume of intake or the gas from carbonated beverages can cause bloat, nausea, or vomiting early on, but, for the most part, limited early oral intake appears to stimulate the bowel in a way that is more beneficial than harmful. This makes sense from a physiologic standpoint given that promotility enterohormones are normally released in response to oral intake. In the very early postoperative period, we let our patients take small amounts of clear liquids and then advance gradually to more substantive intake, as long as they are not feeling full or nauseated and if there is only minimal abdominal distension on physical examination. It is the rare patient who will not limit intake appropriately. Nevertheless, they need to be monitored closely for signs of significant ongoing dysmotility (abdominal distension, belching) at least 3 or 4 times in a 24-h period. Intravenous Fluid It has been suggested that bowel edema increases postoperative bowel dysfunction. This certainly appears to be the case when a patient has a bowel obstruction or chemical peritonitis, but whether the edema is a primary cause or simply a result of the injury is not clear. Some have suggested that excessive intravenous hydration during or after an operation prolongs the postoperative ileus and it has been posited that this could be due to third-space fluid entering the bowel wall, much as it does in a more visible way in the face and other soft tissues of the body. We therefore try to limit the amount of intravenous fluid, both in the operating room and in the postoperative period, to only that which is necessary to maintain adequate tissue perfusion and renal function. Though this is perhaps the part of the protocol with the weakest scientific support, there may be other benefits to avoiding excessive hydration intravenous fluids and certainly no reason why it would be advantageous. The traditional pediatric maintenance fluid formula is empirically based and was designed to err on the side of giving too much fluid. We therefore give 0.8 of the calculated maintenance rate and then, if a patient demonstrates a need for more fluid (low urine output, tachycardia), we provide a bolus of crystalloid solution (20 ml/kg). Increasing the maintenance rate 39 under these circumstances takes too long to have an effect and replaces third-space losses with mostly free water. Regardless of the calculated maintenance rate, we give no more than 84 ml/h since very few patients need more than 2 L of intravenous fluids in a 24-h period. Pain Management That narcotics have a detrimental effect on bowel motility is well documented. They also induce nausea and their sedative effects make it difficult for some patients to participate in a postoperative physical rehabilitation program. It is therefore preferable to minimize the administration of narcotics while still making sure the patient is comfortable. We prefer to use the combined agonist-antagonist narcotic drug nalbuphine (0.1 mg/kg IV every 3 h, as needed for pain), which has good analgesic properties and may have less of a detrimental effect on bowel motility than morphine or dilaudid. We also typically use ketorolac (0.5 mg/kg IV every 6 h, maximum dose 30 mg, around the clock), which has excellent analgesic properties and none of the adverse effects associated with opiates. Because of concerns regarding the use of an NSAID in this patient population, we routinely coadminister an intravenous H2-blocker or proton pump inhibitor as prophylaxis against gastritis, and we limit the use of ketorolac to 72 h to minimize the risk of renal dysfunction. Patient-controlled analgesia is also an excellent option for postoperative pain relief but we have found it best to avoid a basal opiate infusion as it tends to make patients very sedated and appears to delay resolution of the ileus. Clinical trials are under way for use of an intravenous form of acetaminophen, but whether this will prove to be an effective alternative to opiates for postoperative pain relief is unclear. It is well known that narcotics administered through a lumbar epidural catheter prolong the postoperative ileus but that local anesthetics delivered by a thoracic epidural catheter have little such effect and provide excellent analgesia. Ambulation Contrary to traditional surgical teaching, patients cannot walk off their ileus. While being sedentary probably does prolong an ileus, making patients take more than two or three trips around the hospital ward per day is probably excessive, at least as far as the ileus is concerned. Nevertheless, early ambulation is beneficial for many reasons and we therefore encourage patients to walk early in the postoperative period, preferably the night of surgery for their first postoperative void, but certainly no later than the morning of the first postoperative day.

4 40 P. Mattei Constipation Discharge Criteria Because the colon was thought to be the last segment of the intestine to recover from the postoperative ileus, the traditional recommendation was to maintain gastric decompression and nothing by mouth until the patient passed stool or flatus. In retrospect, it seems more likely that what was considered the final phase of the postoperative ileus was simply constipation. There are many factors that promote constipation in postoperative patients including general anesthetic agents, opiates, diminished activity, fluid shifts, and poor oral intake. In our experience, it is clear that inducing a bowel movement on the second or third day in patients who are otherwise recovering nicely from their operation makes them feel better, relieves abdominal distension, and improves their appetite. Barring a postoperative complication, patients are considered ready for discharge to home when they are afebrile, tolerating a regular diet, able to ambulate without assistance, and have good pain control with oral analgesics. It is also preferable that they have at least one bowel movement. We have found that it is very important that parents feel comfortable taking their child home, and this is where the preoperative education to anticipate an early discharge is vital. The fast-track approach is not a one-size-fits-all regimen. The care of every patient must be individualized, which is only possible by getting to know each patient and following them closely in the postoperative period. Every patient should be examined at least 3 4 times daily to be sure that they are able to be advanced on their diet and that a complication has not developed. But the majority of patients will do well and advance appropriately. Summary Points Patients and their families should be educated regarding the criteria for discharge and the fact that some patients are safely discharged in the early postoperative period. Routine nasogastric tube decompression prolongs the postoperative ileus, makes patients more uncomfortable, and ultimately extends the average length of hospital stay. Nasogastric tubes are used in patients who have had surgery on the esophagus, stomach, duodenum, or pancreas, and in infants for whom moderate gastric distension can compromise ventilation. Early postoperative oral intake appears to be safe and, in moderation, hastens recovery of bowel function. Administering excessive intravenous fluids might prolong the postoperative ileus by increasing bowel wall edema. Patients appear to benefit from having a bowel movement in the early postoperative period, which can safely be promoted by administering a rectal suppository. Patients who ambulate early and often recover more quickly, have fewer complications, and are discharged sooner. Narcotics, especially when delivered by lumbar epidural catheter or as a basal intravenous infusion, slow bowel motility and their use in the postoperative period should be limited to the minimum amount necessary to achieve adequate pain relief. Patients are considered ready for discharge to home when they are afebrile, ambulating, tolerating a regular diet, and have adequate pain relief with oral analgesics. Suggested Reading Delaney CP. Clinical perspective on postoperative ileus and the effect of opiates. Neurogastroenterol Motil. 2004;16 Suppl 2:61 6. Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson AL, Remzi FH. Fast track postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg. 2001;88(11): Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surg. 2000;87(11): Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248(2): Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359(9320): Luckey A, Livingston E, Tache Y. Mechanisms and treatment of postoperative ileus. Arch Surg. 2003;138(2): Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev. 2005;(1): CD Senagore AJ, Delaney CP, Mekhail N, Dugan A, Fazio VW. Randomized clinical trial comparing epidural anaesthesia and patient-controlled analgesia after laparoscopic segmental colectomy. Br J Surg. 2003;90(10): Waldhausen JH, Schirmer BD. The effect of ambulation on recovery from postoperative ileus. Ann Surg. 1990;212(6):671 7.

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