Senior Visceral Surgery Fast-Track in Colorectal Surgery The anesthetist s point of view

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1 Senior Visceral Surgery Fast-Track in Colorectal Surgery The anesthetist s point of view 1st Geneva International SCIENTIFIC DAY February 3 rd 2010 E. Schiffer Dept APSI, HUG 1

2 Fast-Track in colorectal surgery Which role for anesthetists?

3 Fast-Track in colorectal surgery: Definitions 1. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183: Kehlet H, Wilmore DW. Fast-track surgery. In: American College of Surgeons (ACS). Principles and Practice. New York: Web MD, 2002;4: Garcia-Miguel FJ, Serrano-Aguilar PG; Lopez- Bastida J. Preoperative assessment. Lancet 2003; 362: Carr DB, Goudas LC. Acute pain. Lancet 1999; 353:

4 Fast-Track in colorectal surgery: Concept Fluid administration Goal-Directed Therapy Multimodal pain management Early feeding / Mobilization / Clinical pathway

5 Multimodal management of pain : Avoids surgical stress Permits early mobilization Enhances bowel function recovery Protects against respiratory complications Reduces nausea and vomiting Opioid sparing programs

6 Multimodal management of pain : Avoids surgical stress Permits early mobilization Enhances bowel function recovery Protects against respiratory complications Reduces nausea and vomiting Opioid sparing programs

7 Anaesthesia, surgery, and challenges in postoperative recovery Henrik Kehlet, Jørgen B Dahl Lancet 2003; 362:

8 Mean VAS Pain Scores by Postoperative Day Block, B. M. et al. Efficacy of Postoperative Epidural Analgesia: A Meta-analysis JAMA 2003;290: Copyright restrictions may apply.

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10 Multimodal management of pain : Avoids surgical stress Permits early mobilization Enhances bowel function recovery Protects against respiratory complications Reduces nausea and vomiting Opioid sparing programs

11 Continuous Preperitoneal Infusion of Ropivacaine In colorectal surgery: 48H continuous infiltrations Deambulation Bowel function recovery Length of hospital stay Satisfaction Beaussier M, Schiffer E, Gervaz P, Lienhart A, Eledjam JJ. Anesthesiology. 2007;107:461-8.

12 Continuous Preperitoneal Infusion of Ropivacaine Provides Effective Analgesia and Accelerates Recovery after Colorectal Surgery: A Randomized, Double-blind, Placebo-controlled Study Morphine sparing effect : Sedation Intestinal transit recovery PONV Beaussier M, Schiffer E, Gervaz P, Lienhart A, Eledjam JJ. Anesthesiology. 2007;107:

13 Continuous Preperitoneal Infusion of Ropivacaine Provides Effective Analgesia and Accelerates Recovery after Colorectal Surgery: A Randomized, Double-blind, Placebo-controlled Study Beaussier M, Schiffer E, Gervaz P, Lienhart A, Eledjam JJ. Anesthesiology. 2007;107:

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15 Multimodal management of pain : Avoids surgical stress Permits early mobilization Enhances bowel function recovery Protects against respiratory complications Reduces nausea and vomiting Opioid sparing programs

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17 Multimodal management of pain : Avoids surgical stress Permits early mobilization Enhances bowel function recovery Protects against respiratory complications Reduces nausea and vomiting Opioid sparing programs

18 Postoperative pneumonia with epidural analgesia compared with systemic analgesia: individual trials and cumulative meta-analysis Popping, D. M. et al. Arch Surg 2008;143: Copyright restrictions may apply.

19 Pulmonary Function and Gas Exchange Popping, D. M. et al. Arch Surg 2008;143: Copyright restrictions may apply.

20 Multimodal management of pain : Avoids surgical stress Permits early mobilization Enhances bowel function recovery Protects against respiratory complications Reduces nausea and vomiting Opioid sparing programs

21 Side effects related to anesthesia Avoid «Benign» complications : Post operative nausea and vomiting (PONV): Incidence > 10% Prevention NNT = 30 Treatment NNT = 10 1% of ambulatory patients need hospitalization for PONV Urinary retention: Opiates / neuraxial block Sore throat / voice raucousness Limited in time (<24H) ~ 15% Rare when persistent >48H ~ 1% Severe <0.1% (ORL) Sedation: Defense stimuli (opiates, hypoxia, residual NM block) Tramèr M. Treatment of postoperative nausea and vomiting. BMJ. 2003; 327:762-3.

22 Multimodal management of pain : Avoid surgical stress Permit early mobilization Enhance bowel function recovery Protect against respiratory complications Reduce nausea and vomiting Opioid sparing programs

23 Opioids sparing programs Thoracic epidural analgesia Continuous wound / preperitoneal LA infusion Continuous systemic Lidocaine infusion

24 Goal Directed Therapy How to manage iv fluid administration?

25 TE aortic Doppler Gan et al. Anesthesiology 2002

26 Gan J. et al. Anesthesiology 2002

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30 Pulse pressure and stroke volume variations from radial artery

31 Automated pulse pressure and stroke volume variations from radial artery: evaluation during major abdominal surgery. Derichard A et al. Br J Anaesth. 2009;103:

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38 Despite substantial evidence on the benefits of fast-track colorectal surgery, European and US surveys show a disappointingly slow change in surgical practice to current evidence. There are several possible reasons for this slow response, including: the lack of multidisciplinary collaboration between anaesthesiologists, surgeons, and surgical nurses; a lack of awareness of evidence-based data; failure to accept the published data H. Kehlet, Lancet, 2008

39 Take-home message Fast track in colorectal surgery Multimodal management of pain (opioid sparing program) Goal Directed Therapy for iv fluids Early feeding and mobilisation No nasogastric tube, no routine use of drains Impact Costs / Hospital stay Outcome Morbidity+++; Reoperation? Mortality?

40 Bibliography Fast-track colorectal surgery. Henrik Kehlet, Lancet 2008; 371: Convalescence after colonic surgery with fast-track vs conventional care D. H. Jakobsen and H. Kehlet Colorectal Disease 2006, 8, Implementing Fast-Track Protocol for Colorectal Surgery: A Prospective Randomized Clinical Trial. Daniela Ionescu et al. World J Surg : Fast-Track Surgery Study Group. The role of the anesthesiologist in fast-track surgery: from multimodal analgesia to perioperative medical care. White PF, Kehlet H, et al. Anesth Analg. 2007; 104:

41 Thank you for your attention! 41

42 «Fast-track anesthesia» Hits 2008: / 2010: «Fast-track surgery» 2008: / 2010: Hits : 2008: 194 / 2010: 251 Journaux anesthésiologiques: 2008: 60 / 2010: 233 Journaux chirurgicaux: 2008: 134 / 2010: pour «Fast-track surgery» Aucun article lié à la médecine avec le terme «fast-track» Aucun article pour «ambulatory surgery» / «ambulatory anesthesia»

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