01 Aug 12

Enhanced recovery pathways as a way to reduce surgical morbidity

Posted in Anesthesia, Enhanced recovery at 0:00 by Laci

By M Grocott, D Martin, M Mythen

Curr Opin Crit Care 2012;18:385-392

The aim of this review is to summarize important publications in enhanced recovery during 2010–2011 and to highlight key themes. Specifically, we focus on updated systematic reviews of high-quality clinical trials of enhanced recovery in colorectal surgery, exemplar studies of enhanced recovery in other specialties, and exploration of which elements of the enhanced recovery package might be associated with improved patient outcome.

Recent findings
An expanding evidence base of clinical trials and implementation evaluations supports the effectiveness of enhanced recovery programmes in improving outcome following major elective surgery. The majority of this literature derives from the study of patients undergoing colorectal surgery, but increasingly enhanced recovery is spreading to other surgical specialties. The combination of reduced length of hospital stay (a surrogate for morbidity) with no increase in readmissions to hospital suggests that morbidity is reduced with enhanced recovery. Inconsistency in morbidity reporting limits the value of pooling data between studies, but within study comparisons in general support this conclusion. Patients adhering to an enhanced recovery programme return to normal function faster than those following traditional care pathways.

Summary
Enhanced recovery adoption is likely to continue to grow (range of specialties and penetration within specialties). This progression is supported by the available published data.

03 Apr 09

British consensus guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP)

Posted in Acid-Base disorders, Enhanced recovery, Fluid management at 16:55 by Laci

By J Powell-Tuck, P Gosling, DN Lobo et al

NHS National Library of Health

From October 2006 the Association of Surgeons of Great Britain and Ireland, SARS, BAPEN Medical, the Intensive Care Society, the Association for Clinical Biochemistry and the Renal Association nominated core members of a steering committee who came together to establish consensus for good perioperative fluid prescribing. Concern arose from a high incidence of postoperative sodium and water overload, and evidence to suggest that preventing or treating this, by more accurate fluid therapy, would improve outcome.

14 Sep 08

Evidence-based surgical care and the evolution of fast-track surgery

Posted in Enhanced recovery at 12:39 by Laci

By H Kehlet, D Wilmore

Annals of Surgery 2008;248:189-198

Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program.

Objective
To assess, synthesize, and discuss implementation of “fast-track” recovery programs.

Data Sources
Medline MBASE (January 1966–May 2007) and the Cochrane library (January 1966–May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work.

Data Synthesis
Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the “fast-track methodology” has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered “surgery-specific” morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology.

Conclusion
Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.

Pre-operative oral carbohydrate loading in colorectal surgery

Posted in Enhanced recovery at 12:30 by Laci

By S E Noblett, D S Watson, H Huong, B Davison, P J. Hainsworth and A F Horgan

Colorectal Disease 2006;8:563-569

Surgery induces a catabolic response with stress hormone release and insulin resistance. The aim of this study was to assess the effect of pre-operative carbohydrate administration on grip strength, gastrointestinal function and hospital stay following elective colorectal surgery.

Methods
Thirty-six patients undergoing elective colonic resection were randomized into one of three groups. Group 1 were fasted; Group 2 were given pre-operative oral water, Group 3 received equivalent volumes of a Maltodextrin drink. Time to first flatus, first bowel movement and hospital stay were recorded. Muscle strength was measured pre-operatively, and on alternate days thereafter until discharge using a grip strength dynamometer.

Results
Patients in the carbohydrate group had a median postoperative hospital stay of 7.5 days compared with 13 days in the water group (P > 0.01) and 10 days in the fasted group (P = 0.06). The median time postsurgery to first flatus was 3 days for both the fasted and water groups compared with 1.5 days in the carbohydrate group (P = 0.13). First bowel movement occurred on day 3 in the carbohydrate group, day 4 in the fasting group and day 5 in the water group. The fasted group showed a significant reduction in postoperative grip strength (P < 0.05) with a median drop of 10% at discharge. Neither the water nor the carbohydrate groups showed significant reductions in muscle strength.

Conclusion
We found that pre-operative administration of oral carbohydrate leads to a significantly reduced postoperative hospital stay, and a trend towards earlier return of gut function when compared with fasting or supplementary water.

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