Optimoitu toipuminen, kirurgin näkökulma. Tom Scheinin, kirurgian dosentti, FRCS

Transkriptio

1 Optimoitu toipuminen, kirurgin näkökulma Tom Scheinin, kirurgian dosentti, FRCS

2 Sidonnaisuudet kahden viimeisen vuoden ajalta LKT, kirurgian ja gastroenterologisen kirurgian erikoislääkäri, kirurgian dosentti, lääkärikouluttajan erityispätevyys Päätoimi HY, Kliininen opettaja Sivutoimet HYKS, erikoislääkäri, osaston vastuulääkäri yksityislääkäri Eiran sairaala Tutkimus ja kehitystyö Kliininen tutkimus tyrä- sappi- ja suolistokirurgiasta Koulutustoiminta Luentoja eri lääkealan yritysten koulutuksissa (Olympus, Aesculap Academy, Takeda) Osallistunut lääkealan yrityksen koulutusten suunnitteluun ( BBraun) Suomen Gastrokirurgit Ry lukukausittain toistuvien erikoistuvien laparoskopiakurssien vetäjä Suomen Gastrokirurgien ja Gastroenterologiayhdistyksen koulutusvaliokunnan jäsen Luottamustoimet terveydenhuollon alalla - ESCP Board of trustees - AGC-Course Davos, faculty member - Suomen Gastrokirurgit, pj - Suomen Kirurgiyhdistys, hallituksen jäsen Toiminta terveydenhuollon ohjaukseen pyrkivissä hankkeissa HYKS operatiivisten toimintojen sijoittumistyöryhmä Muut sidonnaisuudet Osakkeenomistaja Eiran sairaala

3 Fast track

4 Fast track = Lentokentät = LP I = Päivystyksen hoitopolku = Kaikkea muuta, ei kirurgiaa

5 Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study In a randomized, observer-and-patient, blinded trial, 60 patients (median age 75 years) underwent elective laparoscopic or open colonic resection with fast-track rehabilitation and planned discharge after 48 hours. Basse L et al. Ann Surg 2005;241:416-23

6 Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study 30 open 30 laparoscopic OR time 131,5 min Discharge 2,3 pop Re-admitted 8 (27%) OR 215,5 min Discharge 2,9 pop Re-admitted 6 (20%) Basse L et al. Ann Surg 2005;241:416-23

7 Anestesia Intraoperatiiviset ja kirurgiset Preoperatiiviset tekijät OT (ERAS) Postoperatiiviset

8 Evidence Based Medicine

9 Wind J et al. Br J Surg 2006;93: Systematic review of enhanced recovery programmes in colonic surgery 17 ERAS items 5 or more ERAS items = ERAS programme

10 ERAS-criteria PRE-OP WARD Patient information Avoid fasting Synbiotics No bowel-prep SURGERY Mini-invasive/transverse incisions Avoid drains ANAESTHESIA No opioid/benzo premedication Limited iv fluids O Avoiding hypothermia Epidural analgesia Minimise need of opioids Avoid NG-tube POST-OP WARD Early mobilisation Early enteral nutrition Laxative Early removal of urinary catheter Wind J et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 2006

11 Laparoscopic pelvic surgery steep Trendelendburg blood pressure placement of epidural gastric reflux (NG) IAP - CO 2 diuresis compression of veins compression of lungs atelectasis

12 LAPAROSCOPIC SURGERY IMPAIRS TISSUE OXYGEN TENSION

13 Home day 4 postop Home day 3 postop

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15 ERAS society recommendations Evidence level and recommendation grade Info: low, strong No bowelprep: high, strong Preop limited fasting and carbohydrate treatment: Fasting: moderate, strong Carbohydrate loading: low, strong Preop optimisation: Prehab: low, no Alcohol: low, strong Smoking: high, strong Gustafsson UO et al. Guidelines for perioperative care in Elective colonic surgery: ERAS society recommendations. World J Surg 2013

16 ERAS society recommendations Evidence level and recommendation grade No long acting sedatives: high, strong DVT propylaxis: high, strong Antibiotics and skinprep: high, strong Standard anaesthesia protocol: Rapid awakening: low, strong Reduce stress response: moderate, strong Open surgery: high, strong Lap surgery: moderate, strong Multimodal approach to PONV: low, strong Gustafsson UO et al. Guidelines for perioperative care in Elective colonic surgery: ERAS society recommendations. World J Surg 2013

17 ERAS society recommendations Evidence level and recommendation grade Laparoscopy and modified access: Oncology: high, strong Morbidity: Low, strong Recovery: moderate, strong Nasogastric tube: high, strong Avoid hypothermia: high, strong Periop fluid management: high, strong No routine drainage: high, strong Urinary drainage 1-2 d: low, strong (epidural!) Gustafsson UO et al. Guidelines for perioperative care in Elective colonic surgery: ERAS society recommendations. World J Surg 2013

18 ERAS society recommendations Evidence level and recommendation grade Avoiding ileus: Thoracic epidural lap: high, strong Chewing gum: moderate, strong Oral magnesium, alvidopan: low, weak/strong Postop analgesia: TEA, open surgery: high, strong TEA not essential in lap: moderate, strong Local anaesthetic & opioid: moderate, strong NSAID/paracetamol: moderate, strong Gustafsson UO et al. Guidelines for perioperative care in Elective colonic surgery: ERAS society recommendations. World J Surg 2013

19 Epidural analgesia diminished pain but did not otherwise improve enhanced recovery after laparoscopic sigmoidectomy: a prospective randomized study Turunen P et al, Surg Endosc Jan;23(1):31-7. Epub 2008 Sep patients with complicated diverticular disease: with or without epidural anesthesia Postoperative oxycodone consumption, pain, and recovery parameters were followed for 14 days

20 Turunen P et al, Surg Endosc Jan;23(1):31-7. Epub 2008 Sep 24 Epidural analgesia diminished pain but did not otherwise improve enhanced recovery after laparoscopic sigmoidectomy: a prospective randomized study Epidural No epidural op time (min) blood loss (ml) Bowel/air (d) Bowel/feces (d) hospital stay (d) readmission (n) 135 (60-165) 20 (20-800) 1 (1-4) 2 (1-7) 3 (2-9) (85-230) 20 (20-200) 1 (1-4) 2 (1-9) 3 (1-14) 1

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22 CONCLUSIONS: Epidural analgesia significantly alleviates pain, reducing the need for opioids during the first 48 h after laparoscopic sigmoidectomy. However, epidural analgesia does not alter postoperative oral intake, mobilization, or length of hospital stay

23 Diuresis with or without epidural Day of operation Controls Epidural P Efedrin (mg) 18 (±12) 26 (±17) ±25 ( ml/h ) Diuresis 83± ( l/d ) Fluids 5.5± ± CRP (mg/l) ±36) 51 ( ±31) 66 ( ± 9 ( mg ) Oksicodon 3 ±

24 Randomized Clinical Trial on Epidural Versus Patient- Controlled Analgesia for Laparoscopic Colorectal Surgery Within an Enhanced Recovery Pathway 128 patients undergoing elective laparoscopic colorectal resection Epidural or PCA Hübner M et al, Ann Surg 2014

25 Results: Recovery required a median of 5 days in EDA patients and 4 days in the PCA group, P = PCA patients had significantly less overall complications;19 (33%) vs 35 (54%); P = Hübner M et al, Ann Surg 2014

26 Conclusions: Epidurals seem to slow down recovery after laparoscopic colorectal resections without adding obvious benefits EDA can therefore not be recommended as part of ERAS pathways in laparoscopic colorectal surgery Hübner M et al, Ann Surg 2014

27 SIC! Mikä epiduraali käytössä: - pre- vai postop - korkeus - opiaatti - puudute

28 Home day 2-4 postop

29 Criteria for going home Patient eats, drinks, bowel and diuresis function, pain manageable with oral painkillers, no nausea, staying at home feasible