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UntitledMajor surgery induces profound physiological Consideration should be given to appropriate premedication. In the fast-track surgical setting, and impaired pulmonary function. These com- premedication is aimed at reducing the surgical plications can lead to delayed mobilization, stress response. In this respect, there is increas- prolonged hospital stay, and significant post- b-Blockers suppress the surgically induced increase in circulating catecholamines and can Professor Henrik Kehlet in Denmark in the therefore reduce perioperative cardiovascular early 1990s.1,2 The term refers to a multimodal morbidity. They also have analgesic-sparing package of techniques which aim to decrease and anticatabolic properties, which may facili- post-surgical organ dysfunction and compli- cations, and hence to improve postoperative recovery. The centres that have pioneered this opioid-sparing effects when used as premedica- approach have achieved impressive reductions tion. There is also evidence that they reduce in hospital stay and surgical morbidity. The perioperative myocardial ischaemia, intraopera- tive blood loss, and postoperative nausea and enhanced recovery) programmes, as applied to major abdominal surgery, are reviewed here.
Each aspect uses evidence gleaned from the shorten the duration of ileus and improve pain attempts to integrate these ideas into a seamless programme of clinical care. For this to be asuccess, the multidisciplinary team involved Traditionally, patients for elective surgery are Well-organized prospective audit is an import- fasted overnight to reduce aspiration risk, which may lead to significant dehydration.
There is evidence that avoidance of preopera-tive dehydration can reduce postoperative pain and nausea. Clear fluids taken orally up to 2 hbefore surgery have been shown to have no effect on gastric volume and pH, and therefore Postoperative organ dysfunction and compli- no effect on aspiration risk. Clear carbohydrate cations are related to preoperative co-morbidity.
fluids given before operation may also have a Preoperative assessment allows estimation of role. They reduce the sensations of thirst and risk and an opportunity to stabilize co-existing hunger, and in smaller trials have been shown disease and optimize organ function before to reduce anxiety levels. There is a reduction in perioperative insulin resistance, and a small reduction in perioperative muscle catabolism.
opportunity for patient education. In fast-track Whether this translates into an effect on length programmes, patients are given information of hospital stay requires further study.
about their anticipated postoperative course, Bowel preparation is traditionally adminis- analgesia, mobilization programme, and dis- tered to all patients before colorectal surgery.
charge. Several studies have demonstrated that However, a recent meta-analysis has demon- such information can reduce anxiety, analgesic strated that, at least for segmental resections, requirements, and length of hospital stay.
bowel preparation may not be necessary and Continuing Education in Anaesthesia, Critical Care & Pain | Volume 9 Number 2 2009 & The Author . Published by Oxford University Press on behalf of The Board of Directors of the British Journal ofAnaesthesia. All rights reserved. For Permissions, please email: [email protected] may increase the risk of septic complications and aggravate preo- are ideal. In order to minimize the incidence of PONV, total i.v. anaesthesia (TIVA) is often favoured. In major abdominalsurgery, serious consideration should be given to the use of thoracic epidural analgesia. Although there is no definitiveevidence that epidural analgesia reduces mortality, it has a number Surgery initiates a complex metabolic, neuroendocrine, and inflam- of other significant benefits in this population. In comparison with matory stress response, which results in stimulation of the sym- i.v. opioid-based patient-controlled analgesia regimes, epidural pathetic nervous system, profound catabolism, and retention of local analgesia better preserves exercise capacity after laparotomy, sodium and water. These changes are not beneficial to the patient reduces time to ambulation, provides better static and dynamic and indeed most postoperative organ dysfunction and morbidity pain relief, and reduces postoperative pulmonary complications can be attributed at least in part to the stress response.
after upper abdominal procedures. Thoracic epidural analgesia can Intraoperative management is aimed at reducing the stress response reduce ileus after colorectal surgery, although not consistently after to surgery, and facilitating early feeding and mobilization after upper gastrointestinal tract surgery.
There has recently been some debate of the need for routine use of epidurals for major abdominal surgery.7 The MASTER trial8 showed that there was no reduction in mortality after major abdominal surgery in the epidural group (although there was a The use of minimally invasive surgical techniques reduces the reduction in the incidence of respiratory failure when compared inflammatory component of the stress response but does not appear with i.v. analgesia). However, the MASTER trial did not address to have significant effects on the neuroendocrine and metabolic the issue of length of hospital stay, and was ambiguous regarding response. However, minimally invasive surgery is generally associ- early feeding, early mobilization, and other features of a fast-track ated with reduced pain and shorter hospital stay when compared programme. If mortality outcomes are not different in fast-track with open techniques. This difference is most marked where the programmes, but median length of stay is reduced by 3 days, our open procedure requires a long vertical incision. Pain and pulmon- view is that, at a time when healthcare is threatening to consume ary dysfunction are reduced where transverse or oblique incisions an ever greater proportion of our national income, a safe technique are used instead of vertical, presumably due to the reduced number which reduces length of hospital stay is a priority. This of course brings its own benefits, including a reduction in hospital-acquired Minimally invasive surgical approaches may not always be the best technique. When fast-track surgical principles are applied toperioperative care, the differences in median length of hospital staybetween minimally invasive and open surgical techniques become less marked. Particularly, in procedures where a long vertical Ideal perioperative fluid management has been the subject of much incision is not necessary, such as colonic resection, the advantages debate. ‘Liberal’ fluid administration can reduce nausea and vomit- of a minimally invasive approach are not clear-cut. Kehlet5 has ing, dizziness, drowsiness, thirst, and hospital stay, particularly in repeatedly argued that laparoscopic approaches to abdominal minor-to-moderate and ambulatory surgery. However, overhydra- surgery need to be evaluated within a fast-track programme to tion can lead to cardiac and pulmonary dysfunction. Excess fluid accurately assess their impact on length of stay and postoperative may also reduce tissue oxygenation leading to impairment of wound healing. Healing of the surgical anastomosis is a particularconcern. The salt and water retention induced by the surgical stress Avoidance of routine nasogastric tubes and drains response can exacerbate these problems. Conversely, fluid restric- Nasogastric tubes have long been part of the routine care of tion can reduce effective circulating volume and lead to inadequate patients after major abdominal surgery. However, there is increas- ing evidence that, at least for mid-to-lower abdominal procedures, Preoperative volume status varies greatly, and the magnitude of their use is not routinely indicated. Indeed, they may actually the surgical insult (and the resulting stress response) can lead to hinder recovery by prolonging paralytic ileus and predisposing to very different fluid requirements. Hence, individually tailored goal- pulmonary aspiration.6 Similarly, surgical drains may slow recov- directed fluid therapy would appear to be the optimal approach, ery of bowel function and make pain control difficult.
the goal being maintenance of tissue perfusion and cellular oxy-genation. This strategy is based on the assumption that the optimalblood volume for a given individual is defined by that preload which is required to produce a maximal cardiac output (or stroke Anaesthetic technique should be geared towards rapid recovery volume). Starling’s law of the heart shows that successive fluid with minimal carry over of opioid effects into the recovery period.
challenges (i.e. increasing preload) will increase the stroke volume For this reason, short-acting anaesthetic and analgesic agents until a given point (the flat portion of the curve). Beyond this, Continuing Education in Anaesthesia, Critical Care & Pain j Volume 9 Number 2 2009 further increases in preload will cause a reduction in stroke evidence that epidural analgesia with local anaesthetics is associated volume. Therefore, the goal for fluid therapy for an individual with faster resolution of postoperative ileus after major abdominal would be that point where a fluid challenge no longer produces an surgery. Consideration should be given to a combination of local or increase in stroke volume. Stroke volume can be estimated using a regional anaesthetic techniques (including continuous infusion of number of non-invasive methods, including oesophageal Doppler wounds with local anaesthetic), paracetamol, non-steroidal anti- and forms of pulse pressure analysis. Typically, successive fluid inflammatory drugs (NSAIDs), and other agents such as gabapentin, challenges of 250 ml colloid are given until this no longer pro- clonidine, and ketamine. By using such an approach, the need for duces an increase in stroke volume of at least 10%. This is thought opioids should be reduced; this should minimize their side-effects to represent optimal circulating volume. Several recent studies (e.g. sedation, nausea, ileus, and urinary retention) all of which have demonstrated a reduction in morbidity measures, particularly hamper the aims of early mobilization and enteral nutrition.
length of stay and duration of ileus by using such an individualized If a thoracic epidural is chosen as the main analgesic technique, approach.10 Ultimately, it would be ideal to use a more direct the appropriate level should be chosen to match the surgical measure of tissue perfusion to guide fluid therapy. Various tech- incision. For example, for most colorectal surgery, the level of the niques such as gastric tonometry and near-infrared spectroscopy incision lies between T8 and T11 dermatomal levels. An epidural have been studied, but have not yet been well validated.
sited at T8/9 will spread easily upwards if the drug is injected manu-ally through a syringe. However, once connected to a volumetric Prevention of postoperative nausea and vomiting pump, the local anaesthetic seeps slowly into the epidural space, andthe influence of gravity then becomes important in the postoperative Nausea and vomiting is a common complication of anaesthesia period. With the patient sat up, the block will tend to sink. An epi- and surgery. It causes patient distress and discomfort, and delays dural sited at a lower thoracic level will thus struggle to cover the resumption of a normal diet. Multimodal strategies to reduce the upper level of the incision, but the lumbar roots may be persistently incidence of PONV include adequate hydration, balanced analgesia blocked, causing lower limb weakness, and impeding mobility.12 to minimize perioperative opioid use, avoidance of volatile anaes- The importance of acute pain medical and nursing team review thetic agents (although the effect of TIVA wears off after a few cannot be overemphasized. At least twice daily review is needed, hours), avoidance of nitrous oxide, and the administration of differ- as a patchy epidural, or one not covering the wound incision can ent types of antiemetic drugs. In particular, glucocorticoids (e.g.
be improved substantially, or even re-sited. It is crucial to maintain dexamethasone) reduce the risk of nausea and vomiting, have an the confidence of the patient in their pain relief if early mobiliz- effect on reducing tissue swelling, and a small analgesic effect.
ation is to follow. We establish the block with either bupivacaine0.5% or in the elderly bupivacaine 0.25%, and then continue the epidural infusion with bupivacaine 0.15% and fentanyl 2 mg ml21.
Once connected, we try at all costs not to disconnect the infusion Prevention of intraoperative hypothermia is important in minimiz- again, as this increases the risk of infection. Most epidural cath- ing the stress response. Hypothermia is associated with increased eters are removed at 48 h, and all by 72 h. The risk of infection wound infection, blood loss, and coronary events. Hypothermia increases substantially if epidural catheters are left .72 h. Pain also increases patient discomfort. Catecholamines and cortisol are not covered by the epidural (e.g. shoulder tip pain) is treated with also increased, which can further contribute to the stress response.
paracetamol or a NSAID. If the epidural does not cover the Forced-air warming devices, warmed i.v. fluids, and warmed incision, despite boluses from the pump, and an increase in the humidified gases should be used, and patient temperature should rate of infusion, the epidural is either re-sited or a patient- be monitored continuously during surgery.
controlled analgesia opioid infusion started.
After epidural removal, the patient takes regular NSAID and paracetamol, with severe breakthrough pain treated with oral mor-phine or tramadol. Severe pain at 72 h should raise the possibility of intra-abdominal complications, and the patient must be carefully Good analgesia is essential for postoperative mobilization and reviewed by the surgical team. Our practice is normally to remove resumption of normal activities. A cornerstone of fast-track surgery the urinary catheter on the same day as the epidural catheter.
programmes is the use of multimodal or balanced analgesia. Theprinciple of this is to gain additive analgesic effects from different modalities of pain control while minimizing side-effects, particularlythose of opioids. A recent systematic review of postoperative Oral intake has traditionally been limited in the postoperative analgesia concluded that due to the low incidence of complications, period and, when allowed, has involved a gradual progression from there was insufficient evidence to confirm or deny the ability of liquid to solid food. However, adequate nutrition is important to specific postoperative analgesic techniques to affect major post- enhance wound healing, reduce infection, and maintain muscle operative mortality or morbidity.11 However, there was consistent strength for mobilization and to counter fatigue. Reduced Continuing Education in Anaesthesia, Critical Care & Pain j Volume 9 Number 2 2009 Table 1 Key components of a fast-track programme 2 – 4 days for resection of the colon. Concerns have been raisedthat this may have been achieved at the expense of increased readmission rates or an increased burden on community healthcare providers. However, this does not appear to be the case.
Successful implementation of a fast-track surgical programme requires multidisciplinary collaboration between anaesthetists, approach involving the pre-assessment clinic and clinical nurse specialists and also ward and theatre staff. All staff involved Air/O2/TIVA or quick-onset volatile agents need to understand and be motivated by the principles of the fast-track approach (Table 1). A clear care pathway is vital in journey and defining clear discharge criteria. Roles of the surgeon include: appropriate case selection; type and size of Multimodal analgesiaAcute pain team managing epidural incision; minimizing the use of drains; ensuring drains or cath- eters used are removed promptly; early feeding; and early mobil- ization. Roles of the anaesthetist include: the use of ananaesthetic technique with rapid recovery (consideration ofTIVA); optimal fluid balance; prevention of PONV; and a Table 2 Fast-track programme outcomes (adapted from Kehlet)2 balanced analgesic regime ideally including thoracic epidural Decreased cardiopulmonary morbidityIncreased muscle strength and exercise capacityDecreased length of hospital stay and reduced hospital costsNo effect on readmission rate Fast-track surgical programmes involve implementation of a nutritional intake contributes to catabolism and muscle wasting.
package of multidisciplinary evidence-based interventions which Caution has been exercised with oral feeding after abdominal have the potential for significant reductions in postoperative com- surgery, particularly in the presence of a surgical bowel anastamo- plications and length of hospital stay (Table 2). Anaesthetists have sis. However, early enteral nutrition reduces gut permeability when a key role to play in many of these interventions. There are still compared with either late enteral feeding or parenteral nutrition.
areas of uncertainty where best practice remains to be elucidated.
This reduction in gut permeability is thought also to reduce bac- These include the role of minimally invasive surgical techniques terial translocation and hence infection. Several studies have and the place of epidural analgesia.
shown that early oral intake is safe even after bowel resection.13 Postoperative ileus is common after abdominal surgery. It increases pain and discomfort, hinders mobilization, and delays oral nutritional intake. Strategies to reduce the incidence of ileus 1. White PF, Kehlet H, Neal JM, Schricker T, Carr D. The role of the include the use of minimally invasive surgical techniques to reduce anesthesiologist in fast-track surgery: from multimodal analgesia to peri- the stress response and minimizing bowel handling, and also avoid- operative medical care. Anesth Analg 2007; 104: 1380 – 96 ance of the routine use of nasogastric tubes as discussed above.
2. Kehlet H. Fast-track colorectal surgery. Lancet 2008; 371: 791 – 3 3. Wu CT, Jao SW, Borel CO et al. The effect of epidural clonidine on peri- operative cytokine response, postoperative pain and bowel function inpatients undergoing colorectal surgery. Anesth Analg 2004; 99: 502 – 9 Prolonged bed rest after surgery is undesirable as it increases 4. Guenaga KF, Matos D, Castro AA, Atallah AN, Wille-Jorgensen P.
muscle loss and weakness, predisposes to venous stasis and throm- Mechanical bowel preparation for elective colorectal surgery. Cochrane boembolism, and impairs pulmonary function. Ambulation can enhance gut mobility and therefore reduce any ileus. Effective 5. Kehlet H, Kennedy RH. Laparoscopic colonic surgery—mission accom- plished or work in progress? Colorectal Dis 2006; 8: 514 – 7 analgesia is vital to allow early mobilization.
6. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2007; 3: CD004929 7. Low J, Johnston N, Morris C. Epidural analgesia: first do no harm.
8. Rigg JR, Jamrozik K, Myles PS et al., MASTER Anaesthesia Trial Study Where fast-track surgical programmes have been pioneered, post- Group. Epidural anaesthesia and analgesia and outcome of major operative inpatient stays have been reduced significantly, down to surgery: a randomised trial. Lancet 2002; 359: 1276– 82 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 9 Number 2 2009 9. Delgado-Rodriguez M, Bueno-Cavanillas A, Lopez-Gigosos R et al.
12. Armitage EN. Thoracic and lumbar epidural block. In: Wildsmith JAW, Hospital stay length as an effect modifier of other risk factors for noso- Armitage EN, McClure JH, eds. Principles and Practice of Regional comial infections. Eur J Epidemiol 1990; 6: 34 – 9 Anaesthesia. London: Churchill Livingstone, 2003; 139 – 67 10. Bundgaard-Nielson M, Holte K, Secher NH, Kehlet H. Monitoring of 13. Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24 h of peri-operative fluid administration by individualised goal-directed colorectal surgery versus later commencement of feeding for therapy. Acta Anaesthesiol Scand 2007; 51: 331 – 40 postoperative complications. Cochrane Database Syst Rev 2006; 4: 11. Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg 2007;104: 689 – 702 Please see multiple choice questions 1 – 4 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 9 Number 2 2009
RESOLUCIÓN Instituto Psiquiátrico Dr. José Horwitz Barak FECHA 30 diciembre Nº VERSIÓN Titulo: Protocolo de Referencia y Contrarreferencia en Trastorno de la Personalidad Limítrofe RESOLUCIÓN Instituto Psiquiátrico Dr. José Horwitz Barak FECHA 30 diciembre Nº VERSIÓN OBJETIVOS . 3 DISTRIBUCIÓN . 5 7. RESPONSABILIDAD DEL ENCARGADO . 5 8