Fast track pelvic surgery evidence from Denmark. Charlotte Møller Hot Topics in Helsinki Oct. 2007

Transkript

1 Fast track pelvic surgery evidence from Denmark Charlotte Møller Hot Topics in Helsinki Oct. 2007

2 Why? Best treatment surgery anaesthesia pain treatment reducing drains and catheters ensuring mobilisation and food intake information Evidence?

3 What do we recommend? 500 Danish General Practitioners & all Danish Gynaecologists (438) Uncomplicated hysterectomy Length of convalescence Resumption of 7 daily activities Restrictions for lifting 0 12 weeks 0 12 weeks Ref. Moller, Ugeskr Læger 2001,7043

4 GPs: Lifting restrictions Max. kg Weeks Response: 55%

5 Gynaecologists: Lifting restrictions Max. kg Weeks Response: 72%

6 Regimen at Hvidovre Hospital Focus on Information oral and written Early mobilisation Early food intake Pain treatment Duration of hospitalisation Duration of convalescence

7 Innovation Standardised pain treatment Standardised care Standardised information

8 Standard anaesthesia/analgesia Anæstesi og postoperativ smertebehandling ved hysterektomi Præmedicin Præoperativt (på CO eller opvågningen) Induktion Efter induktion Vedligeholdelse Ved lukning af fascien Ved operationens afslutning Tbl. Panodil Retard 2 g samt vigtig vanlig medicin. Abdominal hysterektomi Epiduralkateter (T9-T11) Testdosis: 3 ml Lidokain m. adrenalin 2% Abdominal hysterektomi Remifentanil (0,5 µg/kg/min) pumpen startes. Bolus Propofol 2-3mg/kg til patienten sover. Nimbex 0,15 mg/kg til intubation. Dexamethason 8 mg i.v. Abdominal hysterektomi Epiduralt: 8 ml Bupivacain 1/4% + 2 mg epimorfin (pt. < 70 år) / 1 mg epimorfin (pt. > 70 år). Der tilsluttes ingen pumpe. Remifentanil 0,5 µg/kg/min Propofol 6 mg/kg/time Abdominal hysterektomi Epiduralt: Bolus 12 ml Bupivacain 1/8%. Inj. Toradol 30 mg i.v. Inj. Zofran 4 mg i.v. Inj. Droperidol 0,625 mg i.v. Laparoskopisk hysterektomi Remifentanil (0,5 µg/kg/min) pumpen startes. Bolus Propofol 2-3mg/kg til patienten sover. Nimbex 0,15 mg/kg til intubation. Dexamethason 8 mg i.v. Remifentanil 0,5 µg/kg/min Propofol 6 mg/kg/time Inj. Sufenta µg i.v. Inj. Toradol 30 mg i.v. Inj. Zofran 4 mg i.v. Inj. Droperidol 0,625 mg i.v. Vaginal hysterektomi Remifentanil (0,5 µg/kg/min) pumpen startes. Bolus Propofol 2-3mg/kg til patienten sover. Oftest anvendes larynxmaske, ingen Nimbex. Dexamethason 8 mg i.v. Remifentanil 0,25-0,5 µg/kg/min Propofol 4-6 mg/kg/time Inj. Sufenta µg i.v. Inj. Toradol 30 mg i.v. Inj. Zofran 4 mg i.v. Inj. Droperidol 0,625 mg i.v. Antibiotika Som engangsbehandling: Inj. Cefuroxim (Axacef) 1,5 g i.v. peroperativt. Abdominal hysterektomi Laparoskopisk hysterektomi Vaginal hysterektomi Inj. Sufenta 10 µg i.v. pn eller Inj. Sufenta 10 µg i.v. pn eller Inj. Sufenta 10 µg i.v. pn eller Inj. Morfin 5-10 mg i.v. pn. Inj. Morfin 5-10 mg i.v. pn. Inj. Morfin 5-10 mg i.v. pn På opvågningen Epiduralkateteret fjernes inden udskrivelsen fra opvågningen 2 4 timer postoperativt Inj. Fragmin 2500 IE i.m. Fast medicin: Tbl. Vioxx 25 mg x 1 + Tbl. Paracetamol Retard 2 g x 2 + Tbl. Magnesia På sengeafdelingen 500 mg x 2. Escapemedicin : Tbl. Morfin mg p.o. max. x 6 Mod kvalme: Inj. Zofran (Ondansetron) 8 mg i.v./i.m. eller supp. Primperan (Metoclopramid) 20 mg. Væskebehandling I øvrigt NaCl max ml i hele operationsforløbet. Blodtab erstattes peroperativt jævnfør anæstesiafdelingens instruks. Epiduralkateteret kan bibeholdes, hvis pt. er svær at smertedække. Hun overgår så til anæstesiafdelingens sædvanlige epiduralregime. Kateter à demeure fjernes 4-6 timer postoperativt på sengeafdelingen. Pt. forventes tilbage i afd. 420 ca. 2-3 timer postoperativt.

9 Standard plans and forms Dagen efter operationen: D. / - Plejeopgav er Almen tilstand BT, puls OK & temperatur mane Iv-adgang bevaret KAD / vandladning fungerer Cikatrice OK Vaginalblød ning tilladelig Epiduralkat eter fungerer Smertebeha ndling tilstrækkelig Flatus Afføring Init NV DV AV Mobiliseret Spise almindelig kost Drikke mindst 2 liter Hgb. normal / Diskutere set af læge udskrivelse ved Evt. TEDstrømper & stuegang AK-beh. Sygeplejeproblemer Observationer / bemærkninger: (Anfør venligst årsagen, hvis patienten ikke kan klare de beskrevne mål) BT: p: Temp.: Seponeres KAD seponeres kl. kl. (samtidig med fjernelse af epidural kateter) Ved gennemsivning forstærkes Vandladning forbindingen om efter muligt. sep. Ved behov for skiftning kontakt CM / MS. Seponeres kl. (Gerne før kl. 08) E.L. 2 x 2 timer i hver vagt + ved måltider Gåture i afdelingen ½ l. - ½ l. - ½ l. - ½ l. Inkl. 3 stk. proteindrikke Udskrivelse kl. ca.

10 Recommendations for postoperative activity Exercise Sports Lifting Work Sex immediately 2 weeks max. 10 kg for 2 weeks 2-3 weeks 3 weeks or ended vaginal bleeding

11 Trial set-up - 30 abd. hyst. Information, early mobilisation & food intake Per oral pain treatment Local anaesthesia in the wound Ketamine 0,5 mg/kg i.v. PONV prophylaxis: Ondansetrone 4 mg iv (end) Epidural analgesia (bupivacaine + morphine) continuous for 24 hours Planned postoperative hospitalisation: 1 day

12 Length of stay % Days 67% had PONV within 12 hours Epi w opioids (N=30)

13 Trial set-up - 30 abd. hyst. Information, early mobilisation & food intake Per oral pain treatment Local anaesthesia in the wound Ketamine 0,5 mg/kg i.v. PONV prophylaxis: Dexamethasone 8 mg i.v (start) Ondansetrone 4 mg iv (end) Epidural analgesia (bupivacaine) continuous for 24 hours Planned postoperative hospitalisation: 1 day

14 Length of stay % % had unsatisfactory effect of epidural Epi w opioids (N=30) Opioid free epi. (N=30) Days

15 Trial set-up - 20 abd. hyst. Information, early mobilisation & food intake Per oral pain treatment Ketamine 0,5 mg/kg i.v. PONV prophylaxis: Dexamethasone 8 mg i.v (start) Ondansetrone 4 mg iv (end) No epidural Bilateral n. ilioinguinalis bloc at closure Sufentanil 30 microg i.v. at closure Planned postoperative hospitalisation: 1 day

16 Length of stay % % had moderate/severe pain within 6 hours Epi w opioids (N=30) Opioid free epi. (N=30) No epidural (N=20) Days

17 Trial set-up - 31 abd. hyst. Information, early mobilisation & food intake Per oral pain treatment PONV prophylaxis: Dexamethasone 8 mg iv (start) Ondansetrone 4 mg iv (end) Droperidol 0,625 mg iv (end) Epidural analgesia (bupivacaine og morphine) peroperatively (+ 2 hours) Planned postoperative hospitalisation: 1 day

18 Length of stay % % no PONV, 77% no/light pain at rest within 24 hours Epi w opioids (N=30) Opioid free epi. (N=30) No epidural (N=20) Perop. epidural (N=31) Days

19 Current regimen Information, early mobilisation & food intake Per oral pain treatment (paracetamol and NSAID) PONV prophylaxis: Dexamethasone 8 mg iv (start) Ondansetrone 4 mg iv (end) Droperidol 0,625 mg iv (end) Epidural analgesia (bupivacaine + morphine) peroperatively (+ 2 hours) Planned postoperative hospitalisation: 1 day

20 Hours out of bed after abdominal hyst. - cumulated for 4 series (N=108) 20 Hours out of bed Postoperative day

21 Resumption of common activities after abdominal hyst. cumulated for 4 series 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Postoperative day Getting dressed (n=108) Personal hygiene (n=108) Climbing stairs (n=108) Cooking (n=108) Cleaning (n=107) Shopping (n=107) Driving (n=70)

22 Resuming work and leisure cumulated 100 Leisure (n=96) Work (n=99) % Days

23 Length of stay, Hvidovre, DK (benign indication) 1996,2 1997,1 1997,2 1998,1 1998,2 1999,1 1999,2 2000,1 2000,2 2001,1 2001,2 2002,1 2002,2 2003,1 2003,2 2004,1 2004, Days

24 Danish Hysterectomy Database Start 2004 All planned hysterectomies on benign indication All Danish gynaecological departments (incl. private hospitals). compulsory! Registering: Risk factors, thrombosis prophylaxis, surgical procedures, pain treatment, length of stay, complications, reoperations and readmissions

25 Length of stay in DK, N= 4451 No hyst L of stay 0 Ref: DHD & Hansen CT

26 Conclusion Hospitalisation and convalescence can be reduced considerably after abdominal hysterectomy Choice of analgesia has less influence on length of stay Patient education is of major value in fast track surgery

27 Focus in the future Improved perioperative treatment with reduction of nausea and vomiting Homogeneous postoperative restrictions and advice Continuous revision of routines Out-patient abdominal hysterectomy?