Fast-track surgery: Toward comprehensive peri-operative care.

Fast-track surgery is a multimodal approach to patient care using a combination of several evidence-based peri-operative interventions to expedite recovery after surgery. It is an extension of the critical pathway that integrates modalities in surgery, anesthesia, and nutrition, enforces early mobilization and feeding, and emphasizes reduction of the surgical stress response. It entails a great partnership between a surgeon and an anesthesiologist with several other specialists to form a multi-disciplinary team, which may then engage in patient care. The practice of fast-track surgery has yielded excellent results and there has been a significant reduction in hospital stay without a rise in complications or re-admissions. The effective implementation begins with the formulation of a protocol, carrying out each intervention and gathering outcome data. The care of a patient is divided into three phases: Before, during, and after surgery. Each stage needs active participation of few or all the members of the multi-disciplinary team. Other than surgical technique, anesthetic drugs, and techniques form the cornerstone in the ability of the surgeon to carry out a fast-track surgery safely. It is also the role of this team to keep abreast with the latest development in fast-track methodology and make appropriate changes to policy. In the Indian healthcare system, there is a huge benefit that may be achieved by the successful implementation of a fast-track surgery program at an institutional level. The lack of awareness regarding this concept, fear and apprehension regarding its implementation are the main barriers that need to be overcome.

INTRODUCTION

The concept of “fast-track surgery” also known as “enhanced recovery after surgery” or “multimodal rehabilitation after surgery” has found mention in the surgical literature over the last two decades. Professor Henrik Kehlet was one of the first to describe a peri-operative care regime which facilitated early ambulation and discharge after surgery.[1] In such an approach, there is an attempt to “protocolise” patient care. The aims of this program are earlier ambulation, early and appropriate discharge from the hospital and an early return to productivity. The interventions involved in such a protocol targets the patient in each phase before, during, and after surgery [Figure 1]. Each of these interventions has been shown to independently be favorable and beneficial to the patient undergoing surgery. In a fast-track protocol, the simultaneous use of such interventions seems to have a synergistic effect which facilitates early recovery.

Figure 1

Components of fast-track surgery

There is an understanding that the peri-operative period is not exclusively a domain of any particular specialty. There is thought and discussion that since peri-operative care is a unique area of clinical practice there should be development of a new position that of a peri-operative specialist practitioner.[2] There might be a long waiting period before such specialists are available in each public and/or private sector hospital in many countries. Whether available or not the fact that there has to be a coordinated effort and a multi-disciplinary team approach to each patient undergoing surgery will remain unchanged. The partnership between the surgeon and anesthesiologist and any other specialist, is essential to ensure a favorable outcome of surgery. The same applies to the implementation of fast-track surgery principles to clinical practice. The successful application of such a recovery program requires the involvement of anesthesiologist right from the pre-operative period up to late into the post-operative period. In a recently completed trial in a tertiary public sector hospital in Mumbai, India, the authors have been able to demonstrate that such a program may be planned and implemented with interdepartmental coordination even in a modest public sector hospital setup effectively.[3] It helps achieve better patient outcome, earlier discharge and does not increase complications.

The approach may be divided into three phases:

Pre-operative phase: It involves conditioning the patient such that an optimized patient is taken up for surgery

Operative phase: Where operative and anesthetic maneuvers reduce the surgical stress response such that there is minimal disturbance of physiology

Post-operative phase: In this phase, there is a multimodal approach to patient rehabilitation. Optimum analgesia, reduction of post-operative nausea and vomiting and early ambulation are few important goals in this phase.

The composition of the multi-disciplinary team is as shown in Table 1. This team shall be responsible for reviewing and adopting the best evidence based practices into an institutional protocol. Flexibility and individualization are possible in the formulation of the protocol.[4] There is no “one size fit all”. Anesthesiologists have a key role in policy formulation. They may bring to the table their specific requirements to plan protocol implementation. In these meetings, every specialty concerned is assigned their specific roles in patient care. There also should be communication as to what each faculty expects of the other. Cross-over areas where the patient may need more than one specialist care need to be discussed in detail. The need of inter-departmental coordination is paramount.

Table 1

Membership of the inter-disciplinary team

DISCUSSION

There is probably no time period as important as the peri-operative period in a patient's stay in the hospital. The patient is often seen by many specialists. The level of care may be compromised in settings where there may not be efficient inter-departmental coordination and communication. The surgeon and the anesthesiologist occupy the central role in patient management. They are assisted by several other specialists mentioned in Table 1. We have attempted to outline and give an overview of each one's role in the peri-operative period.

ROLE OF THE ANESTHESIOLOGIST

The role of the anesthesiologist is divided into the three phases of patient care.

Pre-operative issues

The first and most important consideration is patient selection. There must be an evaluation of the existing organ function, which must obviously be followed by advice to optimize the same. Post-operative complications are related to pre-operative co-morbid conditions.[5] Pre-operative evaluation offers the opportunity to identify patients who may benefit from β-blocker therapy,[6] smoking cessation,[7] weight reduction, and/or better glycemic control. Nutritional status and physical fitness must be assessed. Poor nutrition and reduced exercise tolerance have been shown to have adverse outcomes post-operatively.[89] Even a short period of nutritional support pre-operatively has been shown to be beneficial.[8]

The pre-operative fasting period is electively kept short under the protocol. There is evidence to suggest that a 2 h fasting for liquids and 6 h fasting for solids is safe.[10] There is also evidence to suggest that pre-operative oral carbohydrate loading is beneficial to the patient. We carried this out in our trial at a public hospital in Mumbai by loading with 100 g of glucose with water before surgery. It is known to reduce the surgical catabolic stress response and post-operative insulin resistance.[11] The pre-operative encounter also provides an opportunity for the anesthesiologist to interact with the patient. It may be used to educate the patient and allay the fears of impending major surgery.

There are many ways by which pre-medication helps in fast-track surgery. Benzodiazepines are used as anxiolytics in their oral or intravenous (IV) form. Fentanyl is the only opioid that finds use in fast-track surgery due to its pharmacokinetic profile. The side-effects of other opioids like respiratory depression and constipation have led to the use of multimodal analgesic techniques to produce opioid sparing effects. Acetaminophen and selective cyclo-oxygenase-2 (COX-2) inhibitors have shown to have opioid sparing effects when used orally or rectally before surgery.[12]

Beta-blockers and alpha-2 agonists may be used in fast-track surgery. There is evidence regarding beta-blockers that suggests that they have several advantages like reduced anesthetic agent requirements and even anti-catabolic properties that may help in early recovery.[13] Alpha-2 agonists on the other hand have been shown to reduce post-operative ileus and vomiting after use in colorectal surgery.[14] Acid suppressive agents and/or prokinetics are used like they would have been routinely. Administration of a single dose gluco-corticoids like dexamethasone has shown to not only reduce post-operative nausea vomiting but also reduces the surgical stress response without a rise in any complications.

Operative issues

The anesthesia used intra-operatively should allow early ambulation and in some cases even same-day discharge in fast-track surgery. There exists a multimodal approach to anesthesia where several techniques may be used concomitantly. Achieving a minimal stress response and optimum analgesia are priority whichever may be the mode of anesthesia used. The anesthesia used is at the discretion of the surgeon-anesthesiologist team. Mentioned below are the agents preferred in each mode of anesthesia.

General anesthesia

Propofol has emerged as the popular choice of IV induction agent in fast-track surgery.[15] Its short duration of action and favorable side-effect profile make it an obvious choice for induction. Maintenance has been shown to be superior with highly volatile agents like desflurane and sevoflurane when compared to propofol or isoflurane. They have shown to facilitate early recovery.[16] The use of nitrous oxide in fast-track gastrointestinal surgeries is avoided in surgeries over an hour long due to bowel distension and increased post-operative nausea and vomiting. The use of volatile anesthesia also pre-disposes to post-operative nausea and vomiting, which may be reduced by using dexamethasone.[17] Among the opiods fentanyl is the agent of choice for fast-track surgery. Ultra-short acting remifentanil may provide an alternative, but the cost is at times prohibitive. Nonopioid analgesics (e.g., non-steroidal ant-inflammatory drugs (NSAIDs), [including COX-2 inhibitors], acetaminophen, alpha2 agonists, glucocorticoids, ketamine, and local anesthetics in the wound) may be used as part of a multimodal analgesic regimen aimed at opioid sparing.[18] Short acting muscle relaxants are used in patients that may facilitate early reversal or mitigate the need of reversal.

Regional anesthesia

The use of regional anesthesia as a standalone or adjuvant to general anesthesia has been used in fast-track surgery. It may sometimes be possible to perform procedures under spinal anesthesia only. This has several advantages including improved pulmonary function, decreased cardiovascular demand, a lower incidence of ileus, and good quality of analgesia at rest and on ambulation. At other times, epidural anesthesia is used liberally as an adjuvant to general anesthesia in abdominal surgeries. It has several beneficial effects. Neuraxial blockade is known to reduce the surgical stress response and also known to be associated with lower morbidity and mortality.[19] It may be used as an infusion or patient controlled anesthesia. It has been shown to facilitate the return of bowel function, while resulting in better preservation of peri-operative nutritional profiles, higher health-related quality-of-life scores, and improved exercise capacity after colon surgery.[20] When epidural anesthesia was used in a fast-track surgery program it has helped to reduce the incidence of ileus and facilitated early discharge.[21]

Local anesthesia

In keeping with the multimodal approach to anesthesia any fast-track program must incorporate the use of local anesthesia at the operative site. It has shown to contribute in the ability to perform ambulatory surgery.[22] Local anesthesia may be achieved by infiltration at the operative site or continuous infusion wound pumps. This has shown to yield improved analgesia, greater patient satisfaction, reduced incidence of post-operative nausea vomiting and shorter hospital stay.[23]

Other issues that have been identified as maneuvers that may assist in accelerated recovery are: (1) Maintenance of normothermia, (2) fluid management, (3) IV lidocaine, and (4) alvimopan.

Maintenance of normothermia

The fall in core body temperature during surgery is known to elicit a stress response in the patient. The shivering and vasoconstriction lead to increased cardiovascular demand and increase oxygen consumption. The maintenance of normothermia either by active or passive warming devices is advisable. It has shown to not only reduce wound infection[24] but also has shown to reduce hospital stay.[25]

Fluid management

There is a lack of clarity with regards to the use of intra-operative fluids in fast-track gastrointestinal surgeries. There is evidence to suggest that both under and over-hydrating the patient has detrimental effects.[26] Under-hydration leads to decreased perfusion and results in diversion of blood away from the intestines. Over hydration on the other hand has shown to increase venous pressure and lead to pulmonary and peripheral edema that may compromise peripheral oxygenation. There is evidence to suggest that excessive hydration can increase post-operative morbidity and lengthen the hospital stay after major abdominal surgery.[27] The balanced approach seems to be a “goal directed” fluid management. This should take into account pre-operative hydration status (fasting and bowel preparation if any) and intra-operative losses. Invasive monitoring and measures such as intra-esophageal Doppler monitoring help goal-directed fluid administration. Using this specific target value of cardiac index may be achieved. The goal directed fluid management has shown to shorten hospital stay.[28]

IV lidocaine

In a study conducted on colectomy patients, the use of IV lidocaine (as a bolus at induction and a continuous infusion intra-operative and for 24 h later) has shown to improve post-operative analgesia, fatigue, and facilitate earlier return of bowel function after laparoscopic colectomy. These benefits are associated with a significant reduction in hospital stay.[29] Even though, the topic needs further research there might be a role of IV lidocaine especially where epidural anesthesia has not been used. The role of lidocaine in a fast-track program needs further research.

Alvimopan

The peripherally acting mu-opioid receptor antagonist has been found to hasten the return of bowel function as well as shorten hospital stay when given after major abdominal surgery under a fast-track surgical program.[30] This must be used as one of the measures in a multimodal approach to counter post-operative ileus. Its use as an independent measure still needs further research.

Post-operative issues

The post-operative period requires the involvement of the anesthesiologist beginning from the recovery room right, which may last up to the time of discharge. The main issues here are analgesia and reduction of post-operative nausea and vomiting.

Pain management

Post-operative pain is the single most important factor leading to delay in ambulation and discharge from the hospital after ambulatory surgery or fast-track surgery.[31] The approach to post-operative pain should be a multimodal too, where a combination of several techniques may be used. Ideally, there should be no pain or a minimally tolerable pain after surgery. There is obviously a role of continuous epidural analgesic infusion over the immediate post-operative period whenever it has been inserted. The use of patient controlled analgesia with IV morphine within fast-track surgery has been shown to be effective and does not increase hospital stay.[32] It may be used when thoracic epidural catheters are not inserted. Opioids remain the most effective agents in terms of reducing post-operative pain. The side-effect profile on the other hand is detrimental to a fast-track protocol. Therefore, the intra- and peri-operative use of opioid sparing measures like the use of NSAIDs, ketamine, clonidine, dexmedetomidine, adenosine, gabapentin, dexamethasone, lidocaine, beta blockers, magnesium, and neostigmine is advised to reduce opioid related adverse effects (acute opioid tolerance, hypoventilation, sedation, ileus, nausea and vomiting, and urinary retention).

Post-operative nausea and vomiting

Post-operative nausea and vomiting is a troublesome side-effect of general anesthesia. Although the real incidence is not known, across studies done in fast-track surgery settings incidence has ranged from 10% to 20%, respectively. It is also a cause of seeking medical attention after ambulatory surgery.[33] Post-operative nausea and vomiting has also been associated with risk of aspiration and suture dehiscence. It leads to considerable patient dissatisfaction. Current strategies to tackle this problem are the concomitant use of several drugs and peri-operative maneuvers known to reduce post-operative nausea and vomiting. A recent systematic review of the Cochrane database shows that dexamethasone, ondansetron, droperidol, propofol (instead of volatile agents), ultra-short-acting narcotics, supplemental oxygen, and avoiding nitrous oxide all help reduce the incidence of post-operative nausea and vomiting. This review shows no superiority of one drug over the other. It also shows that when selected drugs are used together there is a better outcome.[34]

CONTINUING CARE

Even though strictly transfer from a post-anesthesia care unit to the surgical ward usually marks the end of an active role of the anesthesiologist, participation and inputs may help formulate a good analgesic regimen prior to and after discharge. A follow-up of the patient in the post-operative period gives an anesthesiologist an opportunity to determine the overall success of the anesthetic techniques used in the program. Follow-up serves as an internal quality check. Complications like delayed nausea and vomiting or constant pain at the operative site may need consultation with an anesthesiologist.

ROLE OF THE SURGEON

The surgeon in a fast-track surgery setting has the task of convening the multi-disciplinary team and formulating policy with this team. Implementation begins with proper patient selection. A detailed assessment is required to identify patients who may not be included in the protocol. Surgeons hesitate including patients with severe comorbidities and/or complex abdominal surgeries. In the pre-operative period, the surgeon must educate the patient regarding the procedure to follow. Patients need to be educated regarding the concept of fast-track surgery and its expected outcomes. In this phase, the surgeon may also use measures like avoiding mechanical bowel preparation,[35] pre-operative oral carbohydrate loading,[11] keep starvation times minimum[36] and implement a pre-operative exercise and physical therapy regimen. Operative techniques like the application of minimally invasive surgery have further led to the development of fast-track protocols. There is sufficient evidence to suggest that laparoscopic surgery reduces the surgical stress response.[37] Most clinical trials investigating the fast-track methodology have involved liberal use of laparoscopic techniques. Avoiding large incisions, reduced incidence of ileus and preservation of pulmonary function are some of the claimed benefits.[38] However, when an optimum peri-operative care protocol was applied to surgeries performed by the open approach there was no significant difference observed between the two.[39] Therefore, the inability to perform a laparoscopic procedure should not discourage the implementation of a fast-track surgery protocol. Minimal tissue handling, shorter operating time and a good surgical technique are pre-requisites as for any surgery. There is also emphasis on the elective rather than routine use of nasogastric tubes, abdominal drains and urinary catheters in the peri-operative period.[3] The presence of tubes, drains, and catheters has shown to reduce ambulation time after surgery.[40] In the post-operative period, the surgeon must work closely with the anesthesiologist to ensure analgesia and minimal to no post-operative nausea and vomiting. The elective use of nasogastric tube in the post-operative period[41] must be followed by the institution of early enteral nutrition. Early enteral nutrition has shown to reduce anastomotic leak, wound and other infections, pneumonia, and mortality. There is also an associated reduction in length of hospital stay.[42] There is a role for enforced early ambulation after surgery under a fast-track protocol. Early ambulation has shown to facilitate an early discharge from the hospital and has benefits for the patient even after discharge.[43] It was observed that patients who obeyed an enforced ambulation plan had reduced fatigue, normal sleep, earlier return to leisure activity and activities of daily living. The patient must be discharged when he/she is relatively pain free, able to care for him/herself or has an attendant to do so at home and is passing flatus and/or stool. Post-discharge follow-up is essential and rates of complications and re-admission during this period serve as a yardstick to measure protocol success.

ROLE OF OTHER HEALTHCARE PROVIDERS

The physician

There are several clinical situations where inputs from the physician can impact patient management in the peri-operative period. Cardiovascular comorbidity and diabetes mellitus is seen very commonly in surgical patients. Optimizing patients before they undergo surgery has been shown to have several benefits and influences outcome. Though the physician may not be a part of the multi-disciplinary team, he is an invaluable contributor to patient care.

The nursing staff

The active participation of the nursing staff is critical for program success. All the components mentioned in a fast-track protocol require the help and assistance of the nursing staff, may it be ensuring pre-operative investigations, oral carbohydrate loading or in the post-operative period enforcing an active mobilization plan and early enteral feeding program. They should also be active contributors to policy formation. Feedback from the nursing staff provides great insight to the analysis of the outcomes. It goes on to allow a good review of the policy and changes required.

Others

The nutritionists after understanding specific goals of the surgeon-anesthesiologist team can plan dietary intervention to optimize nutritional status before and after surgery. Understanding specific surgical goals especially in gastrointestinal surgery is crucial like giving a low residue diet in colonic surgery or jejunal tube feeding, etc.

The physical therapist consultations are used both in the pre-operative and post-operative period. As mentioned above a good pre-operative exercise plan is as important as the post-operative rehabilitation of the patient. It is not uncommon many a times to have performed a good surgery, but not have the patient return to productivity for prolonged periods of time. Physical rehabilitation seeks to do exactly that as soon as possible after surgery.

Patient liaisons and social workers act as the link between doctors and patient. Ensuring follow-up after an early discharge is critical to analyze protocol success. Apprehensions to return to the home environment after a surgery and availability of help at home are some crucial issues that may be addressed by these workers.

CONTRA-INDICATIONS

Even though, there are not any specific contra-indications to fast-track surgery its application in the elderly and those with severe comorbidities has been viewed with apprehension. In a large multi-centric study in Germany investigators were able to show a high compliance rate of the protocol in an elderly population with a significant reduction in hospital stay (40% reduction in hospital stay). More than 30% of these patients had severe comorbid conditions (American Society of Anesthesiology Grade 3 or 4).[44] There was no rise in complications or re-admissions observed in this study. Hence, this protocol may be used in the elderly and those with comorbidities safely. Another issue is an application of the fast-track methodology to complex abdominal surgeries and/or multi-cavitary surgeries. Fast-track surgery has been safely applied to complex pelvic and re-operative procedures with successful results.[45] When studying the protocol application to Ivor-Lewis esophagogastrectomy more than 75% of patients over the age of 70 years failed the protocol.[46] More research is required in this area as there are not many large randomized trials for this specific subset of patients.

OUTCOME

The outcomes of all reported trials comparing fast-track to traditional peri-operative care protocols have shown significant reduction in hospital stay without a rise in complications or re-admissions.[21] There is a lack of data from India regarding the use of fast-track methodology. The authors have demonstrated that the benefits of fast-track surgery can be reproduced in India too.[3] There remains significant variability in peri-operative care between institutes, surgeons, and anesthesiologists across this country. Even though the concept of fast-track surgery does not prescribe to any one pre-set protocol the concept itself provides a vast database of evidence based practices from which a multi-disciplinary team may formulate an appropriate protocol.

FUTURE DIRECTIONS

The field of peri-operative care is very dynamic and is ever evolving in the light of new emerging evidence. In light of the vast knowledge that exceeds any one specialty, peri-operative care deserves to become a sub-specialty. Anesthesiologists and surgeons are the most suited to specialize in this field to provide expert care to the patient undergoing surgery.

CONCLUSION

Fast-track surgery is just an extension of the critical pathway that integrates new modalities in surgery, anesthesia and nutrition, enforces early mobilization and feeding, and emphasizes reduction of the surgical stress response. It intends to remove the patient's pathology with minimal disturbance to physiology. It is hoped that this approach will not only improve efficiency by shortening the hospital stay, but also decrease the physiologic impact of major surgery. An anesthesiologist is a key (probably the most important) ally of the surgeon in the formulation and implementation of a fast-track surgery protocol at an institutional level. Familiarity with concepts of peri-operative care amongst surgeons and anesthesiologists combined will lead to widespread application of such practices and improve outcomes after surgery.