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Optimoitu toipuminen, kirurgin näkökulma
Tom Scheinin, kirurgian dosentti, FRCS
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
Fast track
Fast track = Lentokentät = LP I = Päivystyksen hoitopolku = Kaikkea muuta, ei kirurgiaa
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
Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study
• 30 open
– OR time 131,5 min – Discharge 2,3 pop – Re-admitted 8 (27%)
• 30 laparoscopic
– OR 215,5 min – Discharge 2,9 pop – Re-admitted 6 (20%)
Basse L et al. Ann Surg 2005;241:416-23
OT (ERAS)
Pre-operatiiviset
tekijät
Anestesia Intra-
operatiiviset ja kirurgiset
Post-operatiiviset
Evidence Based Medicine
Wind J et al. Br J Surg 2006;93:800-809 Systematic review of enhanced recovery programmes in colonic surgery
17 ERAS items 5 or more ERAS items = ERAS programme
ERAS-criteria PRE-OP WARD • Patient information • Avoid fasting • Synbiotics • No bowel-prep
ANAESTHESIA • No opioid/benzo premedication • Limited iv fluids • O2 0.6 - 0.8 • Avoiding hypothermia • Epidural analgesia • Minimise need of opioids • Avoid NG-tube
SURGERY • Mini-invasive/transverse incisions • Avoid drains
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
Laparoscopic pelvic surgery
• steep Trendelendburg • blood pressure • placement of epidural • gastric reflux (NG)
• IAP - CO2 • diuresis • compression of veins • compression of lungs • atelectasis
LAPAROSCOPIC SURGERY IMPAIRS TISSUE OXYGEN TENSION
Home day 3 postop
2005-2008
Home day 4 postop
2000-2005
www.erassociety.org
ERAS society recommendations Evidence level and recommendation grade
Gustafsson UO et al. Guidelines for perioperative care in Elective colonic surgery: ERAS society recommendations. World J Surg 2013
• 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
ERAS society recommendations Evidence level and recommendation grade
Gustafsson UO et al. Guidelines for perioperative care in Elective colonic surgery: ERAS society recommendations. World J Surg 2013
• 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
ERAS society recommendations Evidence level and recommendation grade
Gustafsson UO et al. Guidelines for perioperative care in Elective colonic surgery: ERAS society recommendations. World J Surg 2013
• 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!)
ERAS society recommendations Evidence level and recommendation grade
Gustafsson UO et al. Guidelines for perioperative care in Elective colonic surgery: ERAS society recommendations. World J Surg 2013
• 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
Epidural analgesia diminished pain but did not otherwise improve enhanced recovery after laparoscopic sigmoidectomy: a prospective
randomized study Turunen P et al, Surg Endosc. 2009 Jan;23(1):31-7. Epub 2008 Sep 24
• 60 patients with complicated diverticular disease: with or without epidural anesthesia
• Postoperative oxycodone consumption, pain, and recovery parameters were followed for 14 days
Turunen P et al, Surg Endosc. 2009 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
op time (min) blood loss (ml) Bowel/air (d) Bowel/feces (d) hospital stay (d) readmission (n)
Epidural 135 (60-165) 20 (20-800) 1 (1-4) 2 (1-7) 3 (2-9) 3
No epidural 120 (85-230) 20 (20-200) 1 (1-4) 2 (1-9) 3 (1-14) 1
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
Diuresis with or without epidural
0.01 3 ± 4 8 ± 9 Oksicodon (mg)
±31CRP (mg/l)) 66( ±36) 51( 0.03
0.01 4.7±0.9 5.5±1.5 Fluids (l/d)
0.05 83±29 69±25 Diuresis (ml/h)
0.053 26 (±17) 18 (±12) Efedrin (mg)
P Epidural Controls Day of operation
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
Results:
• Recovery required a median of 5 days in EDA patients and 4 days in the PCA group, P = 0.082
• PCA patients had significantly less overall complications;19 (33%) vs 35 (54%); P = 0.029
Hübner M et al, Ann Surg 2014
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
- pre- vai postop - korkeus - opiaatti - puudute
SIC! Mikä epiduraali käytössä:
Home day 2-4 postop
2008 -
Criteria for going home Patient eats, drinks, bowel and diuresis function, pain manageable with oral painkillers, no nausea, staying at home feasible