Table 1

The essence of the fast track care program and standard care program.

FAST-TRACK CARE

STANDARD CARE


PRE-OPERATIVE PHASE

Outpatient department of Surgery

- Scheduling of operation

-Information about the fast track program

-Informed consent

- Scheduling of operation

-Informed consent

Outpatient department of anesthesiology

- Pre-assessment for risk adjustment

-Discussion focusing on placement of thoracic epidural catheter for management of perioperative analgesia

-Discussion of the essence of the fast track program

- Pre-assessment for risk adjustment

-Open discussion about different possibilities for management of perioperative analgesia

Pre-admission counseling and guided tour on surgical ward

- Yes

- No

DAY OF ADMISSION

Intake

- Additional fast track information

- Routine

Bowel preparation

- Only enema

- Only enema

Pre-operative carbohydrate loaded liquids

- 4 units (preOp®)

- No

Diet

- Last meal 6 h before operation

- Last meal until midnight

Pre-anesthetic evening medication

- Lorazepam, 1 mg the evening before operation, if necessary

- Lorazepam, 1 mg or Temazepam 10 or 20 mg

DAY OF SURGERY

Pre-operative fasting

- No, 2 units CHL 2 h before surgery

- Yes

Pre-anesthetic medication

- No

- Lorazepam 1 mg, or Midazolam 7.5 mg

Anesthetic management

- Placement of thoracic epidural catheter (T6–T10, depending on the surgical resection); test-dose (Bupivacaine 0.25% with adrenaline 1:200,000), top-up dose (Bupivacaine 0.25% [± 10 ml] with Sufentanil 25 μg, followed by continuous infusion (Bupivacaine 0.125% with Fentanyl 2.5 μg.ml-1) until day 2 postoperative

-Combined with balanced general anesthesia

-Restricted per-operative fluid infusion regime (Ringers lactate 20 ml.kg-1 in the 1st h followed by 6 ml.kg-1.h-1)

-Use of vasopressor drugs as 1st choice for management of mean blood pressure drop > 20% of baseline

-Forced body heating (Bair hugger system and warmed IV fluids)

-Removal of naso-gastric tube before extubation

-Prophylactic use of Odansetron (4 mg) to prevent PONV

- Placement of thoracic epidural conform fast track group, or lower level, or PCA-pump.

-Combined with balanced general anesthesia

-Standard per-operative fluid infusion regime (Ringers lactate 20 ml.kg-1 in the 1st h followed by 10–12 ml.kg-1.h-1)

-Use of extra fluid challenge as 1st choice for management of mean blood pressure drop > 20% below baseline

-Forced body heating (Bair hugger system and warmed IV fluids)

-Removal of naso-gastric tube before extubation

-Use of Odansetron, Dexamethason or Droperidol for PONV management according to attending anesthesiologist

Surgical Management

- Minimal invasive incisions/laparoscopy

-Supra-pubic urine catheter

-Infiltration of surgical wounds with Bupivacaine

-No standard use of abdominal drains

- Median laparotomy approach/laparoscopy

-Urine catheter according to attending surgeon

-No infiltration of surgical wounds with local anesthetic drugs

-No standard use of abdominal drains

Early post-operative management

- Use of epidural catheter as mentioned before to which Paracetamol 4 × 1 g.d-1 is added

-First oral drinks at 2 h post-surgery, supplemented with CHL liquids, 2 units (Nutridrink®)

-IV infusion of Ringers lactate 1.5 l.d-1

-Mobilization in the evening (>2 h out of bed)

-First semi-solid food intake in the evening

- Epidural or PCA-morphine to which Paracetamol 4 × 1 g.d-1 and/or Diclofenac 3 × 50 mg.d-1 are added

-Small amount of water orally

-IV infusion of Ringers lactate 2.5 l.d-1

-No mobilization scheme

DAY 1 AFTER SURGERY

Postoperative Management

- Oral intake > 2 l (including 4 units CHL liquids)

-Normal diet

-Stop IV fluid administration (leave canulla)

-Start laxative (MgO, 2 × 1 g.d-1)

-Close supra-pubic urine catheter and remove when residue < 50 ml

-Expand mobilization (> 6 h out of bed)

- Diet increased on daily basis

-IV fluid administration (2.5 l.d-1) is continued till adequate oral fluid intake

-Mobilization according to attending surgeon

DAY 2 AFTER SURGERY

Postoperative Management

- Remove epidural add Diclofenac 3 × 50 mg.d-1

-Remove IV cannula

-Continue Paracetamol 4 × 1000 mg and laxative

-Normal diet

-Expand mobilization (> 8 hours)

-Plan discharge

- Epidural removed according to attending anesthesiologist

-Continue as on day 1 untill discharge criteria are fulfilled

DAY 3 AFTER SURGERY

- Continue as on day 2 untill discharge criteria are fulfilled

Continue as on day 2 untill discharge criteria are fulfilled


CHL: CarboHydrate Loaded, PCA: Patient Controlled Anesthetics, IV: Intra Venous, PONV: PostOperative Nauseaand Vomiting, MgO: Magnesium Oxide

Wind et al. BMC Surgery 2006 6:16   doi:10.1186/1471-2482-6-16

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