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The essence of the fast track care program and standard care program. |
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| FAST-TRACK CARE |
STANDARD CARE |
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| PRE-OPERATIVE PHASE |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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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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