What is Fast-Track And Why Bother?

1. What is Fast-TrackAnd Why Bother? Ian Smith, MD, FRCA Editor, Journal of One-day Surgery Senior Lecturer in Anaesthesia University Hospital of North Staffordshire Stoke-on-Trent

2. Operating room Recovery room Ward area Overnight stay HOME Traditional approach Operating room Recovery room Ward area HOME Day case surgery Operating room Ward area HOME Fast track approach Fast Track Recovery

3. 3 Stages of Recovery • Early • awakening & return of protective reflexes • Intermediate • recovery to point of discharge • still needs support • Late • recovery to preoperative state

4. Rationale for Fast Tracking • Early recovery occurs in operating room • Patient may meet discharge criteria on arrival • Use of recovery room: • increases bureaucracy • increases cost • delays other patients • delays discharge

5. Fast Track = Faster Discharge * * Total recovery time (min) * Song, et al. —Br J Anaesth 93: 768, 2004 * p <0.05, from recovery room group

6. Assessing “Fast-track Eligibility” • Clinical • awake • fully oriented • comfortable • stable cvs signs • stable resp signs

7. Recovery Scores Score Activity: Respiration: Circulation: Consciousness: Oxygenation: Moves all 4 limbsMoves 2 limbsNo limb movement Can deep breathe & coughDyspnoea / limited breathingApnoea BP ± 20% baselineBP ± 40% baselineBP ± 50% baseline Fully awakeArousableUnresponsive SpO2 >92% on airSpO2 >90% onO2SpO2 <90% on O2 210 210 210 210 210 Maximum score 10;need >9 Aldrete —J Clin Anesth 7: 89, 1995

8. “Fast-track” Score • Similar to Aldrete + • Pain: • none or mild discomfort 2 • controlled moderate–severe pain 1 • persistent moderate–severe pain 0 • PONV • minimal nausea no vomiting 2 • controlled transient retching 1 • persistent PONV 0 • Maximum 14 • >12 (no score <1): fast-track eligible • White — J Clin Anesth 11: 78, 1998

9. Who Can We Fast Track? • 13.9 – 42.1% of all ambulatory GA patients met discharge criteria in OR • Apfelbaum, et al. — Anesthesiology 87: A32, 1997 • 75% receiving sevoflurane and90% receiving desflurane for tubal ligation were fast track eligible(only 26% with propofol) • Song, et al. — Anesth Analg 86: 267, 1998

10. Success of Fast-tracking • 207 patients in RCT • 110 fast-track; 97 conventional • 81% successfully bypassed PACU • arthroscopy 97% • hysteroscopy 77% • laparoscopy 72% • Song, et al. —Br J Anaesth 93: 768, 2004

11. Do We Need The Recovery Room?

13. A Question Worth Asking? “Is your journey to the recovery room really necessary?” Jean Millar — Editorial,Br J Anaesth 93: 756, 2004

14. Do We Need The Recovery Room? • Manage unconscious patient • Extubation & airway support • Manage complications • Administer O2 • Treat early pain • Treat early PONV

15. Propofol-isoflurane Propofol-desflurane 5.1 ± 2.3 4.4 ± 1.4 6.5 ± 2.5 5.4 ± 1.3 18 ± 10 Ashworth & Smith —Anesth Analg 87: 312, 1998 Propofol-sevoflurane Sevoflurane (VIMA) 4.6 ± 1.8 3.6 ± 1.8 5.9 ± 1.5 4.4 ± 1.8 22 ± 7 Smith & Johnson —Anesthesiology 89: A39, 1998 Mean ± SD The Unconscious Patient Eye opening (min) Oriented (min) Duration (min) Anaesthetic

16. Early Awakening • Wound dressing & transfer takes »5 min. • Discontinue (/ reduce) anaesthetic towards end • Titrate anaesthetic: “AS DEEP ASNECESSARY, AS LIGHTAS POSSIBLE” • clinical response • end-tidal • (BIS)

17. Bispectral Index • Processed EEG, index 0–100 • high awake; low deep • Claimed no recall £60 • May permit dose reduction • May improve recovery times • Song, et al. — Anesthesiology 87: 842, 1997 • May predict “fast-track eligibility” • Song, et al. — Anesth Analg 87: 1245, 1998

18. propofol desflurane BIS & Fast-Track Recovery Time tofast-trackeligible(min) BIS at end of anaesthesia Song, et al. —Anesth Analg 87: 1245, 1998

19. BIS May Not be Necessary • 99 patients gynae laparoscopy • Sevoflurane induction & maintenance • BIS 50–60 or BP/HR ± 20% • Bypass PACU if Aldrete >9 within 10 min Clinical group: 90% “Fast-tracked” BIS titrated: 86% “Fast-tracked” Ahmad, et al. —Anesthesiology 98: 849, 2003

20. Do We Need The Recovery Room? • Manage unconscious patientPatients are awake! • Extubation & airway support • Manage complications • Administer O2 • Treat early pain • Treat early PONV

21. LMA commonly used Well tolerated Complications rare Removed when awake: by patient Extubation & Airway Support LMA out (min) 3.8 ± 1.8 Eyes open (min) 4.5 ± 1.7 • Data from 171 pts in ongoing research project

22. Do We Need The Recovery Room? • Manage unconscious patient • Extubation & airway supportLMA! • Manage complications • Administer O2 • Treat early pain • Treat early PONV

23. Complications in Recovery • 6,914 Day case GA in 4 Canadian hospitals • PONV 7.3% • Hypotension 0.23% • Hypertension 0.1% • Respiratory 0.43% Duncan, et al. — Can J Anaesth 39: 440, 1992

24. Complications in Recovery • 17,638 Day cases at Toronto Western • “PACU Incidents” 7.3% • Pain 4.7% • PONV 2.2% • All CVS 0.8% • All respiratory 0.6% Chung, et al. — Br J Anaesth 83: 262, 1999

25. Complications in Recovery • CVS events predictable by: • CVS disease • smoking • obesity • Respiratory events predictable by: • obesity • smoking • respiratory disease Chung, et al. — Br J Anaesth 83: 262, 1999

26. Do We Need The Recovery Room? • Manage unconscious patient • Extubation & airway support • Manage complicationsComplications are rare • Administer O2 • Treat early pain • Treat early PONV

27. Oxygen Therapy Admission SpO2 SpO2 <90% • 10 / 11 pts with SpO2 <90% had admission value £92% • 8 / 282 remaining pts had admission SpO2£92% Regimen Number Nasal O2 Humidified O2 Deep breaths Nothing 69 72 69 72 96.8 ± 2.3 96.7 ± 2.1 97.1 ± 1.6 97.4 ± 1.4 2 (3%) 2 (3%) 4 (6%) 3 (4%) Gift, et al. — Anesth Analg 80: 368, 1995

28. What’s the Harm of O2? • Delay recovery • Uncomfortable for patient • Fire risk • Expense of disposables • Waste

29. Do We Need The Recovery Room? • Manage unconscious patient • Extubation & airway support • Manage complications • Administer O2 Only if SpO2£92% • Treat early pain • Treat early PONV

30. Optimal Pain Relief • NSAID • Local anaesthesia • infiltration • topical • block • Intraoperative opioids • only if needed

31. Pain on Awakening • Should be minimal with appropriate measures: • Severe 1% • Mild 15% • None 84% • Data from 171 pts in ongoing research project

32. Do We Need The Recovery Room? • Manage unconscious patient • Extubation & airway support • Manage complications • Administer O2 • Treat early painWhat pain? • Treat early PONV

33. And Vomiting Postoperative Nausea

34. Risk Factors For PONV History of Motion Sickness / PONV Female Opioid Therapy Non-smoker

35. Treatment & Prevention of PONV • Consider hydration, analgesia • Prophylaxis if high risk • dexamethasone 4–5 mg • Combination therapy • for highest risk • different classes • AVOID OPIOIDS

36. Nausea on Awakening • Should be minimal with appropriate measures: • Moderate 2% • Mild 2% • None 96% • Data from 171 pts in ongoing research project

37. The Case for Fast-tracking • Modern anaesthetics allow rapid recovery • if carefully titrated • Early complications are rare (& predictable) • Pain & PONV may be minimised • treatment may still be given in ward • Recovery room admission may be unnecessary

38. Is There Risk? “Importantly, this accelerated recovery process was not associated with any increased postoperative side effects or patient discomfort” Song, et al. —Br J Anaesth 93: 768, 2004

39. Are There Benefits? • No reduced nursing workload • No reduced interventions • less time measuring vital signs • No cost savings • Song, et al. —Br J Anaesth 93: 768, 2004

40. But... • Savings unlikely unless staff reduced • Recovery and staff still needed • for fast-track failures

41. Benefits May Occur... • In integrated units with • phase I & II recovery close together • flexible working • In predictable groups with rapid turnover • By reducing congestion and theatre delays

42. Patient Benefits • Patients feel good • clear-headed recovery • no oxygen masks • no pain • no sickness • Earlier return to home