| FAST-TRACK CARE | STANDARD CARE |
---|---|---|
PRE-OPERATIVE PHASE | Â | Â |
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 | Â | Â |
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 | Â | Â |
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 | Â | Â |
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 | Â | Â |
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 |