|Year : 2013 | Volume
| Issue : 3 | Page : 114-121
Fast-track surgery: A new concept of perioperative management of surgical patients
Gabriel Rodrigues, Chandini Ravi, Raghunath Prabhu
Department of General Surgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
|Date of Web Publication||30-Oct-2013|
Kasturba Medical College, Manipal University, Manipal - 576 104, Karnataka
In the past few decades, surgery has advanced greatly because of an improved understanding of perioperative pathophysiology, development of minimally invasive operative techniques and advanced anaesthetic techniques. Fewer operations are requiring extended periods of hospital stay and a growing number of procedures are performed on an ambulatory basis. The pressure on medical systems is continuously growing as a result of economic constraints, increasing numbers of patients undergoing surgical procedures and greater patient autonomy. Patient awareness is steadily increasing along with their participation in their own care, leading to expectations of a higher standard of care. This has led to the development of a new concept of fast-track surgery.
Keywords: Anaesthesia, hospital stay, perioperative, recovery, surgery
|How to cite this article:|
Rodrigues G, Ravi C, Prabhu R. Fast-track surgery: A new concept of perioperative management of surgical patients. J Health Spec 2013;1:114-21
|How to cite this URL:|
Rodrigues G, Ravi C, Prabhu R. Fast-track surgery: A new concept of perioperative management of surgical patients. J Health Spec [serial online] 2013 [cited 2020 Jun 6];1:114-21. Available from: http://www.thejhs.org/text.asp?2013/1/3/114/120843
| Introduction|| |
Surgery initiates a complex stress response comprising of metabolic, neuroendocrine and inflammatory changes, which result in the activation of sympathetic system and a catabolic state. These physiological stress responses due to major surgery frequently lead to pain, nausea, ileus, impaired pulmonary function and increased cardiac demands. These sequelae lead to delayed postoperative recovery.  Enhanced postoperative recovery is measured by the length of hospital stay, morbidity and mortality, length of time taken for complete recovery and patient satisfaction. Fast-track surgery programmes employ a combination of evidence-based strategies to expedite recovery following surgery. These strategies have developed over time and we now have better surgical techniques, anaesthesia and modalities of pain control and rehabilitation at our disposal.  The combination of these approaches aims to reduce the perioperative stress response and organ dysfunction, the incidence of postoperative complications and the cost and duration of hospital stay required.
The principle of fast-track surgery has been applied to a variety of procedures so far including abdominal, gynaecological, orthopaedic and cardiothoracic surgeries, reflecting the growing interest in this concept. While elective abdominal surgery patients are the main focus of fast-track surgery programmes, the same principle may be applied to the management of all surgical patients. [Table 1] provides a comparison of the duration of hospital stay in fast-track surgical programmes as compared with their conventional counterparts.
|Table 1: Comparison of duration of hospital stay in conventional surgery with fast-track surgery programmes|
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This article reviews the core principles employed by fast-track surgery programmes based on evidence available in literature for each component of perioperative care in order to incorporate these components into a multi-modal programme for enhanced postoperative recovery.
Patient care strategies
The fast-track concept should be incorporated into all phases of perioperative care by implementing evidence-based preoperative, intraoperative and postoperative strategies, thus forming an integrated surgical management model in order to optimise patient outcomes [Table 2]. ,
Patient selection and assessment
Postoperative organ dysfunction is related to preoperative co-morbidities in the patient.  Existing co-morbidities must be assessed for an estimation of surgical risk and optimisation of organ function. The continuation of medicines the patient is already taking, especially β blockers  and other medications that blunt catecholamine release must be reinforced, as discontinuing such medications preoperatively may contribute to increased surgical stress and continuing them up to and after surgery has been shown to reduce complications.  The surgical team should identify patients suitable for the fast-track approach, as patient participation is required for accelerated recovery.
Patient education is an integral factor contributing to the success of any fast-track programme. The patients must be provided clear, concise and adequate information regarding the procedure they are about to undergo, as it reduces their anxiety. In addition, a realistic picture of their postoperative period and the recovery process must be provided. Educating the patient also provides a platform of two-way communication between the care provider and the patient whereby the concerns and queries of the patient are addressed, reassurance is provided and their co-operation is gained. It places the patients in their rightful place as a partner in their medical care where they can make well informed decisions, giving rise to increased satisfaction, fewer complaints and therefore better overall outcomes. When sufficient information is not provided by the healthcare providers, patients tend to gather information from other sources such as other patients and the internet, which may not provide an accurate picture and would give rise to gaps in their understanding of the planned surgery. In addition, patient education in the perioperative period has been shown to reduce the need for pain relief by reducing anxiety.  Counselling is therefore a necessary component and it is recommended that it be provided pre-admission.
Patient nutrition must be optimised prior to surgery as patient undernutrition impairs the immunological response, leading to impaired wound healing and increased morbidity and mortality. Those at risk for undernutrition must be identified such as malnourished or cancer patients, in who extended fasting may exaggerate the surgical stress response. The classical overnight preoperative fasting is one of the prime contributors to perioperative undernutrition. While the required fasting period for major surgery is usually around 6 hours, in reality the overnight fast tends to be a few hours longer. This prolonged fasting period results in dehydration and increased risk of aspiration as it reduces gastric emptying, increases the acidity of the gastric content and results in increased volume. Dehydration has been shown to be related to postoperative nausea and vomiting (PONV). 
The fasting period aside, improper and inadequate nutrition is often the case in many hospital admissions. The traditional mechanical bowel preparation has been shown to be unnecessary and potentially harmful by increasing the risk of sepsis and aggravating postoperative dehydration.  A 2-hour fasting period is recommended at present for elective surgery in patients without further risk for aspiration, until which oral rehydration therapy via clear fluids is safe and feasible.  In addition, 150 ml of clear carbohydrate fluids 2 hours prior to elective surgical procedures has shown to increase patient comfort by alleviating thirst, hunger and anxiety through the release of endogenous opioids, which also reduces the amount of intraoperative anaesthesia needed.  This also has beneficial effects in countering the insulin resistance arising as a result of surgical stress,  slightly reducing perioperative muscle catabolism  and promoting gastric emptying.  In cases of a malnourished patient, particularly those undergoing a major surgery, the preoperative nutritional support would be highly beneficial.
Pre-medication in a fast-track setting aims at reducing physiological stress responses to surgery. Alpha2-agonists and beta-blockers have been proven beneficial for the same. Alpha2-agonists such as clonidine and dexmedetomidine have been shown to have opioid-sparing effects when used as pre-medication. They also reduce intraoperative blood loss, perioperative myocardial ischaemia, shorten the duration of ileus  and improve pain control and PONV. Beta-blockers suppress the release of catecholamines, thereby reducing cardiovascular morbidity associated with surgery. They also have analgesic-sparing and anti-catabolic properties, which contribute to accelerated postoperative recovery. 
Optimisation of anaesthesia aims at achieving rapid postoperative recovery with minimal opioid effects postoperatively. Overly deep anaesthesia exacerbates the surgery-induced stress response and postoperative organ dysfunction thus attaining the optimal depth of anaesthesia is important in reducing morbidity and the time to total recovery.  Short-acting anaesthetics and analgesics are therefore preferred. A vast amount of research has shown that regional aesthetic techniques that use local anaesthetics can reduce the classic pituitary, adrenocortical and sympathetic responses to surgery.  Neurogenic blockade techniques (either by administering a local anaesthetic in the spinal or epidural space or by using local anaesthetic techniques that block the nerve impulses from a specific area) improve postoperative nitrogen economy  and glucose intolerance but does not modify inflammatory or immunological responses. Epidural analgesia has been shown to be superior to intravenous narcotics in controlling postoperative pain in both open and laparoscopic colon surgery, , in addition reducing postoperative ileus, , preserving exercise capacity following laparotomy, accelerating ambulation and thereby reducing postoperative pulmonary complications. Perioperative systemic lidocaine is a convenient and inexpensive option for patients not suitable for epidural anaesthesia.  Total intravenous anaesthesia is favourable in reducing PONV.
The use of minimally invasive abdominal surgical techniques, such as laparoscopic cholecystectomy, have not reduced the early endocrine mediated metabolic response to surgery, but this approach has been associated with a slight decrease in various inflammatory responses and immunodysfunction, improved pulmonary function and reduced postoperative ileus. , However, the application of a combination of fast-track rehabilitation techniques may influence the outcome more than the choice between an laparoscopic technique versus 'open' operation per se.  The current evidence suggests that within a fast-track surgery programme, there is no difference between laparoscopic and open surgery in terms of postoperative recovery rates or length of hospital stay. However, minimally invasive surgery does reduce inflammatory responses, pain and catabolism due to the reduced wound size. , In open abdominal surgery, pain and pulmonary dysfunction have been proved to be reduced in cases where transverse and oblique incisions are used instead of a long vertical incision, which may be due to fewer dermatomes affected.
Fluid management must be carefully optimised, as both over hydration and fluid restriction cause their own set of problems. While perioperative administration of liberal amounts of fluid has been shown to reduce nausea, vomiting, dizziness, drowsiness and thirst, excessive hydration may potentially lead to pulmonary and cardiac dysfunction. Excessive hydration also impairs wound healing, particularly in case of anastomoses, by reducing tissue oxygenation. In contrast, restricted fluid intake can cause inadequate organ perfusion via reduction of the effective circulating volume. Therefore, fluid management has to be customised for every patient and goal-directed as the individual preoperative hydration statuses and surgical stress responses vary. Objective assessment of the individual fluid requirement can be done by successive challenges of a small amount of colloid preoperatively and postoperatively and measurement of corresponding changes in stroke volume (and therefore the cardiac output), which can be measured using oesophageal Doppler or pulse pressure. , Improvement in postoperative outcome using this approach has been demonstrated by several randomised trials. , Intraoperative volume therapy is based on administration of colloids and avoidance of excessive crystalloids. Using a combination of crystalloids and colloids avoids intraoperative hypovolaemia while avoiding excessive crystalloids. Similar to overnight fasting, overnight fluid restriction can be avoided to prevent the preoperative hypovolaemia and requirement for intraoperative volume replacement. As per the enhanced recovery after surgery protocol, oral fluid intake of more than 300 ml of fluid on the day of surgery is recommended along with cessation of intravenous fluids on postoperative day 1. 
| Intraoperative Normothermia|| |
Patients undergoing surgery often become hypothermic due to cold operating rooms, inadequate clothing cover and anaesthetics, which hamper their homeostatic defences to cold. As a result, patients undergoing operations lasting over 2 hours often suffer a fall of core temperature of 2 - 4°C, particularly in thoracic and abdominal surgeries. Perioperative hypothermia triples the incidence of adverse myocardial outcomes, increases blood loss due to impaired haemostasis, delayed metabolism of anaesthetic drugs with delayed recovery and the increased incidence of surgical wound infection. In addition, during re-warming, cortisol and catecholamines are released, which augment the stress response of the operation. Keeping patients warm has been associated with a 3-fold decrease in the rate of wound infection, a reduction in operative blood loss, a decrease in untoward cardiac events and a reduction in nitrogen excretion and patient discomfort. Maintenance of intraoperative normothermia is achieved by active warming of the patient using intraoperative hot air warming blankets, which cover the non-operated parts of the body, administration of warm intravenous fluids, forced-air and resistive heating. 
Nausea and vomiting are frequent after administration of general anaesthesia and abdominal surgery. PONV delay recovery by prolonging the time taken to resume oral hydration and feeding. Prevention of PONV begins intraoperatively by avoiding drugs that cause PONV and volatile anaesthetic agents or administering them in reduced doses. The use of a multi-modal approach using prophylactic antiemetics with adequate hydration is associated with improved patient compliance. 
Perioperative oxygen therapy appears to be a potentially effective intervention that may provide a significant reduction in the occurrence of surgical site infection, particularly in patients undergoing colorectal surgery. However, its utility and scope require further study as potential deleterious effects of high FIO 2 oxygen therapy have also been described. ,,,
| Postoperative Strategies|| |
Postoperative pain amplifies the surgical stress response and organ dysfunction and delays recovery.  It hinders postoperative mobilisation and the resumption of daily activities. Major surgical procedures with high intensity pain therefore require the use of invasive analgesic methods, such as continuous epidural analgesia, to hasten recovery.  Based on a systematic review of postoperative analgesia, the effect of choice of postoperative analgesia on postoperative mortality or morbidity has not been established. However, the use of epidural analgesia along with local anaesthetics has been repeatedly associated with faster resolution of postoperative ileus after major abdominal surgery. The site of an epidural must be appropriate to the level of surgical incision. It is advisable to remove epidural catheters before 3 days elapse following their placement and to avoid repositioning or removal and replacement as there is a substantial risk of infection.  Supplemental non-steroidal anti-inflammatory drugs can be used to treat pain not covered by the epidural.
Multi-modal analgesia combines multiple agents, opioid with non-opioids, like ketorolac and provides successful pain control with good patient satisfaction and decreased postoperative urinary retention. ,, The principle of multi-modal or balanced analgesia is to gain additive effects from different modalities of pain control while minimising the side effects, particularly those of opioids (such as sedation, nausea, ileus and urinary retention), which hamper both early mobilisation and enteral nutrition. Several agents such as non-steroidal anti-inflammatory drugs, COX-2 inhibitors, ketamine, gabapentin and local anaesthetics have been evaluated for their utility in reducing the use of opioids for analgesia.  Optimal management of acute pain following major procedures is a prerequisite for fast-track surgery as it facilitates early discharge. Hospital-level pain management protocols should be established along with regular evaluation of pain and its documentation.
Early enteral nutrition
The importance of patient nutrition has been emphasised in the preoperative period. Adequate postoperative nutrition is equally important as it enhances wound healing, reduces fatigue and muscle wasting and the risk of infection. Oral intake is traditionally limited in the postoperative period and involves a gradual transition from liquid to solid feeds. Especially in cases of bowel anastomosis, caution is usually exercised while proceeding with oral feeds. However, several studies have shown that early oral intake is safe even after bowel resection,  as early enteral nutrition reduces gut permeability, which also reduces infection by reducing bacterial translocation. , Limiting oral intake in the postoperative period is not necessary even after colonic procedures using an anastomosis if epidural anaesthesia is used as it attenuates ileus.
Postoperative ileus, which is predominantly caused by a combination of inhibitory neural sympathetic visceral reflexes and the intestinal inflammatory response, increases pain and discomfort and delays early mobilisation and oral intake. It may be considerably alleviated by a combination of epidural local anaesthetics, opioid-sparing analgesia, minimally invasive surgery, minimising bowel handling, avoidance of routine nasogastric tubes, early feeding and pharmacotherapy. , The greatest reduction in postoperative ileus will occur when all these methods are incorporated into a multi-modal rehabilitation strategy.
Tubes and drains
Several trials and meta-analyses , have confirmed the lack of added benefit in utilising nasogastric tubes as a routine. They should be particularly avoided in a fast-track programme as they have been found to increase the incidence of pneumonia in addition to extending the duration of hospital stay. Patients managed without nasogastric tubes need fewer days to resume oral intake.  Oral intake can often be successfully initiated 6 hours following surgery.  Studies have also advocated against the routine use of surgical site drains as they may slow the return of bowel function and hinder effective pain control. ,,,,
In case of patients undergoing anorectal surgery, urinary retention is a common complication postoperatively. The risk factors contributing to urinary retention include excessive intravenous fluid administration and inadequate pain relief.  Therefore, besides good analgesia, intraoperative intravenous fluid restriction must be considered to prevent urinary retention.
Early mobilisation is a universal component of any fast-track plan. Prolonged bed rest increases muscle wasting, predisposes to pulmonary dysfunction, infections and thromboembolism.  Significant improvement on follow-up was found in parameters such as fatigue, sleep, return to leisure activity and activities of daily living following early mobilisation.  Postoperative ambulation and movement should be fully encouraged and facilitated by means of adequate pain relief.
| Conclusion|| |
Results from studies of fast-track programmes employing a multi-modal approach have shown improved outcomes, particularly fast-track colorectal programmes. ,, The reduction of surgical stress and the length of hospital stay are the primary objectives of these programmes. This is achieved by the implementation of improved perioperative pain management, combinations of anaesthesia and analgesia, early enteral nutrition and early mobilisation that counteract fatigue associated with surgery and reduce the incidence of postoperative complications. There is, however, a need for continued study of the basic mechanisms of the surgical stress responses in order to develop interventions that counteract specifically their unfavourable aspects while preserving the aspects required for recovery, such as wound healing and immune responses. Innovations in minimally invasive surgery, pharmacological modulation of surgery-related inflammation and anaesthetic techniques are necessary to further improve the fast-track programmes.
The establishment of a successful fast-track programme relies heavily upon a multi-disciplinary approach.  The commitment of the surgeons is one of the most important factors that has to be considered. At present, there exists a gap between the perception of fast-track methodology and its realisation among surgeons.  Well-defined criteria and a committed team approach form the cornerstones of success at the level of adopting the fast-track principles. Collaboration is required between the surgeons, anaesthetists, nurses, physiotherapists and the patients. A hospital-level protocol for fast-track surgery should be established at the outset, which must include definitions of the role of every discipline in the programme. The role of the surgeon would include selection of the appropriate candidates for the programme, use of minimally invasive techniques, avoidance of tubes and drains and early postoperative mobilisation and feeding. The anaesthetist has to decide on the suitable anaesthetic technique associated with swift recovery, fluid management, prevention of PONV and adequate analgesia with minimal adverse effects. Early postoperative mobilisation and rehabilitation is achieved with the co-operation of nurses and physiotherapists. Ideal nursing care address both physiological and psychological needs. Nurse specialisation and their education have a significant impact on postoperative mortality and morbidity. , In addition to the above, the patients themselves must be made partners in their recovery process and provided with adequate information. The outcomes and costs of on-going fast-track programmes must be frequently assessed by the institutional administration in order to aid continued planning and improvisation.
The evolving understanding of surgical pathophysiology and evidence-based techniques invokes the need for change. Emphasis needs to be shifted from the traditional surgical care, which relies on monitoring and high-level interventions to a more holistic rehabilitative care. Making changes within the complex healthcare system requires dedication, objectives compatible with common practice and well-defined parameters. The provision of information and education on the principles of the fast-track concept must be intensified along with refinement of its individual components. This would pave way for a more widespread understanding and materialisation of these strategies.
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[Table 1], [Table 2]