Ian Smith, MD, FRCA

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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

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Fast Track Recovery
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3 Stages of Recovery

• Early
• awakening return of protective reflexes

• Intermediate
• recovery to point of discharge
• still needs support
• Late
• recovery to preoperative state

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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

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Fast Track Faster Discharge


Total recovery time (min)

Song, et al. Br J Anaesth 93 768, 2004
p lt0.05, from recovery room group
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Assessing Fast-track Eligibility

• Clinical
• awake
• fully oriented
• comfortable
• stable cvs signs
• stable resp signs

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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 gt92 on
airSpO2 gt90 onO2SpO2 lt90 on O2
210 210 210 210 210
Maximum score 10need gt9
Aldrete J Clin Anesth 7 89, 1995
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Fast-track Score

• Similar to Aldrete
• Pain
• none or mild discomfort 2
• controlled moderatesevere pain 1
• persistent moderatesevere pain 0
• PONV
• minimal nausea no vomiting 2
• controlled transient retching 1
• persistent PONV 0
• Maximum 14
• gt12 (no score lt1) fast-track eligible
• White J Clin Anesth 11 78, 1998

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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

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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

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Do We Need The Recovery Room?
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A Question Worth Asking?
Is your journey to the recovery room really
necessary?
Jean Millar Editorial,Br J Anaesth 93 756,
2004
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Do We Need The Recovery Room?

• Manage unconscious patient

• Extubation airway support
• Manage complications
• Administer O2

• Treat early pain
• Treat early PONV

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The Unconscious Patient
Eye opening (min)
Oriented (min)
Duration (min)
Anaesthetic
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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)

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Bispectral Index

• Processed EEG, index 0100
• 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

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BIS Fast-Track Recovery
Time tofast-trackeligible(min)
BIS at end of anaesthesia
Song, et al. Anesth Analg 87 1245, 1998
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BIS May Not be Necessary

• 99 patients gynae laparoscopy
• Sevoflurane induction maintenance
• BIS 5060 or BP/HR 20
• Bypass PACU if Aldrete gt9 within 10 min

Clinical group 90 Fast-tracked
BIS titrated 86 Fast-tracked
Ahmad, et al. Anesthesiology 98 849, 2003
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Do We Need The Recovery Room?

• Manage unconscious patient Patients are
  awake!
• Extubation airway support
• Manage complications
• Administer O2
• Treat early pain
• Treat early PONV

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Extubation Airway Support

• LMA commonly used
• Well tolerated
• Complications rare
• Removed when awake
• by patient

• LMA out (min) 3.8 1.8
• Eyes open (min) 4.5 1.7
• Data from 171 pts in ongoing research project

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Do We Need The Recovery Room?

• Manage unconscious patient
• Extubation airway support LMA!
• Manage complications
• Administer O2
• Treat early pain
• Treat early PONV

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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
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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
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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
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Do We Need The Recovery Room?

• Manage unconscious patient
• Extubation airway support
• Manage complications Complications are rare
• Administer O2
• Treat early pain
• Treat early PONV

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Oxygen Therapy
SpO2 lt90
Admission SpO2
Number
Regimen
96.8 2.3 96.7 2.1 97.1 1.6 97.4 1.4
Nasal O2 Humidified O2 Deep breaths Nothing
2 (3) 2 (3) 4 (6) 3 (4)
69 72 69 72

• 10 / 11 pts with SpO2 lt90 had admission value
  92
• 8 / 282 remaining pts had admission SpO2 92

Gift, et al. Anesth Analg 80 368, 1995
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Whats the Harm of O2?

• Delay recovery
• Uncomfortable for patient
• Fire risk
• Expense of disposables
• Waste

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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

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Optimal Pain Relief

• NSAID

• Local anaesthesia
• infiltration
• topical
• block

• Intraoperative opioids
• only if needed

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Pain on Awakening

• Should be minimal with appropriate measures

• Severe 1
• Mild 15
• None 84
• Data from 171 pts in ongoing research project

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Do We Need The Recovery Room?

• Manage unconscious patient
• Extubation airway support
• Manage complications
• Administer O2
• Treat early pain What pain?
• Treat early PONV

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Postoperative Nausea
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Risk Factors For PONV
History of Motion Sickness / PONV
Female
Opioid Therapy
Non-smoker
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Treatment Prevention of PONV

• Consider hydration, analgesia
• Prophylaxis if high risk
• dexamethasone 45 mg
• Combination therapy
• for highest risk
• different classes
• AVOID OPIOIDS

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Nausea on Awakening

• Should be minimal with appropriate measures

• Moderate 2
• Mild 2
• None 96
• Data from 171 pts in ongoing research project

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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

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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
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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

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But...

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

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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

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Patient Benefits

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

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