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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1849_Библиотеки_им_академика_М_И_Перельмана.pdf
174
J.O.M. Nygren and O. Ljungqvist
Audit is a key instrument for clinicians aiming to implement the ERAS pro-
gramme. This is the only way to gather the necessary information on compliance
with the programme during the change process. By capturing details of where in the
pathway there are problems, one may examine the compliance for interventions that
deal with those specifi c issues, thus providing objectivity when problems are solved.
This helps to direct future education and the modifi cation of other interventions
when necessary.
By auditing the details of the key elements of the clinical pathway it is often easier
to understand the occurrence of certain complications. An example of this would be
the ability to easily review the fl uid balance of patients if a sudden increase in cardiac
complications has been revealed, or perhaps when problems with bowel function
secondary to ileus occur. Both ileus and cardiac complications may result from fl uid
overload and this association can be detected by using the audit. In addition to offer
the local group of clinicians an improved overview of their clinical practice, the
ERAS audit system also provides relevant feedback on clinical outcomes that are
important for patients, health care providers and other decision makers.
References
1. Maessen J et al. A protocol is not enough to implement an enhanced recovery programme for
colorectal resection. Br J Surg. 2007;34(2):224–31.
2. Mayer EK et al. Appraising the quality of care in surgery. World J Surg. 2009;33(8):1584–93.
3. Jamtvedt G et al. Audit and feedback: effects on professional practice and health care outcomes.
Cochrane Database Syst Rev. 2006;2:CD000259.
80
70
60
50
40
30
20
10
0
<50% >70% >80% >90%
Compliance with ERAS protocol elements
Symtoms
Complications
n = 953
p < 0.05
Percent patients affected
Complications & Symtoms
vs. ERAS compliance
*
*
***
*
Fig. 11.2 Symtoms delaying recovery and postoperative complication rates in patients with dif-
ferent compliance with ERAS protocol elements. *p<0.05 vs. low compliance (<50%) (Gustafsson
et al. [
14 ] )
175
11 Data Collection and Audit
4. Forsetlund L et al. Continuing education meetings and workshops: effects on professional
practice and health care outcomes. Cochrane Database Syst Rev. 2009;2:CD003030.
5. O’Brien MA et al. Educational outreach visits: effects on professional practice and health care
outcomes. Cochrane Database Syst Rev. 2007;4:CD000409.
6. Farmer AP et al. Printed educational materials: effects on professional practice and health care
outcomes. Cochrane Database Syst Rev. 2008;3:CD004398.
7. Scott I. What are the most effective strategies for improving quality and safety of health care?
Intern Med J. 2009;39(6):389–400.
8. Levy MM et al. The Surviving Sepsis Campaign: results of an international guideline-based
performance improvement program targeting severe sepsis. Crit Care Med. 2010;38(2):
367–74.
9. Dindo D, Hahnloser D, Clavien PA. Quality assessment in surgery: riding a lame horse. Ann
Surg. 2010;251(4):766–71.
10. Ronellenfi tsch U et al. Clinical pathways in surgery: should we introduce them into clinical
routine? A review article. Langenbecks Arch Surg. 2008;393(4):449–57.
11. Lemmens L et al. Clinical and organizational content of clinical pathways for digestive surgery:
a systematic review. Dig Surg. 2009;26(2):91–9.
12. Lasse K et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced
Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009;144(10):961–9.
13. Ahmed J et al. Compliance with enhanced recovery programmes in elective colorectal surgery.
Br J Surg. 2010;97(5):754–8.
14. Gustafsson U et al. Adherence to the enhanced recovery after surgery protocol and outcomes
after colorectal cancer surgery. Arch Surg. 2011;146(5):571–7.
177
N. Francis et al. (eds.), Manual of Fast Track Recovery for Colorectal Surgery,
Enhanced Recovery, DOI 10.1007/978-0-85729-953-6,
© Springer-Verlag London Limited 2012
A
Action learning process, 133
Adenosine triphosphate (ATP), 20
Anaemia, 23–25
Anaerobic threshold (AT), 20
Anaesthesia
epidural, 42–45
local anaesthetic blocks, 100–101
protocols, 5
spinal anaesthesia, 99–100
Anaesthetic approach
anaesthetist role, 50
CO
2
pneumoperitoneum
cardiovascular effects, 65
head down position, 66
pulmonary effects, 66
renal effects, 66
individualised goal-directed fl uid therapy
cardiac output and oxygen
delivery, 59–61
controversy, 62
fl uid optimisation technique, 59, 60
fl uid shifts, 58
goal-directed therapy, 60, 62
individualised goal-directed
fl uids, 58
postoperative fl uids, 59
stroke volume optimisation, 59
laparoscopic surgery
vs. open surgery, 63–64, 68
physiological consequences, 65
ventilation strategy, 67
open surgery, 63
vs. laparoscopic surgery, 63–64, 68
physiological consequences,
64–65
ventilation strategy, 66–67
postoperative care, 67–68
pre-assessment
cardiovascular risk reduction, 54
functional capacity, 51
non-cardiac surgery, cardiac risk
index, 51–53
peri-operative complications, 54
pre-existing disease optimisation, 53
surgical risk factors, 50–51
secondary complications
postoperative chest infection
reduction, 68–69
venous thromboembolism risk
reduction, 69–70
wound infection risk reduction, 70
stress response modulation, 63
surgical preparation
anaesthesia, 56
anti-microbial prophylaxis, 56
hospital admission, 55
monitoring and vascular access, 57–58
nasogastric tubes, GI surgery, 56
peri-operative hypothermia
avoidance, 57
PONV prevention, 57
preoperative preparation, 55
urinary drainage, 56–57
trimodal approach, 54–55
Analgesia
administration routes, 96
epidural analgesia, 96–99 ( see also
Epidural analgesia)
metabolic stress response, 42–45
methods and regional blocks, 62–63
open and laparoscopic surgery, 106
Angiotensin-converting enzyme (ACE)
inhibitors, 28
Index
178
Index
Angiotensin II (ATII) receptor antagonists, 28
Anti-microbial prophylaxis, 56
B
Beta blockers, 54
C
Cardiopulmonary exercise testing
(CPET), 20, 21
Cardiovascular risk assessment
aerobic capacity, 20
clinical risk indices, 18–19
functional capacity, 19–20
12 Lead Resting ECG, 21
non-invasive stress testing, 21, 23
patient history and physical
examination, 18
perioperative mortality, 20–21
risk evaluation and management, 21, 22
Chronic obstructive pulmonary disease
(COPD), 23
Cyclooxygenase (COX) type 2 inhibitors, 103
D
Diabetes, 28–29
Dobutamine stress echocardiograpy (DSE), 21
Doppler-guided fl uid management, 82
E
Elective abdominal surgery failure, 1
Enhanced recovery after surgery (ERAS)
anaesthetic approach ( see Anaesthetic
approach)
anaesthetic protocols, 5
auditing, 174
barriers and troubleshooting
fi nances and logistical support
restrictions, 140
inadequate staff numbers, 140–141
organisational barriers, 141
professional context, 140
social barriers, 139–140
time pressures and time lack, 140
benefi ts, 121
care pathway creation, 136
change management principle
action learning process, 133
plan-do-study-act cycle, 132
transformation strategy, 132–133
clinical outcomes and monitoring,
9–10, 136–137
colorectal surgery, 115–116
abdominal and pelvic drainage
avoidance, 119
anastomotic leak avoidance, 119
bladder catheter removal, 119–120
epidural analgesia, 116–117
goal-directed perioperative fl uid
administration, 115–116
high perioperative oxygen
concentration, 116
laparoscopic surgery, 118
mechanical bowel preparation, 112–113
nasogastric tubes avoidance, 119
normothermia maintenance, 116
patient positioning, 117–118
postoperative laxatives, 119
rectal cancer recovery, 120
single-port surgery, 120–121
stoma training, 113, 115
transverse incision, 118
complications
anastomotic leak, 122–123
nausea and vomiting, 121–122
postoperative ileus, 122
cost savings, 135–136
data collection
Cochrane Review updates, 171–172
complexity, 172
compliance, 172–174
data registration, 172
perioperative care quality, 172
quality improvement strategies, 172
early mobilisation, 7–8
early oral intake promotion, 7
metabolic conditioning, 4–5
metabolic stress response
( see Metabolic stress response)
multidisciplinary team members, 4
multimodal pain relief, 6–7
pain control ( see Pain control)
patient discharge criteria, 8
perioperative fl uid management
( see Intravenous fl uid therapy)
preadmission information
and counselling, 4
preoperative fasting, 4
principles, 2–3
quality improvements, 135–136
staff education, 137–139
steering group
aims of, 134
ER facilitator, 134
members, 133–134
quality improvements, 135–136
sub-groups and reports, 134
179
Index
success and failure assessment, 159
anaesthetic factors, 167–168
clinical outcome measures, 160
compliance, 161–162
functional recovery, 160–161
implementation factors, 168–169
patient satisfaction, 161
physiological factors, 165–166
post-operative recovery deviations,
162–164
surgical factors, 166–167
surgical incisions, 6
surgical technique, 5–6
Enhanced recovery facilitator
care management
outpatient clinic, 146–147
postoperative recovery, 149,
156–157
preadmission clinic, 147
recovery, 148–149
surgery, 148, 155
surgery admission day, 148, 155
data collection, 149–150
duties and responsibilities
clinical practice and practice
development, 151
fi nancial responsibility, 153
professional/education and training
role, 152–153
research and audit, 152
risk management, 153
service development and management,
152
emergency and assessment ward triage
area, 146
ER phone management, 145–146
ER Programme evaluation, 150
ER team meetings, 145
job description, 150–151
patient discharge information, 145
patient documentation creation, 145
person specifi cation form, 153–154
primary care, 146
responsibilities, 143–144
Epidural anaesthesia
metabolic stress response, 42–45
oliguria, 87
pain control, 97
Epidural analgesia, 5
clinical outcomes, 160
colorectal surgery, 96–99, 116–117
vs. intravenous opioid analgesia, 7
low molecular weight heparin, 70
mid-thoracic, 85
open surgery pulmonary function, 69
side effetcs, 96, 97
urinary catheters removal, 120
urinary retention, 56
Erythropoietin-stimulating agents (ESAs), 25
F
Fluid therapy
cardiovascular monitoring, 80–81
colorectal cancer, 77
ERAS protocol
intraoperative, 85–86
postoperative, 85–86
preoperative, 83–85
goal-directed therapy
vs. inotrope use, 82
oesophageal Doppler-guided fl uid
management, 82
principle, 81
stroke volume, 82
restrictive/standard/liberal regimens, 78–80
H
Hyperglycaemia, 28, 38, 39, 43
Hypertension, 27–28
Hyponatraemia, 77, 78
Hypotension
angiotensin-converting enzyme, 28
angiotensin II receptor antagonist, 28
epidural analgesia, 97–98
oliguria, 86
Hypothermia
anaesthetic contributions, 57
colorectal surgery, 116
fl uid management, 75
I
Individualised goal-directed fl uid therapy
anaesthetic approach
cardiac output and oxygen delivery,
59–61
controversy, 62
fl uid optimisation technique, 59, 60
fl uid shifts, 58
goal-directed therapy, 60, 62
individualised goal-directed fl uids, 58
postoperative fl uids, 59
stroke volume optimisation, 59
vs. inotrope use, 82
oesophageal Doppler-guided fl uid
management, 82
perioperative fl uid administration,
115–116
180
Index
Individualised goal-directed fl uid therapy (cont.)
principle, 81
stroke volume, 82
Intravenous fl uid therapy
fl uid therapy ( see Fluid therapy)
fl uid types, 77
inappropriate fl uid balance
balanced salt solutions, 76
cellular level saline, 76
fl uid restriction, 76
salt and water fl uctuations, 75
sodium and water requirements, 74
sodium chloride, 74–75
third-space losses, 74
K
Ketamine, 104–105
L
Laparoscopic resection, 5
Lee index, 18
LiDCO system, 81
Low molecular weight heparin (LMWH), 70
M
Magnesium, 105
Metabolic equivalent of task (MET), 19
Metabolic stress response
bowel preparation, 41, 44
cancer, 40
carbohydrate treatment, 44
diabetes, 40
epidural anaesthesia and analgesia, 42–45
injury, 37–38
insulin resistance and complications
glucose uptake, 38
hyperglycaemia, 38
postoperative metabolism, 39
protein balance, 39
stress-induced insulin resistance, 39
surgical stress and fatigue, 38–39
tissue healing, 39
malnourished patient, 40
postoperative oral intake, 45
preoperative fasting, 41–42, 44
preoperative nutritional support, 40–41
preoperative outpatient visit, 43–44
Morphine, 95
Multidisciplinary team members, 4
Multimodal pain relief, 6–7
N
National Institute for Health and Clinical
Excellence (NICE), 25
Non-steroidal Anti-infl ammatory Drugs
(NSAIDS), 7, 103
Nutritional Risk Score (NRS), 26
O
Obesity, 27
Opioids, 95
strong opioids, 101–102
weaker opioids, 102–103
P
Pain control
anaesthesia ( see Anaesthesia)
analgesia ( see Analgesia)
beta-blocker, 105
COX–2 inhibitor, 103
glucocorticoids, 105
ketamine, 104–105
lidocaine infusions, 104
magnesium, 105
NSAIDS, 103
paracetamol, 103–104
practical approach, 106
pregabalin, 105
Paracetamol, 103–104
Patient discharge criteria, 8
Patient Education and Conditioning
of Expectations, 30–32
Perioperative fl uid management.
See Intravenous fl uid therapy
Plan-do-study-act (PDSA) cycle, 132
Postoperative nausea and vomiting (PONV)
anaesthetic contributions, 57
ketamine, 104
perioperative fl uid management, 86
Preadmission information
and counselling, 4
Pre-assessment, 15
anaemia, 23–25
cardiovascular risk
abdominal surgery, 17
adverse events, 17
aerobic capacity, 20
clinical risk indices, 18–19
functional capacity, 19–20
incidence, 17
laparoscopy, 18
12 Lead Resting ECG, 21
181
Index
non-invasive stress testing, 21, 23
patient history and physical
examination, 18
perioperative mortality, 20–21
risk evaluation and management,
21, 22
risk factors, 18
diabetes, 28–29
hypertension, 27–28
nutrition, 25–27
obesity, 27
pre-assessment clinics, 16
pulmonary risk, 23
smoking and high alcohol, 29
Pregabalin, 105
Pulmonary risk, 23
S
Spinal anaesthesia, 99–100
Statins, 54
Stress-induced insulin resistance, 39
Surgical incisions, 6
T
Traditional peri-operative care, 1
Transoesophageal Doppler (TOD) probes, 81
Transversus abdominis plane (TAP) block,
100–101
V
Venous thromboembolism (VTE), 69–70