Presentation from the Enhanced Recovery Summit 2012 by Professor Henrik Kehlet Enhanced recovery - future developments and transferability into acute medicine

1. enhanced recovery –
future developments and
transferability into
acute medicine ?

2. improvement of
perioperative outcome?
• every operation can be ambulatory ?
• why is the patient in hospital today ?
• what is it that we cannot control ?

3. why is the patient in hospital today ?
• organ dysfunction (”surgical stress”)
• hypothermia-induced morbidity
• pain
• PONV / ileus
• fluid excess/ hypovolaemia
• cognitive dysfunction/sleep disturbances
• immobilisation
• semi-starvation
• fatigue (early/late)
• traditions (tubes,drains,restrictions,etc.)
Kehlet & Dahl
Kehlet & Wilmore
Kehlet
Lancet 2003; 363: 1921
Ann Surg 2008;248:189
Langenbecks Arch Surg 2011;396:585

4. 1997; 78:606-617
Multimodal approach to control postoperative
pathophysiology and rehabiliation
H. Kehlet
preop
optimisation/
information
attenuation
of stress
pain
relief
exercise
oral
nutrition
enhanced recovery and
reduced morbidity
Kehlet
Langenbecks Arch Surg 2011;396:585

5. Clin Nutri 2010; 29: 434-440
fast-track vs traditional care - morbidity

6. Surgery 2011;149:830-40.
”ERP’s can and should be routinely
used in care after colorectal and other
major gastrointestinal procedures”

7. Br J Anaesth 2011;106:289-91.
established risk indices, but
• fast-track methodology not implemented
• ”surgical” vs ”medical” morbidity ?

8. enhanced surgical recovery
becomes mandatory !
yes !
• process:
- read the literature
- know your data
- multidisciplinary collaboration
- monitoring
- share the economic benefits
Kehlet & Wilmore
Colorectal Dis 2010;12:2-4

9. the hip fracture patient
a ”medical” patient
with a hip fracture

10. mortality analysis in hip fractures
47 perioperative deaths:
12 deaths (25%) unpreventable
prefracture terminal disease – 10
refusing postoperative care - 2
21 deaths (45%) potentially preventable
active care curtailed before death – 14
death due to pre-fracture acute illness - 7
14 deaths (30%) possibly preventable
Foss Br J Anesth 2005

11. enhanced recovery in hip
fracture patients
• early surgery (< 24 h)
• multimodal non-opioid analgesia
• oral nutrition
• standardized fluid therapy
• aggressive transfusion policy
• oxygen therapy
• immediate mobilisation and physiotherapy
• early planning of discharge

12. Anaesthesiologists
Geriatricians
Orthopaedic surgeons and nurses
Physiotherapists
Admission
to surgery
Surgery
Specialist involvement in care
proposed multidisciplinary
hip fracture care
Postoperative phase
stable organ function
Rehabilitation
to discharge

13. enhanced recovery programmes
• elective surgery
• acute surgery (hip fracture)
• ”medical” patients

14. JAMA 2011;306:1800-1801.
• ”iatrogenic” complications due to
• bed rest, inadequate nutritional
support, overuse of monitors, urinary
cathethers, iv lines, opioid-based
analgesia, etc.

15. JAMA 2011;306:1782-1793.
• hospitalization-associated disability
develops between the onset of the acute
illness and discharge from the hospital
• at least 30 % of patients > 70 years and
hospitalized for a medical illness are
discharged with an ADL disability they
did not have before becoming acutely ill

16. fast-track acute older medical
patients ?
secure sufficient assessment of comorbidities, all functional capabilities,
nutritional status, pain, etc.

action on identified problem

post-discharge rehabilitation plan

follow-up, re-admissions etc.

17. enhanced recovery in acute
older medical patients ?
conclusion:
• ”medical” patients different from
”surgical” patients:
• additional resources required (rehab
interventions)

18. enhanced recovery in acute
older medical patients ?
conclusion:
• phase I:
prospective hypothesis-generating
studies
• phase II:
large, prospective data (subgroups)
incl. economic assessment
• phase III:
RCT different interventions/subgroups

19. conclusions:
enhanced recovery programmes
• elective surgery: do it
• acute surgery: do it –
and research
• ”medical” patients:
documentation/ research/
monitoring/ care organisation