Transcript fast track surgery » quelle place pour l` alr?

« FAST TRACK SURGERY »
QUELLE PLACE POUR
L’ ALR?
Dr SLETH JC
CLINIQUE SAINT ROCH
MONTPELLIER
• Fast-track surgery:
programme multimodal permettant une
précoce des patients opérés.
• ERAS : enhanced recovery after surgery
• Réhabilitation précoce
réhabilitation
• L'objectif: faciliter le rétablissement et le confort
des patients, la durée d'hospitalisation et ….donc
les coûts (environ 800 Є/j). En espérant
diminuer la morbidité intrinsèque et extrinsèque
• La recette: optimiser la prise en charge pré, per
et post-opératoire sur la base des données de la
médecine factuelle
Quelques exemples et durées!!
QU’EST-CE QUI RETARDE LE
RETOUR A DOMICILE?
L’EXEMPLE
HISTORIQUE:
LA COLECTOMIE
Le fameux Henrik Kehlet
COMMENT FAIT-ON?
Et au passage on «tord le cou » a
quelques dogmes:
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•
•
•
La préparation colique (Cochrane 2003)
La sonde gastrique
La sonde urinaire
Le jeune jusqu’à la reprise du transit…
Gouvas N, Tan E, Windsor A et al . Fast-track vs standard care in
colorectal surgery: a meta-analysis update.
Int J Colorectal Dis 2009; 24:1119-31
Eleven studies were eligible for analysis (four randomized controlled trials (RCTs) and seven controlled
clinical trials (CCT)), including 1,021 patients.
Primary hospital stay (weighted mean difference -2.35 days, 95% confidence interval (CI) -3.24 to -1.46
days, P < 0.00001) and total hospital stay (weighted mean difference -2.46 days, 95% CI -3.43 to -1.48
days, P < 0.00001) were significantly lower for FT programs.
Morbidity was also lower in the FT group.
Readmission rates were not significantly different.
No increase in mortality was found.
CONCLUSIONS:
FT protocols show high-level evidence on reducing primary and total
hospital stay without compromising patients' safety offering lower
morbidity and the same readmission rates.
Enhanced recovery programs should become a mainstay of elective
colorectal surgery.
APD THORACIQUE
• Analgésie++
Supérieure a PCA (coelio et laparo)
• Prévention iléus et NVPO
Reprise précoce du transit
Réduction des NVPO/PCA
• Réduction réponse endocrinienne, immunologique et
inflammatoire
• Amélioration de la fonction diaphragmatique
postopératoire
• Récidive néoplasique et métastase???????
APD THORACIQUE et colectomie:
quelle place en France actuellement?
Dans une enquête multicentrique internationale:
•APD: 8% en France vs 67% en UK
•DMS supérieure à 10 jours
•Iléus supérieur à 5 jours dans 45% des cas
Kehlet H, Büchler MW, Beart RW Jr, BillinghamRP, Williamson R. Care after colonic
operation--is it evidence-based? Results from a multinational survey in Europe and the
United States. J Am Coll Surg. 2006 ;202(1):45-54.
DES ALTERNATIVES?
Lors d’Échec
Lors de Refus
Lors de Contre-indications
LIDOCAINE IV
Bolus of lidocaine 1.5 mg/kg followed by a continuous
infusion of lidocaine 2 mg/kg/h
• In open and laparoscopic abdominal surgery, significant reductions in
postoperative pain intensity and opioid consumption:
-Pain scores were reduced at rest and with cough or movement for up to
48 hours postoperatively.
-Opioid consumption was reduced by up to 85% in lidocaine-treated
patients when compared with controls.
• Earlier return of bowel function, allowing for earlier rehabilitation and
shorter duration of hospital stay:
-First flatus occurred up to 23 hours earlier, while first bowel movement
occurred up to 28 hours earlier
- Duration of hospital stay was reduced by an average of 1.1 days
McCarthy GC, Megalla SA, Habib AS. Impact of intravenous lidocaine infusion on
postoperative analgesia and recovery from surgery: a systematic review of randomized
controlled trials. Drugs. 2010;70(9):1149-63
.
CATHETER CICATRICIEL
• Beaussier M, El'Ayoubi H, Schiffer E, Rollin M, Parc Y, Mazoit JX, Azizi L,
Gervaz P, Rohr S, Biermann C, Lienhart A, Eledjam JJ.Continuous
preperitoneal infusion of ropivacaine provides effective analgesia and
accelerates recovery after colorectal surgery: a randomized, double-blind,
placebo-controlled study.Anesthesiology. 2007;107(3):461-8.
Continuous preperitoneal administration of 0.2%
ropivacaine at 10 ml/h during 48 h after open
colorectal resection reduced morphine consumption,
improved pain relief, and accelerated postoperative
recovery
Oui mais…
• Polglase AL, McMurrick PJ, Simpson PJ, Wale RJ, Carne PW, Johnson W,
Chee J, Ooi CW, Chong JW, Kingsland SR, Buchbinder R. Continuous wound
infusion of local anesthetic for the control of pain after elective abdominal
colorectal surgery. Dis Colon Rectum. 2007;50(12):2158-67.
Randomized placebo-controlled trial
A total of 310 patients included
Delivery of ropivacaine to midline laparotomy wounds is safe,
No significant clinical advantage over current best practice
• Gupta A, Favaios S, Perniola A, Magnuson A, Berggren L.A meta-analysis of
the efficacy of wound catheters for post-operative pain management.Acta
Anaesthesiol Scand. 2011;55(7):785-96.
Wound catheters provided NO significant analgesia at rest or on activity,
except in patients undergoing gynecological and obstetric surgery
INSTILLATION
INTRAPERITONEALE d’AL
• intraperitoneal ropivacaine (75 mg) before
dissection and postoperative infusion of 0.2%
solution at 4 mL/hour for 3 days continuously.
Kahokehr A, Sammour T, Shoshtari KZ, Taylor M, Hill AG.Intraperitoneal local anesthetic
improves recovery after colon resection: a double-blinded randomized controlled trial.
Ann Surg. 2011.254(1):28-38
PTH-PTG
Selon les principes de l’ERAS
• Sortie à J3-J4…au domicile
critères de sortie…
à domicile
•
•
•
•
marcher 50 m avec des béquilles,
se coucher se lever et s’habiller sans aide
Monter 8 marches d’escalier
VAS inf a 30 au repos et contrôlé par antalgiques
oraux
Le centre de rééducation est une particularité française
APD
"Is lumbar epidural analgesia more efficacious than systemic analgesia or
long-acting spinal analgesia for postoperative pain relief in patients
after elective hip or knee replacement?«
LA REPONSE EST…UTILE mais…
• Avec AL: pas de bénéfice au delà de H6
• Si APD continue: al ou al+morphinique sup a morphinique seul
• Effet indésirables: prurit, retention, hypotension
Choi PT, Bhandari M, Scott J, Douketis J. Epidural analgesia for pain relief
following hip or knee replacement. Cochrane Database Syst Rev. 2003
BLOCS PERIPHERIQUES
L’ innervation de ces 2 articulations relève de 3
contingents: N fémoral, sciatique et obturateur
•
•
•
•
Bloc fémoral+++
Bloc iliofascial
Bloc fémoral et sciatique
Bloc du plexus lombaire+
Injection unique ou cathéter
PTG: Bloc fémoral vs bloc plexus
lombaire…efficaces et match nul
Bloc continu: ropivacaine 0.2%,12 ml/h 48 h
Kaloul I, Guay J, Côté C, Fallaha M. The posterior lumbar plexus (psoas compartment)
block and the three-in-one femoral nerve block provide similar postoperative analgesia
after total knee replacement.Can J Anaesth. 2004;51(1):45-51
Le bloc moteur: un problème peu compatible avec la
réhabilitation précoce
….SINGLE SHOT SINON RIEN
LES INFILTRATIONS
Une autre approche….très scandinave
pour l’instant
PTH-PTG: Inf. sous-cutanée
Group M received continuous i.v. infusion of morphine plus ketorolac for 24 h. Then, a multihole 16 G catheter was placed subcutaneously and infusion of saline was maintained for 55 h.
Group R received i.v. saline. Thereafter the wound was infiltrated with a solution of ropivacaine
0.5% 40 ml, then a multi-hole 16 G catheter was placed subcutaneously and an infusion of
ropivacaine 0.2% 5 ml h(-1) was maintained for 55 h.
Bianconi M, Ferraro L, Traina GC, Zanoli G, Antonelli T, Guberti A, Ricci R, Massari L.
Pharmacokinetics and efficacy of ropivacaine continuous wound instillation after joint
replacement surgery.J Anaesth. 2003;91(6):830-5.
PTG: INFILTRATION EXTRA ET INTRAARTICULAIRE,
un exemple
• at the end of surgery a mixture of 150 mL ropivacaine (2
mg/mL) and 1 mL ketorolac (30 mg/mL) was prepared. 50 mL
of the solution was loaded into one 50-mL syringe. 0.5 mL
epinephrine (1 mg/mL) was added to the remaining 101 mL,
giving a total volume of 102 mL, and loaded into two 50-mL
syringes, which the surgeon used to infiltrate below the capsule,
muscles, and subcutaneous tissues. The syringe without
epinephrine was used to infiltrate skin and subcutis in equal
proportions along the whole length of the wound.
• A multi-hole epidural catheter was placed with the tip in the
joint. The catheter was tunneled 8–10 cm subcutaneously and
connected to an infusion pump delivering a continuous infusion
(flow-rate: 4 mL/h for 48 h) of 190 mL ropivacaine (2 mg/mL)
at 8 mg/h plus 2 mL ketorolac (30 mg/mL) at 1.25 mg/h.
Intracapsular local anaesthetic has
similar analgesic efficacy to intraarticular after total knee arthroplasty.
• Andersen LØ, Husted H, Kristensen BB, Otte
KS, Gaarn-Larsen L, Kehlet H. Analgesic
efficacy of intracapsular and intra-articular
local anaesthesia for knee arthroplasty.
Anaesthesia. 2010;65(9):904-12.
PTG:Infiltration vs APD
Discharge criteria were met earlier in group A
than in group E [4 days(3–5)]
[3 days(3–3.5)]
Andersen KV, Bak M, Christensen BV, Harazuk J, Pedersen NA, Søballe K. A
randomized, controlled trial comparing local infiltration analgesia with
epidural infusion for total knee arthroplasty. Acta Orthop. 2010;81(5):606-10
PTG:Infiltration vs bloc fémoral
Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tønnesen EK,
Søballe K. Comparison of peri- and intraarticular analgesia with
femoral nerve block after total knee arthroplasty: a randomized clinical
trial. Acta Orthop. 2007;78(2):172-9.
PTH
• Inf. extracapsulaire
Aguirre J, Baulig B, Dora C, Ekatodramis G, Votta-Velis G, Ruland P, BorgeatA.
Continuous Epicapsular Ropivacaine 0.3% Infusion After Minimally Invasive Hip
Arthroplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled
Study Comparing Continuous Wound Infusion with Morphine Patient-Controlled
Analgesia Anesth Analg 2012 114:456-61
PTH:Infiltration vs APD
Andersen KV, Pfeiffer-Jensen M, Haraldsted V, Søballe K. Reduced hospital
stay and narcotic consumption, and improved mobilization with local and
intraarticular infiltration after hip arthroplasty: a randomized
clinical trial of an intraarticular technique versus epidural infusion in 80
patients Acta Orthop. 2007;78(2):180-6..
Expérience Saint-Roch
Le programme SHERPA
(Service d’Hospitalisation, d’Education et de
Rééducation après Prothèse Articulaire)
HYSTERECTOMIE
ABDOMINALE
(vaginale ou coelioscopique se
font en ambulatoire!!!)
HYSTERECTOMIE
ABDOMINALE
• Rachianesthésie morphine
Wodlin NB, Nilsson L, Arestedt K, Kjølhede P; 'GASPI' Study Group. Mode of
anesthesia and postoperative symptoms following abdominal hysterectomy in a
fast-track setting.Acta Obstet Gynecol Scand. 2011;90(4):369-79.
• Cathéter et instillation (cf méta analyse AAS)
Hafizoglu MC, Katircioglu K, Ozkalkanli MY, Savaci S. Bupivacaine infusion
above or below the fascia for postoperative pain treatment after abdominal
hysterectomy. Anesth Analg. 2008 ;107(6):2068-72.
NOTRE EXPERIENCE: ASSOCIER LES DEUX TECHNIQUES ET
ANTALGIQUES PERIPHERIQUES
…L’ALR est utile mais il faut faire le
bon choix pour qu’il réponde aux
objectifs de l’ERAS