The 'fast track' to Stracathro? - 18 Weeks

The ‘fast track’ to success?
Dr Christina Beecroft
Consultant Anaesthetist
NHS Tayside

Background
• First case September 2010
• ‘On‐call’ for any problems
• Initially EVERYONE told me about EVERY
problem…….
• Gradual acceptance from all staff with interest
from other Grampian surgeons
• By Spring 2011 all Grampian patients
managed at Stracathro followed enhanced
recovery protocol

Pre‐op information (from PAC/CB)
Change in attitude
– Expect pain
Major surgery
Different to pre‐op pain and it will get better
– Encourage patient to take control of their
recovery
Goals –out of bed day 0, no bed pans, aim for home
day 2

Premedication on day of surgery
• Gabapentin 300 mg
• Paracetamol 1G orally (continue qds)
• If first patient on list, oxycontin 10/20 mg
orally
• Unrestricted intake of water until a minimum
of 2 hours before surgery (avoid prolonged
fasting)

Anaesthesia
• Low‐dose spinal anaesthesia* (2‐2.5 ml of 5 mg/ml
levo‐bupivacaine) with no intrathecal opioid
• Tranexamic acid 15 mg/kg slow IV bolus
• Prophylactic anti‐emetics (triple therapy
dex/ondansetron/droperidol)
• Sedation as required –Midazolam +/‐ TCI Propofol
*Lower dose spinal allows the block to regress more quickly, facilitates earlier
mobilization and reduces the risk of post‐op hypotension and urinary retention.

Peri‐operative fluid balance
• A low‐dose spinal combined with light sedation induces less
peri‐operative hypotension
• Post‐op fluids should only be prescribed if clinically indicated.
If the patient is stable and drinking, the IV can be
discontinued in recovery*
• IV fluid boluses are then prescribed according to target blood
pressure and urine output
• Urinary catheterisation is only performed if clinically indicated
*Patients requiring more active management of postoperative fluid balance include:
those with greater than anticipated blood loss, an unacceptably low blood
pressure, previous MI/CVA/PTE, heart failure, diabetes, pre‐existing renal
impairment (eGFR < 60 ml/min), anaemia, ACE inhibitor, other significant medical
co‐morbidities.

Local Anaesthetic
• Dose of local anaesthetic used
• 0.125% L‐bupivacaine instead of 0.2% ropivacaine
• 150 ml infiltration intra‐operatively
• Ambit pump 20 ml bolus 4 hourly
• Cumulative dose over 24 hours therefore reduced

Levo‐Bupivacaine regime
• Intra‐operative infiltration of 150 ml levobupivacaine
1.25 mg/ml
• TKR –intra‐articular catheter connected to
elastomeric pump containing 250 ml 0.125% L‐
bupivacaine at a rate of 10 ml/hr.
NB dose now 250 mg over 20 hours, total 437.5 mg
(from 312.5 mg)

Additional post‐op analgesia
• Paracetamol 1G qds
• Regular NSAID if not contraindicated medically/surgically
for 48 hours only with PPI cover (omeprazole 20 mg od)
• Oxycontin as per NHST protocol (10 mg bd THR, 20 mg bd TKR)
• Oramorph 10 mg hourly for breakthrough pain
*Morphine sulphate up to 10 mg IV and consider morphine
PCA 1 mg bolus 5 min lock‐out in patients with poor
response to oral analgesia
• Gabapentin 300 mg on night of surgery
• Consider zopiclone 3.75 mg nocte for 2 post‐op nights

Progress
• Driven by nursing staff
– Intrathecal morphine
– Urinary catheter audit
– Mobilisation audit
– ‘Joint school’
– Carbohydrate loading

Colleagues……
• ‘What are we trying to achieve? Our patient’s
already go home on day 3 which is better than
Ninewells, what more do you want’!
• Doing ‘bits’ of the protocol
– Adding gabapentin
– Lower dose spinal but still with ITM
– “Skinny” (dia)morphine
– Enhanced recovery patients take priority which
‘slows’ traditional patient’s mobilisation
• ‘Quality not quantity’

“Enhanced recovery should improve outcome,
shorten hospital stay and thus reduce the
overall cost of care: a win‐win‐win scenario”
Professor Monty Mythen, National Clinical Lead, Department of Health
Enhanced Recovery Partnership
Bulletin of the RCoA Number 69, September 2011