Page 29 - Read Online
P. 29

Ratti et al.                                                                                                                                                               Fast-track management in patients with HCC

           Table 1: Fast-track management protocol            Table 2: Intra- and postoperative management of
           Before surgery                                     volemic status and pain
                           Preoperative counselling (surgeon,                Minor open  Major open Laparoscopic
                           anaesthesiologist, nurse)
                           Normal oral nutrition until midnight  CVC            No         No          No
                           No preanaesthetic medication       Vigileo           Yes        Yes        Yes
                           No bowel preparation                              Gen + Peri or         Gen + Spin &
           Day of surgery                                     Anaesthesia    Gen + Spin   Gen + PVT   TAP
                           Carbohydrate drinks up to 2 h before                &TAP
                           surgery                            Paracetamol      1 g × 3    1 g × 3    1 g × 3
                           Local analgesia*                                  50 mg × 2 (if
                           Short-acting i.v. anaesthetic agent  Tapentadol     spinal)   50 mg × 2  50 mg × 2
                           Nasogastric drainage remove immediately
                           after surgery                                     Ketorolac 30   Ketorolac 30   Ketorolac 30 mg
                                                                                          mg ab
                                                                               mg ab
                           Warm i.v. fluids and lower body air-warming  NSAID  (max 90 mg   (max 90 mg   ab
                           Avoidance of excessive i.v. fluids                   die)       die)   (max 90 mg die)
                           (intraoperative SVV > 12%)*
                           No routine drainage of the peritoneal cavity  CVC: central venous catheter; Gen: general; Peri: peridural; Spin:
                           Allowed intake of water/nutrition after   spinal; TAP: transversus abdominis pain block; PVT: paravertebral;
                           surgery                            NSAID: nonsteroidal anti-inflammatory drug
                           Patient sent to surgical ward
           Postoperative day 1                                (1) Pain adequately controlled with oral analgesics;
                           Patient mobilizes with physiotherapist  (2) Independently mobile (mobile at preoperative level);
                           Patient drinks at least 1.5 L      (3) Tolerance of solid food: fluid and solid food intake is
                           Normal diet                        monitored and must be returned to normal tolerance
                           Continue portable local analgesia  level, i.e. when oral intake of water and normal food
                           1,000 mg paracetamol every 8 h
                           Laboratory tests                   is  resumed  and  continued  for  at  least  24  h.  Since
           Postoperative day 2                                postoperative nausea and  vomiting obviously
                           Continue portable local analgesia  influences the intake of fluid and solid food, a specific
                           Discontinuation of ev fluids       prophylaxis is always performed;
                           Remove urinary catheter            (4) Normal or decreasing serum bilirubin;
                           Continue mobilization              (5) No intravenous fluids.
                           1,000 mg paracetamol every 8 h
                           Normal diet                        Outcome evaluation
           Postoperative day 3
                           Start tapentadol                   Data regarding  general  characteristics of patients
                           Stop local analgesia               and  disease were  recorded.  Intraoperative  and
                           Continue mobilization              postoperative outcome were evaluated, including
                           Normal diet                        morbidity and mortality. Postoperative complications
                           Laboratory tests                   were reviewed for 90 days following liver resection and
                           Check discharge criteria           were graded according to Dindo-Clavien classification
           Postoperative day 4                                                       [14]
                           Check discharge criteria           of surgical  complications.   Ascites  was  defined  as
                           Patient receives telephone number of case   an output > 500 mL per day from abdominal drainage
                           manager nurse                      (when positioned) or a clinically relevant abdominal
                           Discharge                          distension  requiring  diuretics  and/or  iv albumin.
           Discharge criteria                                 Postoperative  mortality  was  defined  as  any  death
                           Adequate oral feeding
                           Adequate pain control with oral analgesics  during postoperative hospitalization or within 90 days
                           Normal deambulation and self-care   after resection.
                           autonomy
                           No complications                   Specific   issue   regarding   ERAS   management
                           Bowel recovery                     (nasogastric tube and drainage  placement, oral
                           Patient agreement                  feeding, mobilization,  bowel  canalization,  adequate
           *See Table 2 for anaesthesiological management protocols. SVV:   pain control with oral analgesics, time for functional
           stroke volume variation                            recovery, agreement for discharge, rate of readmission,
                                                              length of stay) were specifically collected and analyzed.
           of  patients  volemic status  and postoperative pain
           management [Table 2].                              Statistical analysis
                                                              Matching control patients undergoing  laparoscopic
           Definition  of  functional  recovery  was  based  on  the   surgery were selected according to propensity scores
           following criteria (the patient is considered functional   based on 6 covariates in a ratio of 1:1 with the open-
           recovered when all the criteria are met):          group: this study design was chosen to adjust for the
                           Hepatoma Research ¦ Volume 2 ¦ September 30, 2016                              273
   24   25   26   27   28   29   30   31   32   33   34