FAST TRACK SURGERY — MULTIMODAL STRATEGY OF POSTOPERATIVE PERIOD MANAGEMENT IN GYNECOLOGICAL PATIENTS. THE ROLE OF THE ANESTHESIOLOGIST
Keywords:
multimodal strategy, laparoscopy, vaginal hysterectomyAbstract
Introduction. Application of laparoscopic techniques corresponds to the principles of the FTS maximally. Aim — assess the impact of the early multimodal rehabilitation concept use on the postoperative period. Material and methods. The study involved 39 patients who were randomized by method of envelopes into two groups. In the basic group (20 patients) a multimodal protocol of early rehabilitation was used. In the control group (19 patients) a traditional perioperative regimen was performed. In both groups, vaginal hysterectomy with laparoscopic support under general anesthesia combined with mechanical ventilation was carried out. Fentanyl analgesia (5.3 mcg/(kg·hr)), and 0.5 % bupivacaine solution into epidural space (6.8 mL). The volume of the infusion in the main group was 5–6 ml/(kg·hr), in the control group — 10 ml/(kg·hr). The perioperative analgesia includes NSAIDs (dexketoprofen, ketorolac, paracetamol). Noninvasive monitoring carried by monitor “Leon” (blood pressure, heart rate, capnogram), took into account the hourly diuresis, conducted thermometry. Postoperatively the two groups used 24 hrs prolonged epidural small boluses of 0.25 % bupivacaine solution (4 ml/hour) in combination with systemic administration of dexketoprofen (100–150 mg/day) + ketorolac (60 mg/day) + paracetamol (2000 mg/day). Result. The groups were homogeneous in anamnestic (onset of menstruation, number of pregnancies, childbirth, abortion, miscarriage), anthropometric and demographic characteristics, duration of operations and the beginning levels of systolic, diastolic, mean arterial pressure and heart rate. The volume of blood loss (ml) in patients with FTS was (282±22), in patients of the control group — (347±21), p<0,05. Intraoperative gemohydrobalance (ml) in patients with FTS was (547±57), in the control group — (942±62), p<0,05. The postoperative hospital stay in patients of the main group (FTS) was significantly shorter (5.00±0.26) than in the control group of patients without FTS (7.16±0.40), p<0.05. Conclusion. Optimal anesthetic management allows patients to be fast extubated and to eliminate postoperative pain in the first 24 hours effectively. Using the early multimodal rehabilitation protocol reduces the time of patient recovery after vaginal hysterectomy with laparoscopic assistance.
References
Guidelines for pre- and intra-operative care in gynecologic / oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations – Part I / G. Nelson, A. D. Altman, A. Nick [et al.] // Gynecologic Oncology. – 2016. – Vol. 140, N 2. – P. 313–322.
Мизитова М. И. Fast Track хирургия — мультимодальная стратегия ведения хирургических больных / М. И. Мизитова, Э. Р. Мустафин // Казанский медицинский журнал. – 2012. – № 5. – С. 792–802.
Wodlin N. B. The development of fast-track principles in gynecological surgery / N. B. Wodlin, L. Nilsson // Acta Obstet. Gynecol. Scand. – 2013. – Vol. 92 (1). – P. 17–27.
Guidelines for pre- and intra-operative care in gynecologic / oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations — Part II / G. Nelson, A. D. Altman, A. Nick [et al.] // Gynecologic Oncology. – 2016. – Vol. 140, N 2. – P. 323–332.
Nationwide trends in the perforance of inpatient hysterectomy in United States / J. D. Wright, T. J. Herzog, J. Tsui [et al.] // Obstet. Gynecol. – 2013. – Vol. 122. – P. 233–241.
