Fast-track rehabilitation for lung cancer lobectomy: a five-year experience

Objective: Fast-track rehabilitation is a group of simple measures that reduces morbidity, postoperative complication and accelerates postoperative rehabilitation reducing hospital stay. It can be applied to lung cancer lobectomy. Fast-track rehabilitation cornerstones are: minimally invasive surgical techniques using video-assisted and muscle sparring incisions, normovolemia, normothermia, good oxygenation, euglicemia, no unnecessary antibiotics, epidural patient-controlled analgesia, systemic opiods-free analgesia, early ambulation and oral feeding. Our objective is to describe a five-year experience with fast-track rehabilitation for lung cancer lobectomy. Patients and methods: A retrospective non-controlled study including 109 consecutive patients submitted to fast-track rehabilitation in the postoperative care of lung cancer lobectomy was performed. Only collaborative patients who could receive double-lumen intubation, epidural. catheters with patient-controlled analgesia, who had Karnofsky index of 100, previous normal feeding and ambulation, absence of morbid obesity, diabetes or asthma, were eligible. Postoperative oral feeding and aggressive ambulation started as soon as possible. Results: Immediate postoperative extubation even in the operation room was possible in 107 patients and oral feeding and ambulation were possible before the first hour in 101 patients. Six patients could not receive early oral feeding or ambulate due to hypnosis secondary to preoperative long effect benzodiazepines. Two patients could not ambulate immediately due to epidural catheter misplacement with important postoperative pain. Ninety-nine discharges occurred at the second postoperative day, four of them with a chest tube connected to a Heimlich valve due to air teak. No complication of early feeding and ambulation was observed. Postoperative hypnosis due to long duration benzodiazepines or pain does not allow early oral feeding or ambulation. Avoiding long duration preoperative benzodiazepines, immediate postoperative extubation, regional thoracic PCA and early oral feeding and ambulation were related to a lesser frequency of complication and a shorter hospital stay. Conclusion: Fast-track rehabilitation for lung cancer lobectomies can be safety performed in a selected group of patients if a motivated multidisciplinary group of professionals is available and seems to reduce postoperative complication and hospital stay. (C) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

A fast-track program reduces complications and length of hospital stay after open colonic surgery.

BACKGROUND & AIMS: A fast-track program is a multimodal approach for patients undergoing colonic surgery that combines stringent regimens of perioperative care (fluid restriction, optimized analgesia, forced mobilization, and early oral feeding) to reduce perioperative morbidity, hospital stay, and cost. We investigated the impact of a fast-track protocol on postoperative morbidity in patients after open colonic surgery. METHODS: A randomized trial of patients in 4 teaching hospitals in Switzerland included 156 patients undergoing elective open colonic surgery who were assigned to either a fast-track program or standard care. The primary end point was the 30-day complication rate. Secondary end points were severity of complications, hospital stay, and compliance with the fast-track protocol. RESULTS: The fast-track protocol significantly decreased the number of complications (16 of 76 in the fast-track group vs 37 of 75 in the standard care group; P = .0014), resulting in shorter hospital stays (median, 5 days; range, 2-30 vs 9 days, respectively; range, 6-30; P < .0001). There was a trend toward less severe complications in the fast-track group. A multiple logistic regression analysis revealed fluid administration greater than the restriction limits (odds ratio, 4.198; 95% confidence interval, 1.7-10.366; P = .002) and a nonfunctioning epidural analgesia (odds ratio, 3.365; 95% confidence interval, 1.367-8.283; P = .008) as independent predictors of postoperative complications. CONCLUSIONS: The fast-track program reduces the rate of postoperative complications and length of hospital stay and should be considered as standard care. Fluid restriction and an effective epidural analgesia are the key factors that determine outcome of the fast-track program.

Réhabilitation accélérée multimodate postcésarienne, la somme de toutes les astuces [Fast-track multimodal rehabilitation after cesarean, the sum of all tricks].

Fast-track multimodal rehabilitation after cesarean, the sum of all tricks Fast-track multimodal rehabilitation after caesarean is an interdisciplinary concept allowing an accelerated return to normal physiology. Fast-track rehabilitation combines minimising surgical trauma, regional anaesthesia and active management of pain control, minimally invasive postoperative care while promoting return to autonomy.

Thin Bonded Concrete Overlay with Fast Track Concrete, HR-531, Condition and Performance Report, 1987

This report is a supplement to one issued in late summer 1986 which covered construction on U.S. 71, in Buena Vista County Iowa. The work involved rehabilitation of an older 20 feet wide pavement by placing a four inch thick bonded concrete overlay monolithically with two feet of widening on each side. The work was performed on one lane at a time while construction traffic and limited public traffic used the adjacent traffic lane. When work on the first lane was complete traffic was moved onto it and rehabilitation was completed on the second lane. This report covers the condition of the rehabilitated roadway in May 1987 after the first winter. The condition is described by visual observations, core conditions, and various test results including core compressive strength, direct shear tests on cores for bond strength, profilometer results and delamtect test results.

Fast Track Portland Cement Concrete Pavement, HR-538, 1997

In 1987, 1.5 km (0.935 mi.) of Spruce Hill Drive in Bettendorf, Iowa was reconstructed. It is an arteriel street with commercial usage on both termini with single family residential dwellings along most of the project. A portland cement concrete (PCC) pavement design was selected, but a 14 day curing period would have been an undue hardship on the residents and commercial businesses. An Iowa DOT Class F fast track concrete was used so the roadway could be used in 7 to 10 days. The Class F concrete with fly ash was relatively sticky and exhibited early stiffening problems and substantial difficulty in obtaining the target entrained air content of 6.5%. These problems were never completely resolved on the project. Annual visual field reviews were conducted through 1996. In November 1991, severe premature distress was identified on the westbound two lanes of the full width replacement. The most deteriorated section in a sag vertical, 152 m (500 ft.) of the westbound roadway, was replaced in 1996. Premature distress has been identified on a dozen other conventional PCC Iowa pavements constructed between 1983 and 1989, so the deterioration may not be related to the fact that it was fast track pavement.

Special Cements for Fast Track Concrete, MLR-87-4, 1988

Two specialty cements are currently being marketed as a way to achieve portland cement concrete pavement opening strengths at less than 12 hours after placement. The cements are Pyrament from Pyrament/Lone Star Industries of Houston, Texas and Ideal Regulated-Set (RS) Portland Cement from Ideal Cement Company of Saratoga, Arkansas. The objective of the study was to evaluate the strength gain and durability of concrete produced with Pyrament and Ideal RS cement as Fast Track concrete. Mixes with 610 lb/cu yd (362 kg/cu m) cement were made and tested. Both Pyrament and Ideal RS are capable of producing pavement opening times less than 12 hours. Recent changes to Ideal RS cement have produced concrete flexural strengths of 550 psi (3792 kPa) at 4 hours in Iowa tests. Freeze/thaw durability of the concrete was not adversely affected by using either cement.

Evaluation of Type I Cement Fast Track Concrete, MLR-87-6, 1988

There are projects where opening the pavement to traffic in less than the 5 to 7 days is needed, but an 8 to 12 hour opening time is not necessary. The study examined fast track concrete with Type I cement and admixtures. The variables studied were: (1) cure temperature, (2) cement brand, (3) accelerators, and (4) water reducers. A standard water reducer and curing blankets appear to be effective at producing a 24 hour to 36 hour opening strength. An accelerator and/or high range water reducer may produce opening strength in 12 to 24 hours. Calcium chloride was most effective at achieving high-early strength.

Thin Bonded Concrete Overlay with Fast Track Concrete, Final Report, HR-531, 1990

Pavements have been overlaid with thin bonded portland cement concrete (PCC) for several years. These projects have had traffic detoured for a period of 5-10 days. These detours are unacceptable to the traveling public and result in severe criticism. The use of thin bonded fast track overlay was promoted to allow a thin bonded PCC overlay with minimal disruption of local traffic. This project demonstrated the concept of using one lane of the roadway to maintain traffic while the overlay was placed on the other and then with the rapid strength gain of the fast track concrete, the construction and local traffic is maintained on the newly placed, thin bonded overlay. The goals of this project were: 1. Traffic usage immediately after placement and finishing. 2. Reduce traffic disruption on a single lane to less than 5 hours. 3. Reduce traffic disruption on a given section of two-lane roadway to less than 2 days. 4. The procedure must be economically viable and competitive with existing alternatives. 5. Design life for new construction equivalent to or in excess of conventional pavements. 6. A 20 year minimum design life for rehabilitated pavements.

Fast Track and Fast Track II Cedar Rapids, Iowa, HR-544, 1993

Two lanes of a major four-lane arterial street in Cedar Rapids, Iowa, needed reconstruction. Because of the traffic volume and the detour problem, closure of the intersections, even for 1 day was not feasible. Use of Fast Track concrete paving on the mainline portion of the project permitted achievement of the opening strength of 400 psi in less than 12 hr. Fast Track II, used for the intersections, achieved the opening strength of 350 psi in 6 to 7 hr. Flexural and compression specimens of two sections each in the Fast Track and Fast Track II sections were subjected to pulse velocity tests. Maturity curves were developed by monitoring the temperatures. Correlations were performed between the pulse velocity and flexural strength and between the maturity and flexural strength. The project established the feasibility of using Fast Track II to construct portland cement concrete pavement at night and opening the roadway to traffic the next day.

Impact of restrictive intravenous fluid replacement and combined epidural analgesia on perioperative volume balance and renal function within a Fast Track program.

BACKGROUND AND OBJECTIVE: Key factors of Fast Track (FT) programs are fluid restriction and epidural analgesia (EDA). We aimed to challenge the preconception that the combination of fluid restriction and EDA might induce hypotension and renal dysfunction. METHODS: A recent randomized trial (NCT00556790) showed reduced complications after colectomy in FT patients compared with standard care (SC). Patients with an effective EDA were compared with regard to hemodynamics and renal function. RESULTS: 61/76 FT patients and 59/75 patients in the SC group had an effective EDA. Both groups were comparable regarding demographics and surgery-related characteristics. FT patients received significantly less i.v. fluids intraoperatively (1900 mL [range 1100-4100] versus 2900 mL [1600-5900], P < 0.0001) and postoperatively (700 mL [400-1500] versus 2300 mL [1800-3800], P < 0.0001). Intraoperatively, 30 FT compared with 19 SC patients needed colloids or vasopressors, but this was statistically not significant (P = 0.066). Postoperative requirements were low in both groups (3 versus 5 patients; P = 0.487). Pre- and postoperative values for creatinine, hematocrit, sodium, and potassium were similar, and no patient developed renal dysfunction in either group. Only one of 82 patients having an EDA without a bladder catheter had urinary retention. Overall, FT patients had fewer postoperative complications (6 versus 20 patients; P = 0.002) and a shorter median hospital stay (5 [2-30] versus 9 d [6-30]; P< 0.0001) compared with the SC group. CONCLUSIONS: Fluid restriction and EDA in FT programs are not associated with clinically relevant hemodynamic instability or renal dysfunction.

Fast Track and Fast Track II - Cedar Rapids, Iowa, HR-544, Construction Report, 1989

Two lanes of a major four lane arterial street needed to be reconstructed in Cedar Rapids, Iowa. The traffic volumes and difficulty of detouring the traffic necessitated closure for construction be held to an absolute minimum. Closure of the intersections, even for one day, was not politically feasible. Therefore, Fast Track and Fast Track II was specified for the project. Fast Track concrete paving has been used successfully in Iowa since 1986. The mainline portion of the project was specified to be Fast Track and achieved the opening strength of 400 psi in less than twelve hours. The intersections were allowed to be closed between 6 PM and 6 AM. This could occur twice - once to remove the old pavement and place the base and temporary surface and the second time to pave and cure the new concrete. The contractor was able to meet these restrictions. The Fast Track II used in the intersections achieved the opening strength of 350 psi in six to seven hours. Two test sections were selected in the mainline Fast Track and two intersections were chosen to test the Fast Tract II. Both flexural and compression specimens were tested. Pulse velocity tests were conducted on the pavement and test specimens. Maturity curves were developed through monitoring of the temperatures. Correlations were performed between the maturity and pulse velocity and the flexural strengths. The project was successful in establishing the feasibility of construction at night, with no disruption of traffic in the daytime, using fast Track II. Both the Fast Track II pavements were performing well four years after construction.