Abstract
Introduction
Enhanced recovery is a multidisciplinary clinical pathway that can provide multiple benefits, including from a clinical, quality and resource-allocation perspective.1,2 A patient-centred, structured and multidisciplinary protocol enables its implementation from guidelines that reflect local preferences. A successful enhanced recovery programme in thoracic surgery, similar to other surgical specialties, focuses on preoperative optimisation, postoperative mobilisation, minimal invasive surgical access and fluid management. These systems will evolve, over the next few years, to further decrease postoperative complications such as acute lung injury and chronic pain. However, the idea of protection from perioperative surgical and anaesthetic aggression based on clinical outcomes should remain the principal ethos.
Enhanced recovery programmes in thoracic surgery
In the 1990s, Kehlet 3 proposed a modified clinical pathway for patients undergoing colorectal surgery, to limit the response to surgical and anaesthetic aggression. This newly described enhanced recovery programme was based on a bundle of multidisciplinary interventions that were shown to decrease the rate of complications and length of stay in different surgical specialties, such as colorectal, urological, otorhinolaringology and thoracic surgery.1,2 Enhanced recovery is a unique intervention in healthcare service provision, with its ability to increase quality of services without increased resources, and reduced morbidity and length of stay.
Enhanced recovery programme in thoracic surgery.
Source: Modified from Giménez-Milà et al. 5
Over 20 perioperative actions may be classified within the enhanced recovery programme, but only a handful of them are applicable across specialties.
6
The five fundamental principles that facilitate recovery include preoperative optimisation, minimisation of perioperative inflammation, eating and drinking as early as possible, early mobilisation and aggressive pain control (Figure 1).
Graphic representation that summarises the core enhanced recovery principles for thoracic surgery. The five central goals are influenced by a number of interventions that may potentiate them; by improving patients’ conditions before surgery or minimising perioperative stress. COPD: chronic obstructive pulmonary disease: PONV: postoperative nausea and vomiting.
Provision of analgesia, postthoracic surgery, is an integral aspect of the perioperative process that impacts outcome in several aspects. The immediate outcome in terms of patient satisfaction, early respiratory function with airway expansion and expectoration, can significantly impact enhanced recovery goals of early patient mobility and discharge. Additionally, longer-term outcomes with chronic post-thoracotomy pain syndromes may be significantly influenced by the early postoperative pain experience.
Acute lung injury after thoracic surgery is a complex phenomenon with a multietiological origin. Alcohol abuse, presence of heart and obstructive lung disease and predicted postoperative Forced expiratory volume in first second have been associated with it. Recognised surgical risk factors include time on one lung ventilation and extent of resection (pneumonectomy). Anaesthetic factors implicated on genesis of lung injury are the amount of fluid administration in first 24 hours 7 and establishment of lung protective ventilation providing airway pressures less than 30 cmH2O. 8
Modulation of reperfusion injury that takes place after ventilation of collapsed lung has been proposed as a possible mechanism that may reduce incidence of acute lung injury. Administration of halogenated anaesthetics reduces local and systemic cytokine release, and the avoidance of hyperoxia reduces the amount of reactive oxygen species. 9
Acute postoperative pain management
The causes of excessive postoperative pain are multifactorial. These include forceful wound retraction, costochondral dislocation, rib fracture, posterior costovertebral ligament disruption, intercostal nerve trauma and intercostal drains. This is exacerbated by the obligatory wound movement during respiration.
Modes of analgesia
It is unusual for a single modality to be effective alone. A multimodal approach is preferable with a combination of intravenous and oral medication, local infiltration and regional techniques.
Intravenous/oral medication
Patient-controlled analgesia is a core strategy for postoperative thoracic analgesia. Opiates, typically morphine or oxycodone/fentanyl, are widely used in anaesthesia and lend its use to thoracic surgery as well. Apart from the analgesic effects, the anxiolysis and patient control may significantly reduce the need for analgesia. However, the use of non-opioid medication with regional local anaesthetic techniques can reduce the use of opioids, with its side effect profile of drowsiness, respiratory depression and nausea.
Other simple agents greatly enhance a multimodal approach and would include regular paracetamol and non-steroidal agents, 9 steroids and gabapentin. 10 Occasionally, procedure-based limits on drugs (e.g. talc pleurodesis on the use of non-steroidals and steroids) will impact the strategy.
Non-drug strategies may prove remarkably effective in a patient-oriented approach. Often patients have their own experience of analgesic strategies (‘ibuprofen never works but diclofenac is wonderful!’). They may also benefit from physical therapies such as heat, massage or transcutaneous electrical nerve stimulation. 11
Local anaesthetic-based techniques
The nerve supply of the thorax is largely from intercostal nerves of T2–T9. In addition, there is diaphragmatic innervation by the phrenic nerve that returns to C3–5. The thoracodorsal nerve (latissimus dorsi) and the long thoracic nerve (serratus anterior) arise from the brachial plexus with C3–5 innervation, and while these are classically purely motor nerves, it may be that variants have sensory innervation.
Figure 2 shows the different areas where local anaesthetic techniques may be effective. Local infiltration and intercostal blocks are effective in the immediate postoperative phase. The main disadvantage is of limited duration of action, usually less than 8 hours, but they can still be effective tools in rescue strategies for acute pain. Intercostal catheter use has been described more recently.
12
Interpleural local anaesthetic may be useful in the management of diaphragmatic irritation or pleural irritation from drains remote from the surgical incision.
Relevant local and regional anaesthetic intervention in thoracic surgery. Source: Modified with permission from Cox.
13
The mainstays of continuous therapies have been paravertebral and thoracic epidural blockade where catheters can be placed and an infusion continued for days. Several studies have sought to compare between these techniques, but two major developments have increasingly biased practice towards paravertebral blockade. First, the availability of new technology, either video-assisted thoracoscopy approaches (with visual confirmation of correct catheter and local anaesthetic placement) or the use of ultrasound (to direct catheter and drug placement), has improved the success of paravertebral blockade (Figure 3). Second, the increased emphasis on enhanced recovery, with early mobilisation and discharge, has overcome a focus on excellent analgesia (thoracic epidurals) where epidurals require higher grade nursing care and may require urinary catheters and greater assistance to mobilise. However, categorical data are not yet definitive and research continues,14,15 but most enhanced recovery programmes have developed without the use of epidurals.
Ultrasound-guided serratus anterior block performed before surgical procedure (modified for thoracic surgery with patient on side compared to original description).
The availability of ultrasound has also allowed newer techniques to be developed and the serratus anterior block16,17 shows promise. By depositing a large volume of local anaesthetic in the plane between the serratus anterior and latissimus dorsi, the lateral branches of the intercostal nerves are anaesthetised as they pass between the muscle layers. A wide area of the lateral thorax is covered including the long thoracic and thoracodorsal nerves. Experience suggests that these blocks can last up to 30 hours, possibly because local fatty tissue and membranes provide a depot for the local anaesthetic.
Implementation of enhanced recovery programmes
There are several guidelines that are good resources for the design and implementation of a thoracic enhanced recovery programme.6,19 However, to achieve the highest possible compliance and promote the cultural change, these guidelines should be carefully translated into local pathways, and ultimately adapted to local institutional capability and needs. 19
Although the programme implementation should be procedure-specific and tailored to thoracic surgery in particular, it does require a multidisciplinary approach, with general consensus of a wider perioperative team, 20 and continuous audit of the outcomes once the intervention has been instituted. Full standardisation and multidisciplinary agreement can be challenging, so it is important to invest time and resources in the most cost-effective interventions. Every intervention selected to be part of the programme should be in line with the above-mentioned five principles (Figure 1). Therefore, when planning and designing your local pathway, the interventions that clash with the five principles should be reconsidered. For instance, the use of a thoracic epidural offers excellent pain control, but it does limit early mobilisation and increases the risk of urinary retention and later requirement of urethral catheterisation, while other regional techniques may offer a better option to facilitate safe and early mobilisation.
Strategic institutional changes, such as ensuring universal access to preoperative assessment, will facilitate the introduction of other high-impact interventions. This includes organ function optimisation such as chronic obstructive pulmonary disease treatment, smoking cessation or anaemia correction. This may require additional resources, education and training and significant changes in daily practice that should be computed during the design of the local programme.
Anaesthetic management techniques have debatable benefits, such as the use of short-acting anaesthetic agents or total intravenous anaesthesia versus volatile anaesthesia, and these interventions may not translate into real gains for patients’ recovery. In contrast, the creation of an integrated care pathway for pain control, with implementation of a reliable and reproducible multimodal analgesia strategy, that includes a regional technique, is essential for a successful thoracic enhanced recovery programme. Similarly, a standardised and aggressive drain removal strategy will reduce opioids consumption, 21 decrease nausea and vomiting after surgery and increase compliance with mobilisation and early oral intake.
Future development of enhanced recovery in thoracic surgery
Retrospective and randomised controlled trials have shown the benefit of an enhanced recovery programmes in thoracic surgery,1,2 but the degree of implementation in each institution is different. In addition to this evidence, further areas remain to be explored. Long-term outcomes such as patient satisfaction, chronic pain and rate of readmission might provide useful information to continuously improve upon the current programme modifications. Similarly, prehabilitation programmes (nutritional, psychological and physical interventions) have been studied in colorectal surgery showing improved functional capacity. 22 The relevance to the thoracic setting has, however, not been established.
In the future, an enhanced recovery programmes will evolve towards a more community-supported approach. As clinicians, we should ensure that this provides immediate and mid- to long-term advantage for patients, in terms of complication rate, hospital readmissions, primary care appointments and patient and relatives satisfaction. Enhanced recovery supports the development of perioperative medicine with hospital–primary care–community connections where the principal actors are the patient and relatives rather than healthcare providers.