The fast track in thoracic anaesthesia

Fast track surgery anaesthetic management is well established in different areas of cardiac and abdominal surgery (1,2). Anaesthetic management has focused on postoperative pain relief, early mobilization and early enteral nutrition (2). Lung surgery is a major intervention and can create massive postoperative pain. These patients require close attention and nursing care. Today the intensive care resources are limited in most countries and it is of importance if possible, to establish a regimen for total management with early treatment on the general ward. A system with reduced pain and early mobilization will further improve patient satisfaction and well-being. There are several aspects that may counteract an unproblematic recovery. Along with surgical problems and complications severe pain will slow mobilization and keep the patient in severe distress. Improvement of logistics is always possible and it may also provide better patient care and reduce the cost. Focusing on – not only the surgical or the anaesthesiological treatment – but on the whole chain of events, from the preoperative evaluation to the discharge from hospital is the key to success. Preoperative evaluation. Sufficient patient information prepares the postoperative course. Lung surgery is often associated with substantial patient anxiety and fear of the future. Not only are the prospects ominous in many cancer forms but the patients may also fear the operation and postoperative pain. Good information of the analgesic methods may reduce anxiety and ensure a cooperative patient. Some patients are eager to manage without the use of painkillers. This may increase postoperative stress and encouragement of the patients and nurses to communicate may ease the postoperative situation. The day of operation. Cardiothoracic anaesthesiologists use heavy premedication also in fast track cardiac surgery in order to reduce sympathetic drive and myocardial ischaemia. This is usually not needed in the average lung surgery patient. In our hospital we use in the general patient a light premedication consisting of a benzodiazepine (e.g. diazepam 5-10 mg) and a peripherally acting analgesic like paracetamol (1-2g). Antithrombotic medication is under debate due to its potential for creating a haematoma during insertion of the epidural catheter. This is a rare but serious complication which should always be kept in mind. There are now arguments for giving a moderate dose of low molecular weight heparin (LMWH) the evening before the operation or with the same effect, 6 hours after catheter placement (e.g. enoxaparin 40 mg or deltaparin 5000 IE sc). Positioning of the patient on table. It is convenient to let the patient position himself on the operating table before induction of anaesthesia. We use a mattress containing flexible material that is fixed and stable during surgery after the vacuum is established. Many patients have some kind of shoulder pain after surgery. Often this must be attributed to irritation of the diaphragm; however, care must be taken to position the arms to reduce stretch and pressure. Thoracic Epidural Analgesia (TEA) with early activation. The use of epidural analgesia is in our experience the one most important point in the fast track management. It is, however, possible though more cumbersome, to manage with patient controlled intravenous analgesia. The latter should be used in patients with contraindications for TEA. If no system for diagnosis and treatment of a possible epidural haematoma exists, the use of TEA should be discouraged. A warning regarding the use of more drugs interfering with coagulation is pertinent. There is extensive experience in the use of LMWH combined with one antiflogistic like diclofenac 50 mg. An epidural haematoma should always be kept in mind and a strict follow-up regimen is required.