Research Progress on the Application of Fast-track Surgery in Perioperative Nursing

Songhong XIE, Bing LIU

1. College of Nursing, Hubei University of Medicine, Shiyan 442000, China; 2. Research Center for Health Management and Health Development, Hubei University of Medicine, Shiyan 442000, China

Abstract Fast-track surgery is a combination of multiple disciplines, using a series of evidence-based medical measures to promote the recovery of gastrointestinal function, reduce complications and promote the rapid recovery of patients. The concept of accelerated rehabilitation runs through the whole process before, during and after operation, and the perioperative surgical nursing plan is improved, which is expected to provide reference for medical staff to carry out perioperative nursing.

Key words Fast-track surgery, Perinatal nursing, Application, Research progress

1 Introduction

As a country with a large population, China is facing a huge medical burden. How to promote the rehabilitation of patients while reducing medical expenditure is an urgent problem for medical workers, and the concept of accelerated rehabilitation is the key to solving this problem. Fast-track surgery (FTS), also known as rapid rehabilitation plan, refers to evidence-based medicine as the center, combined with multiple disciplines, which aims to optimize perioperative medical measures, reduce physical and psychological adverse stress reactions caused by surgical trauma, achieve rapid recovery, reduce hospital stay, postoperative complications, and medical costs[1-3]. This paper summarizes the literature on the application of FTS concept in perioperative period at home and abroad, and analyzes the contents.

2 Development status of FTS at home and abroad

The concept of FTS is a patient-centered management model, which aims to reduce the stress response caused by surgical trauma, avoid the loss of organ function, and promote the early recovery of patients. Multidisciplinary cooperation is an important part of FTS, involving surgeons, anesthesiologists, rehabilitators, ward nurses, family members and members of the community. FTS is popular abroad and has been introduced into the concept of internal medicine and surgery. The concept of FTS was first put forward by Kehlet and Wilmore in 1997 and applied to perioperative colorectal patients[4]. It was introduced by Li Jieshou into China in 2005 and applied to patients undergoing gastrectomy in perioperative period[5], and achieved good results. It was first reported in 2006 by the Gastrointestinal Rapid Rehabilitation Center of West China Hospital of Sichuan University in foreign medical journal[6]. In 2008, Jiang Zhiweietal.[7]applied the concept of FTS to perioperative colorectal patients in China. The results showed that the concept was safe and effective and worthy of clinical application. In 2010, the FTS Association was established, which is an international authoritative institution organized by multiple disciplines to explore and improve perioperative care and to form the best perioperative nursing guidelines[8]. The Clinical Practice Guide of Fast-track Surgery in China was issued in 2021 to provide evidence support for domestic clinical practice[9].

The concept of FTS is prevalent in the field of general surgery, especially in colorectal surgery, and its clinical benefits have been verified. In recent years, with the continuous development of this concept, it has been gradually applied to other surgical fields, such as orthopaedics[10], urology[11], gynecology[12], tumor resection[13-14], thoracic surgery[15]and so on. Its effectiveness has been fully recognized in this field.

2 Application of FTS in perioperative nursing

2.1 Before operation

2.1.1Health education. Health education is an important part of FTS, including psychological nursing and health education. Patients often do not understand anesthesia and surgery before operation, and are prone to anxiety and fear. Medical staff should carry out psychological nursing according to the specific conditions of patients to alleviate adverse psychological stress reactions and make patients spend the perioperative period with peace of mind. It has been reported that psychological nursing can relieve patients’ bad mood and disease symptoms, increase the cognition of postoperative adverse reactions, and effectively reduce postoperative nausea and vomiting[16]. Health education is the guarantee to speed up the implementation of the rehabilitation plan. The contents and methods of preoperative education of nurses are in line with the age and education level of patients. The contents of education include preoperative cardiopulmonary exercise, early postoperative exercise, early eating, limb functional exercise and so on. In recent years, various forms of education, including manuals, display boards and multimedia videos, have been used to mobilize the enthusiasm of patients and their families to participate in the implementation of the accelerated rehabilitation plan. It has been reported that the use of multimedia video to educate patients can enhance the effect of publicity, improve the ability of self-management, reduce complications and speed up the recovery of patients[17].

2.1.2Gastrointestinal management. According to the traditional view, food should not be provided for 12 h and water should not be provided for 6 h during gastrointestinal preparation, which can promote gastric emptying and avoid pulmonary complications caused by aspiration during anesthesia. Fasting for a long time will not only make patients feel uncomfortable, but also make them have hypoglycemia, insulin resistance, increasing physiological adverse stress reaction, which is not conducive to the recovery of body function. Some studies have found that shortening the time of fasting can reduce the discomfort of patients, reduce insulin resistance and reduce the incidence of pulmonary complications[16]. In 2021, the domestic FTS experts also made it clear that in addition to emergency surgery, patients should eat nothing for 6 h and drink nothing for 2 h before operation[9]. Based on the concept of FTS, it is a safe and feasible diet management program to advocate shortening the time of fasting and reducing the discomfort of patients. The traditional view is that preoperative intestinal preparation (through diet control, taking drugs, mechanical enema,etc.) is very necessary, and aims to clean the intestinal tract, reduce intestinal bacteria, reduce the risk of postoperative abdominal distension and anastomotic leakage. It has been reported that there is no risk of anastomotic leakage and incision infection for intestinal preparation before operation[18]. Except for colorectal examination and patients with severe constipation, FTS currently does not advocate mechanical intestinal preparation. Long-term enema leads to intestinal mucosal edema and affects anastomotic healing. The residual enema fluid leads to the disorder of water and electrolyte, the imbalance of acidity and alkalinity, disturbing the internal environment of the body and increasing stress factors. FTS believes that preoperative oral administration of compound polyethylene glycol electrolyte powder can meet the requirements of preoperative intestinal preparation, reduce postoperative intestinal discomfort symptoms, promote the recovery of gastrointestinal function, avoid the increase of postoperative complications, and shorten hospital stay[19].

2.2 Intraoperative nursing

2.2.1Intraoperative heat preservation. Perioperative hypothermia is a common complication during operation. Some studies have found that if the operation time is more than 2 h, the incidence of hypothermia can reach 70%[20]. If anesthesia[21], operation time is too long, hypothermia can be caused by excessive skin exposure during operation[22], rehydration at room temperature[23], extensive use of washing fluid during operation, individual factors[24]and so on. Hypothermia not only increases the risk of surgical wound infection, cardiovascular events, but also affects blood coagulation. If there are increased perioperative bleeding, arrhythmia, increased metabolism of the body, it will affect the metabolic time of anestheticsinvivo, and increase the potential risk of anesthetics[25]. The study of Xiao Mengetal.[26]confirmed that perioperative heat preservation can reduce complications, shorten hospital stay, achieve the better effect, and play a positive effect in patients undergoing laparotomy. Therefore, hypothermia protection is an important part of FTS. The intraoperative heat preservation measures mainly include: adjusting the room temperature to 24-26 ℃[27], heating blood products to 35-37 ℃, heating washing solution and infusion liquid to 36-37 ℃[28], using thermal blanket during operation[29]and so on. At present, medical staff have different understanding of heat preservation and lack equipment. Therefore, it is necessary to constantly improve the heat preservation awareness of medical staff, improve heat preservation equipment, establish personalized heat preservation measures, reduce perioperative complications and promote rapid recovery of patients.

2.2.2Liquid management. Fluid therapy is an important part of FTS management strategy. Due to the individual differences of patients, the amount of perioperative fluid replacement should be individualized according to the actual situation of patients, in order to avoid adverse reactions caused by fluid replacement. Some scholars have pointed out that too much fluid infusion aggravates the cardiac load, resulting in the enhancement of capillary permeability, and excessive fluid replacement can cause tissue edema and increase the incidence of postoperative complications[30]. In recent years, with the increase of perioperative restricted fluid infusion research, domestic research reported that compared with traditional fluid replacement, the results of restricted fluid replacement show that restricted fluid replacement can shorten hospital stay, reduce medical expenses and improve patient satisfaction[31]. At present, FTS advocates target-directed fluid therapy, which aims to improve the homeostasis of the body and avoid related complications caused by volume load and volume deficiency. Wang Xiangetal.[32]reported that 32 patients were treated with target-directed fluid therapy under FTS. The results showed that it was helpful to fluid management during operation and to the recovery of patients after operation. Scholars of Chongqing Medical University found that the implementation of target-oriented fluid management for surgical patients only had an advantage in the incidence of readmission, but had no significant effect on the recovery of gastrointestinal function, shortening the duration of hospitalization and the incidence of postoperative complications[33]. At present, there is still a debate on target-oriented liquid management, and further exploration of perioperative liquid management is needed in the future.

2.2.3Anesthesia plan management. Choosing a reasonable anesthetic scheme can reduce the complications and accelerate the recovery of the patients. The Clinical Practice Guide of China Fast-track Surgery[34]proposes that general anesthesia combined with epidural or peripheral nerve block and local infiltration anesthesia can not only meet the needs of anesthesia, but also reduce stress reaction. FTS advocates reducing and avoiding the use of opioids and reducing gastrointestinal reactions during perioperative period. During the operation, the anesthetic with rapid effect and short metabolic time should be selected to make the patients wake up in time, shorten the time of endotracheal intubation and reduce the adverse stress reaction of anesthesia.

3 Postoperative nursing

3.1 Early eatingThe traditional view is that after operation, patients can eat after the first gas passing to avoid nausea, vomiting and abdominal distension caused by eating too early. FTS believes that early eating inhibits body consumption, reduces body stress, promotes the recovery of gastrointestinal function, and reduces postoperative complications. Some studies have pointed out that early oral feeding can not only promote the recovery of gastrointestinal function, protect intestinal mucosal barrier, prevent bacterial imbalance, but also reduce postoperative complications and shorten hospital stay[35]. Early eating is not merely a simple enteral supplement, and it can also promote gastrointestinal peristalsis, protect intestinal mucosa, preparing for getting out of bed early after operation[36]. Kingmaetal.[37]found that early chewing gum to imitate eating can reduce vagus nerve stimulation, reduce postoperative complications and promote the recovery of gastrointestinal function. Therefore, on the premise of fully evaluating and ensuring the safety of patients, early postoperative eating does not increase the risk of nausea and vomiting, but also reduces the energy consumption of the body.

3.2 Effectively easing painPostoperative pain affects patients’ rest and sleep, increases negative emotions, restricts out-of-bed activities, and increases the risk of deep venous thrombosis, which is not conducive to body rehabilitation. Therefore, FTS recommends prophylactic, personalized, multi-mode analgesia management[38], which combines different mechanisms of action of drugs to reduce the dosage of a single drug to make it play the best analgesic effect. Ding Qianetal.[39]pointed out that perioperative multi-mode analgesia management can relieve postoperative pain, reduce postoperative complications, shorten hospital stay and improve patient outcome. Therefore, effective postoperative pain management can reduce the incidence of complications, reduce stress factors, and promote the rapid recovery of patients.

3.3 Removal of tubePostoperative patients are often inserted with gastric tubes, urinary catheters and drainage tubes. Long-term indwelling of various tubes will not only increase the risk of infection, but also affect patients’ comfort, increase psychological burden and hinder getting out of bed. FTS does not advocate indwelling gastric tube and drainage tube for patients undergoing elective surgery. When there are risk factors of anastomotic infection, indwelling of abdominal drainage tube is recommended[40]. FTS recommends that urinary catheters be removed 24 h after operation to reduce the chance of urinary tract infection. Huang Yanfenetal.[41]found that the longer the indwelling of catheter, the higher the probability of urinary tract infection. The gastric tube should be removed immediately after anesthetic awareness, and the drainage tube should be removed as early as possible according to the specific conditions of the patient[42].

3.4 Early activitiesLong-term bed rest after operation can lead to pulmonary complications, decreased muscle strength and reduced intestinal peristalsis. Early getting out of bed can restore the respiratory and gastrointestinal system, which has important clinical significance in increasing appetite, reducing pulmonary infection and preventing deep venous thrombosis. Zhang Lilietal.[43]compared the early getting out of bed with the traditional concept, and the results showed that early getting out of bed can promote early extubation, recovery of lung function, relieve pain and accelerate the recovery of patients. FTS recommends that patients move in bed after anesthetic awareness, and get out of bed with the help of family members and nurses 1 d after operation[34]. Medical staff should establish a personalized activity plan according to the actual situation of patients, and the amount and intensity of activities should be carried out step by step.

4 Conclusion

As a new concept and new term in the field of surgery, FTS, based on evidence and multidisciplinary assistance, can reduce the stress factors caused by surgical trauma, reduce perioperative complications, shorten hospital stay, reduce hospitalization expenses, save medical costs, and reduce the risk of readmission and death. At present, the clinical implementation of FTS still faces some challenges, including lack of communication among various disciplines, imperfect facilities and equipment, different cognitive levels of medical staff, and so on. In order to speed up the clinical application of FTS, it is also necessary for medical staff to strengthen the study and update of ideas and clinical practice, and enhance the timely communication and assistance among various departments, so that FTS can be used in more surgical fields in the future.