The first 24 hours after surgery: how an anesthetist, a surgeon and a nurse would like to be treated if they were patients

摘要

Over the last 20 years improvements in surgical and anesthesiological techniques have reduced mortality, morbidity and the length of hospital stay. Despite these considerable efforts, a great number of patients still develop perioperative complications. The ERAS (Enhanced Recovery After Surgery) concept aims to apply an evidence-based, standardized perioperative care protocol instead of traditional management based on habits [1].The philosophy behind the protocol can be summarized in two crucial points:the knowledge of factors that can lead to complications in surgical patients; the application of a specific strategy during the perioperative period aimed at patient well being with swift recovery after surgical stress.In order to put this idea into practice a team of healthcare professionals is required, made up not only of surgeons, anesthesiologists and nurses, but also of physiotherapists, nutritionists and administrative staff. The program is developed during those phases where the patient is involved, namely the pre-operative, intra-operative and post-operative periods:pre-operative: evaluation of the patient’s physical, nutritional and mental status, with patient participation through counseling with the surgeon, anesthetist and nurse; intra-operative: mini-invasive surgery, anesthesia with short acting drugs avoiding fluids overload and, if possible, regional anesthesia;post-operative: pain control, early nutrition and mobilization.Retrospective and prospective randomized studies support the growing evidence that an integrated multimodal approach to perioperative care can result in overall enhancement of recovery, reducing complications and length of stay.The anesthesiologist I would like to have received general anesthesia with short-acting drugs and without premedication, to guarantee a more rapid emergence from the anesthetic state, together with specific myorelaxant antagonists to preclude post-operative residual paralysis, respiratory complications, and infections. General anesthesia, associated with locoregional anesthesia whenever possible, offers many advantages. Using local anesthetics (peripheral nerve or plexus blocks, epidural or spinal anesthesia) during surgery reduces the amount of morphine needed and provides better pain control. Nausea and vomiting occur less often, and I will be able to eat and drink sooner, which will help me to have a quicker recovery.I am sure that if the infusion of fluids had been controlled during surgery to avoid their overload, my tissues would be less edematous, and the surgical anastomosis would be better preserved. In fact, intravenous crystalloid fluids expand into the interstitial volume, rather than into intravascular space, during surgical stress. I should not have to suffer pain. Pain after elective surgery is “programmed” and harmful, and it has to be measured and treated to avoid, whenever possible, the use of morphine.The multimodality approach [2] can lead to better pain control and preclude complications. Without pain, my post-surgery stress response, anxiety, and discomfort will be reduced; I will be able to leave my room, drink and eat food, which will probably mean that I will be discharged from hospital earlier.The surgeonAlthough we surgeons are used to dealing with patients undergoing surgery, the scenario would change totally should we ourselves become the patient. We would find ourselves on the other side of the knife, so to speak. I, as a patient, would definitely hope to meet a team prepared to spend a lot of time talking about the scheduled process of care, and clarifying all details concerning the procedure. In fact, a relevant source of anxiety in patients undergoing surgery is generated by their not knowing what will happen before, during, and after the operation. Concerns about the possible occurrence of postoperative complications, long-term sequelae, and quality of life after surgery need to be addressed specifically. Preoperative