Fast-track Criteria Research Articles

Comparative Analysis of the Modified Aldrete Score and Fast-Track Criteria for Post-general Anaesthesia Recovery: A Narrative Review.

There are two commonly used scoring systems to evaluate recovery from general anaesthesia (GA): the Modified Aldrete Score (MAS) and the Fast-Track Criteria (FTC). Recently, concerns have been expressed about the safety and effectiveness of the Aldrete scoring system due to its exclusion of an assessment for pain or nausea, which can exacerbate recovery from surgery and anaesthesia and cause many patients to experience these side effects. FTC was created to evaluate post-operative nausea vomiting, and pain in order to assess recovery from GA. More data are needed to compare these scoring criteria in low-income countries like India. Understanding how these scores can be effectively utilised in our settings is crucial for ensuring the timely transfer of patients from the operating theatre to the Post-anaesthesia Care Unit and, subsequently, to the ward. This review aims to evaluate the available literature on MAS and FTC and compare their effectiveness. It was found that FTC is more appropriate for outpatient or day surgery procedures where rapid throughput and patient comfort are a priority. MAS, in itself, is very good for a low-income country like India. However, the addition of FTC can only enhance patient care if resources are made available. MAS can ensure consistency and efficiency in the discharge process, while using FTC can address broader recovery-related indicators and improve patient care. More research and modifications are further necessary.

Comparison of three scoring criteria to assess recovery from general anesthesia in the postanesthesia care unit in the indian population.

Different discharge criteria are available for shifting patients out from postanesthesia care room following surgery. This study was done to compare the three-scoring system namely traditional time-based criteria, Fast track criteria and modified Aldrete score, in Indian population patients who recover after general anesthesia in postanesthesia care unit (PACU). Three hundred and seventy-five patients scheduled for general anesthesia were included in this study. Induction of anesthesia was done with intravenous (IV) propofol and maintained with sevoflurane inhalation with oxygen and nitrous oxide. Reversal of residual neuromuscular blockade was done with IV neostigmine and glycopyrrolate. Patients were shifted to PACU following tracheal extubation and recovery was assessed using the traditional time-based criteria, fast track criteria, and modified Aldrete score. As per modified Aldrete score, mean time of shift out is 19 min with median of 15 min and standard deviation of 21.7 min. As per fast-track score, mean time of shift out is 187 min with median of 30 min and standard deviation of 243.7 min. As per the time-based criteria, mean time of shift out is 222 min with median of 240 min and standard deviation of 136.8 min. While using modified Aldrete score, majority of patients had a shorter stay in PACU and faster time to shift out as compared to fast-track criteria and traditional time-based criteria. Modified Aldrete score when compared to fast-track scoring and time-based criteria shows early recovery and reduces the length of stay in PACU.

Comparative Study on Postoperative Recovery Profiles of Desflurane and Sevoflurane Using I-GEL in Elective Ambulatory Surgeries

Introduction: In providing general anesthesia for ambulatory surgery, the goal is to achieve optimal surgical conditions while ensuring a rapid early recovery without side effects. Desflurane and sevoflurane are proven as effective ambulatory inhalational anesthetic agents. The aim of this research is to investigate and compared the hemodynamic stability, postoperative outcome and airway responses in elective ambulatory surgeries in patients receiving anesthesia with desflurane or sevoflurane using I-Gel supraglottic airway.Methods: A prospective, observational study was conducted involving 60 patients of age 18 – 50 years undergoing ambulatory surgeries under general anesthesia, randomly allocated into 2 equal groups receiving desflurane (Group D) or sevoflurane (Group S) for maintenance of anesthesia with suitable size I-Gel. Patients were monitored for hemodynamic parameters and postoperative recovery profile using fast track criteria (FTC) score at different time intervals. Pearson’s Chi Square test and Mann- Whitney U test were used for statistical analysis.Results: The mean time taken for postoperative recovery characteristics were significantly lower in Group D than Group S (p<0.001).The FTC score was significantly higher (p<0.001) in Group D than Group S at all-time intervals for 30 minutes. The requirement of additional analgesics was 46.7% in Group D and 60% in Group S (p>0.301) and that of antiemetic was 30% in Group D and 26.67% in Group S (p>0.774).Conclusions: Desflurane showed superior postoperative recovery characteristics and better FTC score without any increase in adverse airway events than sevoflurane.

Comparison of balanced anesthesia in spine surgery with dexmedetomidine added to sevoflurane and dexmedetomidine added to desflurane on recovery profile

Background: Spine surgery is challenging to anesthesiologist due to various factors. It is important to provide intraoperative hemodynamic stability, clear surgical field and a conscious, and pain free comfortable patient post-operative. Sevoflurane and desflurane provide rapid recovery. Dexmedetomidine provides sedation, stable, hemodynamics and analgesia. Dexmedetomidine has become an integral part of balanced anesthesia along with inhalational anesthetics in spine surgery. Aims and Objectives: Our study was done to compare recovery profile of sevoflurane and desflurane with dexmedetomidine and compare total dose of dexmedetomidine required in both the groups. Materials and Methods: Sixty ASA I-II patients undergoing spine surgery were randomly divided into two groups: Group A – Sevoflurane + Dexmedetomidine and Group B – Desflurane + Dexmedetomidine. Postoperatively, time to eye opening and extubation time was measured. The patient was shifted to post-anesthesia care unit (PACU) 10 min after extubation. Fast-track criteria (FTC) score was assessed for 1 h post-extubation in PACU. Results: Mean time to eye opening in Group A: 13.07±2.08 min which was significantly longer than in Group B: 9.17±2.23 min (P<0.05). Similarly, mean extubation time was shorter in Group B than in Group A, 12.77±2.50 min versus 17.83±2.68 min, respectively (P<0.05). FTC score was significantly higher in Group B as compared to Group A at all times (P<0.05), except at 60 min, when it was similar (P=1.000). Discharge criteria from PACU in all patients were achieved at 15 min in Group B, while in Group A, it was achieved at 30 min. Conclusion: We found that desflurane and dexmedetomidine combination is superior to sevoflurane and dexmedetomidine in time to eye opening and extubation time. Higher post-anesthesia recovery score (FTC score) is seen in desflurane/dexmedetomidine group than sevoflurane/dexmedetomidine group.

Forecasting effects of "fast-tracks" for surgery in the Swedish national guidelines for distal radius fractures.

Background and purposeNational guidelines for treatment of distal radius fractures (DRFs) were presented in Sweden in 2021. In the guidelines, a fast-track is recommended for 4 subgroups of highly unstable DRFs. Regardless of the results of the closed reduction these are recommended for surgery within 1 week of injury. This study aims to evaluate the potential consequences of the newly presented national guidelines on incidence of surgical interventions.Patients and methodsIn all, 1,609 patients (1,635 DRFs) with primary radiographs after a DRF between 2014 and 2017 at two Swedish hospitals were included in a retrospective cohort study. An estimation was made of the percentage of patients in the historical pre-guidelines cohort, that would have been recommended early primary surgery according to the new national guidelines compared to treatment implemented without the support of these guidelines.ResultsOn a strict radiological basis, 32% (516 out of 1635) of DRFs were classified into one of the 4 defined subgroups. At 9–13 days follow-up, cast treatment was converted into delayed primary surgery in 201 cases. Out of these, 56% (112 out of 201) fulfilled the fast-track criteria and would with the new guidelines have been subject to early primary surgery.InterpretationThe fast-track regimen in the new guidelines, has a high likelihood of identifying the unstable fractures benefitting from early primary surgery. If the proposed Swedish national guidelines for DRF treatment are implemented, a greater proportion of fractures would be treated with early primary surgery, and a delayed surgery avoided in the majority of cases. The potential benefits in relation to possible costs when using the fast-track criteria in every day practice are still unknown.

SP1.2.7Developing a fast- track pre-assessment pathway for laparoscopic cholecystectomy

Abstract Aims To develop a safe and reliable assessment process for patients undergoing laparoscopic cholecystectomy and negate the need for formal pre- assessment. Methods A system consisting of a health screening questionnaire completed by patients (previous general anaesthesia, cardiac and respiratory history, bleeding disorders and medications) along with a functional capacity assessment (Duke Activity Status Index), allied with screening blood tests was developed. Only patients who passed all 3 components were fast-tracked to surgery while the remainder proceeded to formal pre-assessment. Results Data was collected and analyzed on 90 consecutive patients. An interim analysis identified the format of some questions needed to be altered to facilitate patient completion, resulting in 59% (rather than 36%) of patients successfully fulfilling the fast-track criteria and not excluded by incomplete entries. Overall, 40 of the 90 patients (44%) successfully completed the fast-track assessment of whom 38 underwent surgery (2 waiting). Six patients incorrectly passed the assessments due to misinterpretation of the Duke Activity Status Index but proceeded to surgery. All 38 patients had an uneventful peri-operative course. 45 of the 50 patients who failed fast-track assessments subsequently passed formal nurse-led pre-assessment, as did 4 of the remaining 5 patients after anaesthetic review – all had an uneventful peri-operative course. Conclusion Pre-assessment driven by a health screening questionnaire, activity index and simple blood tests is safe, reduced formal pre-assessment by 44% and avoids delays. Such tools may have a significant resource impact in appropriate patient populations. The health screening questionnaire needs further revision.

A study of modified Aldrete score and fast-track criteria for assessing recovery from general anaesthesia after laparoscopic surgery in Indian adults

Study ObjectiveThe primary objective of the study was to compare and evaluate two of the recovery assessment tools, i.e. the Modified Aldrete score (MAS) and fast-track criteria (FTC), for assessing time to recovery from general anaesthesia after laparoscopic surgeries in Indian settings. As a secondary objective we explored the factors associated with time to recovery. DesignLongitudinal observational study. SettingOperative room, Post-op recovery area and general ward of SSK Hospital, New Delhi, India PatientsAfter a thorough pre-anesthetic evaluation, 100 consecutive subjects 18–65 years, ASA I/II, posted for laparoscopic surgery were included. MeasurementsBaseline and clinical parameters were noted. Post-extubation recovery scores were recorded every 5 min until 30 min and at 2, 6, 12 and 24 h in the post-operative period using both the criteria. Main ResultsMean time to recovery from anaesthesia was found to be 14.8 ± 3.8 and 13.0 ± 3.5 minutes when assessed by MAS (score ≥ 9) and FTC (score ≥ 12), respectively. At 2 and 6 h. post-extubation a dip in the FTC scores were observed in 7% and 3% of the subjects though the MAS scores remained unaffected. This corresponds to the incidence of severe post-op pain and nausea vomiting in the study subjects. Older age > 35 years, pre-operative medication with fentanyl and midazolam and duration of surgery are factors which were significantly associated with time to recovery. ConclusionFTC and MAS seem to be equally good in assessing recovery in immediate postoperative period from general anaesthesia after laparoscopic surgery. However, the former criterion is better for documenting adequate recovery for transfer of patients from post-anaesthesia-care-unit/high-dependency-unit (PACU / HDU) to the ward as it provides assessment of postoperative-nausea-vomiting (PONV) and pain.

Application of Discharge Criteria for Home Readiness Using Bispectral and Supraglottic Airway Devices in Day-care Surgery without Using Muscle Relaxants.

Introduction:The availability of rapid and short-acting intravenous and volatile anesthetics has facilitated early recovery that is why nowadays ambulatory surgery is becoming more common. If the criteria used to discharge patients from the Postanesthesia Care Unit (PACU) are met in the operating room (OR), it would be appropriate to consider bypassing the PACU and transferring the patient directly to the step-down unit. This process is known as “fast-tracking” after ambulatory surgery.Aims:To compare hemodynamic characteristics and recovery profile as per fast-track criteria (FTC) of recovery and postanesthesia discharge scoring system (PADSS) between sevoflurane and desflurane.Materials and Methods:One hundred American Society of Anesthesiologists Class I–II patients aged 20–50 years were randomly divided into two groups. Following anesthesia induction with injection propofol and injection dexmedetomidine airway was secured with i-gel, Group D (n = 50) received desflurane + dexmedetomidine + O2 + N2O and Group S (n = 50) received sevoflurane in place of desflurane. Emergence time was noted and FTC was evaluated in the OR, Score >12 is considered as shifting criteria for ambulatory surgery unit (ASU). PADSS was noted in ASU at an interval of 15 min for 3 h and Score >9 is considered as ready to discharge home.Results:Response to pain, verbal commands, and spontaneous eye opening in Group D was shorter than that in Group S (P = 0.001). Mean time to achieve FTC score >12 was 15 min in both the groups. Eighty-six percent of patients were ready to go home between 60 and 90 min using PADSS.Conclusion:We concluded that early recovery is faster for desflurane, and there is no difference in ready to go home time between desflurane and sevoflurane.

Fast-Tracking Ambulatory Surgery Patients Following Anesthesia

The purpose of this process improvement project was to introduce and evaluate the efficacy of fast-tracking ambulatory surgical patients in a community hospital. An observational pre-post design was used, in which patient data from a reference period (pre-fast-tracking) was compared with patient data collected during an implementation period (post-fast-tracking). Anesthesia providers were trained to use a tool to assess patients for eligibility to bypass the postanesthesia care unit (PACU). Fifty-nine patients met the fast-track criteria during the implementation period and were transferred directly to the ambulatory care unit from the operating room. During the fast-track implementation period, a PACU-bypass rate of 79% was achieved, and a significant decrease in the total number of patients held in the operating room and in total length of stay was noted. Results suggest that fast-tracking is a suitable intervention to increase work flow efficiency and decrease both patient and hospital costs while promoting a more rapid discharge from the facility.

Low preoperative cerebral oxygen saturation is associated with longer time to extubation during fast-track cardiac anaesthesia

Fast-track cardiac anaesthesia programs aiming at early tracheal extubation have not only been linked to a decrease in intensive care unit and hospital length of stay but also to a decrease in morbidity and mortality as well as a containment of rising medical costs. General recommendations for the inclusion criteria concerning fast-track programs are not available. The present study determined the factors influencing the time to extubation in patients undergoing a newly implemented fast-track protocol. Seventy-nine patients were retrospectively studied. Successful fast track was defined as time to extubation within 75 min after admission to ICU. Sixty patients fulfilled the successful fast-track criteria with a mean time to extubation of 43.9 min (range 15-75 min). Nineteen patients needed more than 75 min to be weaned from the respirator with a mean time to extubation of 135 min (range 90-320 min). Analysis of pre- and intraoperative factors revealed that these groups differed only with respect to preoperative cerebral oxygen saturation levels: 67.7 ± 5.2 versus 60.8 ± 7.4%. Cerebral oxygen saturation assessment prior to cardiac surgery is significantly related to time to extubation and may thus be used to stratify candidates in fast-track programs.

Respiratory Impairment in the Obese Following General Anesthesia –Impact of Anaesthesia and Patient Related Factors

Background: Respiratory impairment is common in the perioperative period, especially in the obese. In this study we evaluated the impact of anesthesia related factors, use of neuromuscular blocking agents, choice of anesthesia maintenance, duration of surgery and patient related factors such as age, gender and body-mass index on postoperative pulse oximetry and lung function in the obese. Methods: We studied postoperative lung function and pulse oximetry saturation in 397 obese or overweight patients (Body Mass Index 25-40) undergoing minor surgery . Inspiratory and exspiratory lung function as well as pulse oximetry were measured preoperatively (baseline) and at 10min, 0.5h, 2h and 24h after surgery, with the patient supine, in a 30° head-up position. All factors were added within stepwise regression analysis to create a statistical model. Further analysis was performed using the t-test and Wilcoxon-test. Results: Stepwise regression analysis revealed that, relaxation, in particular using rocuronium rather than cisatracurium (p<0.008) as well as anesthesia maintenance with propofol in contrast to desflurane (p<0.0028), are the most important factors affecting postoperative respiratory impairment and pulse oximetry saturation within the first 24 postoperative hours. Patient related factors as age, body-mass index and surgery time exhibit a minor effect. Conclusion: Anaesthesia related factors rather than patient related factors exhibit a greater effect on lung function impairment within the immediate postoperative period. Lung function impairment occurs independently from fast-track criteria and can be attenuated by choosing well predictable agents for general anaesthesia.

Cutting edge discussions of management, policy, and program issues in emergency care

Answer: At a recent national lecture directed to a nursing audience, a Joint Commission for Accreditation of Healthcare Organizations (JCAHO) surveyor discussed the new JCAHO requirement for a verification process. Effective January 1, 2004, a final verification process to confirm the correct patient, procedure, and site using active, not passive, communication must be undertaken before any invasive procedures are performed. According to the surveyor, ‘‘time out’’ is one acceptable verification process. This requirement will be scored at Standard PC.13.20 and EP9. One exception to this requirement is when the physician has a continuous attendance with the patient. The only other exception would be such an emergency that even the time out and/or marking would add more risk than benefit to the patient. The surveyor said that what has changed from the original draft of the standard is a requirement for site marking. Marking should focus on cases involving right/ left distinction, multiple structures (eg, fingers or toes), or multiple levels (eg, the spine). Organizations no longer are required to mark the site for other types of procedures, including mid-line sternotomies, cesarean sections, and interventional procedures for which the insertion site is not predetermined. When a JCAHO surveyor visits, he or she will interview leaders to determine the expectations and how the leaders know they are being met. In addition, they will interview physicians, nurses, and technicians involved in surgery/ procedures to determine how consistently this is done. This inquiry is being done, in part, because inspectors have found

New drug treatments for HIV infection and AIDS. A review following the Seventh International Conference on AIDS, Florence 16-21 June 1991.

1. OBJECTIVE--To evaluate the status of clinical development of zidovudine and new drugs for the treatment of Human Immunodeficiency Virus (HIV) infections. 2. METHOD--A critical review of the clinical trial reports and assessment of the design and methodology of the therapeutic trials. Evaluation of the drugs being tested and of the specific difficulties in testing drugs in AIDS. 3. CONCLUSIONS--Drugs are being tested in a unique climate of public opinion characterised by (1) fast track criteria for regulatory approval (2) parallel track (compassionate release) of new drugs before adequate determination of safety and efficacy (3) resistance to the use of placebos in controlled trials.