Everything you need to know about rapid recovery after surgery (RRAC)

Learning that surgery will relieve your pain and/or reduce your disability can be very comforting. However, this news can also cause concern, anxiety, a feeling of helplessness, and even delay recovery. Preparing yourself mentally and physically for surgery is therefore an important step in ensuring its success, promoting rapid recovery, and avoiding prolonged stays in care centres and the complications that can ensue. The idea is to prepare for the consequences of the operation and your postoperative state of health, both physical and mental, as early as the pre-operative phase, by taking concrete, well-considered action on the part of both you and the medical profession.

It has now been proven that keeping patients informed is vital in medicine, as it allows them to participate in their treatment and gives them hope of a better future. It has also become legal, as underlined by these two extracts from the hospitalised patient charter (annex to ministerial circular 95-22 on the rights of hospitalised patients)

"Information given to patients must be accessible and fair. Patients participate in the therapeutic choices that concern them".
"A medical act may only be carried out with the free and informed consent of the patient".

To achieve this, the practitioner must, during the consultation, explain the medical problem from which the patient suffers as well as the methods of treatment.

In the field of orthopaedic surgery, the best way to meet these requirements is to follow the recommendations of the So.F.C.O.T. (Société française de chirurgie orthopédique et traumatologique) by attempting to answer the following ten questions:

1) What is the pathology in question?
2) What is the presentation of the pathology in question?
3) How can we assess the state of the body affected by the condition in question?
4) What are the different treatments available, whether medical or surgical?
5) What are the different types of operation?
6) How will the proposed operation be carried out?
7) What benefits can be expected from the operation?
8) What are the most common complications?
9) Is there a risk of failure? What precautions can be taken to avoid this?
10) What post-operative precautions and monitoring are necessary?

What is Rapid Recovery After Surgery (RRAS)?

It is an innovative form of care that places the patient at the centre of all medical decisions and management. Originally invented in the 1990s in the Nordic countries for digestive surgery, it is a new concept, applicable to all types of surgery, which aims to achieve a faster recovery of functional capacities after orthopaedic surgery, with the objective of a quicker return to the family environment and to normal daily activities, in complete safety.

This objective requires the establishment of "clinical pathways", i.e. a step-by-step progression, with the patient validating precise medical objectives according to the type of operation, enabling him or her to leave the surgical centre more quickly. At the most, the patient no longer sleeps there and the surgery is performed on an outpatient basis.

What are the main principles of Rapid Recovery After Surgery (RRAS)?

There are five of them:

1. Prepare for convalescence and the post-operative after-effects of the planned operation, right from the pre-operative phase

- by providing detailed information (verbally from your surgeon, patient information sheets, internet support, description of the various stages of recovery, case studies, pre-operative meetings, etc.);

- by a visit from paramedical staff before the operation (the physiotherapist who will take care of you, the nurse responsible for the care programme, the occupational therapist who will help you adapt your home when you return, or even a pre-operative functional assessment in a day hospital in the rehabilitation centre planned after the operation);

- by preparing all post-operative requirements (prescriptions, convalescence centre, specific needs at home, etc.) as early as the pre-operative consultation;

- by preparing the patient before the operation (mental preparation, maintaining physical and muscular exercise, stabilising any medication taken, stopping smoking, etc.).

2. Putting the patient at the heart of the approach and ensuring a team dynamic around him/her to secure and tackle the various stages of the care pathway.

All the professionals involved in the care pathway are involved in the approach and pool their knowledge, which helps to improve care and reduce the potential risks associated with surgery. This systematic, cross-disciplinary assessment of each stage of the care pathway means that each stage can be validated on an ongoing basis, enabling the patient to be discharged more quickly once the prerequisites have been met (no fever, no pain, no respiratory congestion, resumption of eating and bowel movements, satisfactory wound healing, rehabilitation objectives achieved). In this way, patients become active participants in their own recovery. They are aware of each stage of their journey, as well as the criteria they will have to meet before they can return home safely. What's more, if they are well informed, they know exactly what they can and cannot do when they get home, and what they should and should not be worried about.

3. Modulate and adapt the diet before and after the operation, without resorting to systematic fasting

The RRAC favours modern fasting (solid food for up to 6 hours and non-carbonated drinks for up to 2 hours before the operation. This makes it easier to cope with the stress caused by the operation. Immunity is strengthened, and the patient is better equipped to fight infections and the fatigue induced by prolonged fasting (usually from the evening before).

4. Use modern minimally invasive surgical techniques

The RRAC favours minimally invasive, arthroscopic or even robotic surgical techniques, which cause less damage to the tissues and less muscle breakdown, thereby guaranteeing optimum functional recovery and allowing patients to walk around on the same day without any associated risks (fractures, dislocations, falls, etc.). In this context, the use of catheters and drains is very rare, as they are a source of infection.

5. Managing pain before, during and after surgery

The combination of several techniques (infiltration of the tissues operated on, use of peripheral nerve blocks, combination of molecules acting on the pain centres while avoiding morphine derivatives), together with less aggressive surgical techniques, make it possible to reduce the doses administered and the duration of treatment, and above all to reduce the side effects (nausea, vomiting, constipation, etc.). Pain-free, patients can quickly stand up and eat. Early mobilisation reduces the risk of complications associated with prolonged bed rest (phlebitis, pulmonary embolism, skin problems, etc.).

What are the benefits?

It has been proven that the introduction of RRAC significantly reduces the risk of postoperative complications (up to 40% for certain operations ). It is safer than traditional hospitalisation, the pitfalls of which include hospitalisation the night before, prolonged fasting, excessive premedication, prolonged operating techniques, poor pain management, prolonged use of catheters or drains, late raising, etc. The patient returns to his or her family environment more quickly, and is able to return to his or her own home more quickly.

Patients can return to their family environment more quickly, in complete safety, according to predetermined medical criteria and personalised monitoring. They will also have less risk of contracting a nosocomial infection or care-related infection (an infection contracted in hospital but unrelated to the problem for which they were admitted).

RRAC aims to reduce all the physiological dysfunctions induced by surgery, enabling the patient to regain his or her capabilities more quickly. To achieve this, RRAC requires specific information and preparation for patients, and their adherence to the programme (not all patients are eligible). It aims to reduce the secondary effects induced by surgery and/or anaesthesia (reduced pain, sedation, intestinal or urinary problems, etc.), and enables active post-operative recovery with early mobilisation and an earlier return home.

Today, rapid recovery has largely proved its superiority over conventional treatment. It can be implemented after digestive, orthopaedic and urological surgery in particular, and can reduce post-operative complications by up to 40-50%.

It is currently practised in many Scandinavian countries and in the United Kingdom, and is spreading rapidly in France.

Talk to your doctor about it.