enhanced recovery after surgery
TRANSCRIPT
ENHANCED RECOVERY PROGRAMMES
DR. MASUMA HAQUE SHARMINMS RESIDENT - GENERAL SURGERY
SU - III
Dogma: Back to the Past….Senior surgeons had strong principles and they were assumed as a dogma.• Preoperative prolonged fasting, Mechanical bowel
preparation and nasogastric tubes were thought to be necessary to
empty the bowel to prevent intraoperative contamination and to prevent early passage of bowel content
through an anastomotic suture line while it is healing. • Drain tube was believed essential in any GIT surgery• Prolonged bed rest were recommended to facilitate
abdominal wall healing.
…but Evidence always trumps Dogma
DOG
M
A
EVIDENCE
Evolution of surgical principles brought about the
concept of
E R A SThis concept was first described in 1990s by Henrik Kehlet, MD, PhD, Surgical Gastroenterologist.
What is ERAS and ERPs?
ERAS stands for Enhanced Recovery After Surgery
also Known as
Fast Track SurgeryERAS consists of Enhanced Recovery Programs which is a multimodal perioperative care pathway that aims at reducing stress response to surgery and acceleration of recovery.
ERAS - Goals
• Reduction of stress response to surgery
• Acceleration of recovery.Usual hospital stay following major colorectal surgery: 7-14 days.Strict adherence to ER Programme reduces hospital stay to 2-3 days
Team Members for Successful ERPNurses
DietitiansPhysiotherapists
Occupational therapistsPain team
Theatre staffAnesthetists
SurgeonsHospital management
Audit team
Pre-AdmissionOptimizationCounseling
Oral Supplements
Pre-OperativeAdmission on the day of surgery
Preoperative fasting and Carbohydrate LoadingNo Mechanical Bowel Preparation
Prophylaxis: DVT, AntibioticPerioperative opioid sparing analgesiaAnesthesia
NormothermiaMid Thoracic Epidural Analgesia
Avoidance of fluid overload
SurgicalApproach: Laparoscopy/ Short Incision/ Transverse Incision
Avoid Surgical Drains or Nasogastric tubes
Post-OperativeHydration
Active, Multimodal and preventive pain controlAggressive management of nausea and vomiting
Early oral feeding and mobilizationNutritional support
Remove urinary catheters and drainsDischarge criteria
ERP Components
1. Pre admission counseling:• A clear explanation of what is to happen
during hospitalization• Explanation of role of the patient about
food intake, oral nutritional supplements and mobilization after surgery
ERP - Key Elements
ERP - Key Elements
2. Selective Bowel Preparation:• Avoid mechanical bowel preparation• 6 hour fast for solid food and liquids
containing fat or particulate material• Clear fluids can be taken until 2 hour
before induction of anesthesia.
ERP - Key Elements
3. Pre operative carbohydrate loading and metabolic conditioning:• Clear carbohydrate-rich beverage i.e.
Nutricia Preop™ before midnight and 2–3 hour before surgery .
“This reduces preoperative thirst, hunger and anxiety, and significantly reduce postoperative insulin resistance.”
ERP - Key Elements4. Avoid pre anesthetic sedatives or anxiolytics if possible5. Nasogastric Tubes in GI Surgery- (Avoid)
• Can impair return of gut function.• Are disliked by patients.• Increase the incidence of postoperative fever, atelectasis and pneumonia.• Lower GI surgery: Only insert if gastric distension or requested by surgeon.• Upper GI Surgery: May be necessary.
ERP - Key Elements6. Thoracic Epidural Anesthesia:• Reduces pain and the dosage of general
anesthetic agents. • Blocks stress hormone release and decrease
postoperative insulin resistance. • In colonic surgery the epidural catheter in mid-
thoracic level (T7/8) blocks sympathetic nerves and prevents gut paralysis
ERP - Key Elements
7. Short acting anesthetic agents:Use Propofol, Remifentanil instead of
Fentanil or Morphine.Short acting Inhalational anesthesia is
an alternative to Total intravenous anesthesia (TIVA)
ERP - Key Elements
8. Individualized perioperative fluid administration:
Avoid Na and Fluid overloadGoal directed fluid therapy via
Oesophageal Doppler(OD) monitoring Fluid overload is associated with delayed gut function and increased complication rates.
ERP - Key Elements9. Avoid Perioperative Hypothermia
• Warm air blowers on the patients during surgery and warm IV fluids administered.• Continue warming into the postoperative period. Keep Temp. > 96.7˚F• Monitor temperature, avoid hyperthermia.• Hypothermia increases the risk of wound infection, bleeding and transfusion requirements
ERP - Key Elements10. Short, Transverse Incision/ Laparoscopic Colon surgery:
• reduce in-patient stays, • lessen morbidity • and lower postoperative pain
11. Avoid Drain Tubes in routine colonic resections above peritoneal reflections and consider short-term (<24 h) drainage for low anterior resections.
ERP - Key Elements12. Prevention of Postoperative Nausea and Vomiting (PONV)• PONV is unpleasant, delays gut function,
affects mobility and has metabolic consequences.
• Give prophylactic anti-emetics i.e. Ondansetron during anesthesia around 30 min before the end of surgery.
ERP - Key Elements13. Encourage Early Postoperative Oral Intake• Facilitates early return of bowel function,• Allows stopping of intravenous drips,• Aids mobilization, • Leads to faster recovery.• Reduces postoperative morbidity and is not
associated with an increased risk of anastomotic dehiscence
ERP - Key Elements14. Early mobilizationBed rest • ↑ insulin resistance , muscle loss and risk of
thromboembolism.• ↓ muscle strength, pulmonary function and tissue
oxygenation .• The aim is for patients to be out of bed for 2 h on
the day of surgery, and for 6 h a day until discharge.
ERP - Key Elements15. Non-opiate Analgesics/NSAIDs
Opiates are associated with decreased gut motility.
Short term NSAIDs use can avoid Gastric irritation.
Day of Surgery
1st POD
TWOC- Trial Without Catheter
NMBM- No Meal by Mouth
2nd POD
3rd POD
ERP – Discharge CriteriaPatients can be discharged when they meet the following criteria:• Good pain control with oral analgesia• Taking solid food, no intravenous fluids• Independently mobile or same level as prior to
admission• All of the above and willing to go home.
Reference• 1. Manual of Fast Track Recovery for Colorectal Surgery- Nader
Francis, Robin H. Kennedy, Olle Ljungqvist, Monty G. Mythen• 2. Enhanced recovery programme in colorectal surgery: Does
one size fit all?- Alison Lyon, Christopher J Payne, Graham J MacKay World J Gastroenterol 2012 October 28; 18(40): 5661-5663
• 3. Multimodal Approach to control postoperative Pathophysiology and rehabilitation- Henrik Kehlet. Brit. J A 1997; 78: 606-617
• 4. ERAS (Enhanced Recovery after Surgery) in Colorectal Surgery- Raúl Sánchez-Jiménez, Alberto Blanco Álvarez, Jacobo Trebol López, Antonio Sánchez Jiménez, Fernando Gutiérrez Conde and José Antonio Carmona Sáez
Thank You All