Download Enhanced Recovery After Surgery

Enhanced Recovery
After Surgery
“The immediate challenge to improving the
quality of surgical care is not discovering
new knowledge, but rather how to integrate
what we already know into practice.”
Urbach & Baxter, 2005
LAUREN NORTHEY, VASCULAR CNC – MARCH 2015
 What is ERAS?
ERAS - PNAQ
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Colorectal Surgery
 Preoperative
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Counselling
Medical Optimisation
Carbohydrate Drinks & Fasting
Bowel Preparation
 Intraoperative
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Anaesthetic & Analgesia
Fluid Management
 Postoperative
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Nutrition
Mobilisation
 Nambour General Hospital
What is ERAS?
 An innovative approach to recovery after surgery which
emphasises the patients’ optimal return to normal function
 A series of evidence-based interventions covering the entire
perioperative period and using a standardised pathway of
care
 Pathways aim to reduce surgical stress, maintain
postoperative physiological function and enhance
mobilisation after surgery resulting in
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Reduced rates of morbidity
Faster recovery
Decreased length of stay in hospital
ERAS in Colorectal Surgery
Early
Mobilisation
Patient
Counselling
No Bowel
Preparation
Carbohydrate
Drinks &
Minimal Fasting
Early Post-op
Oral Nutrition
No
Premedication
Early Removal
of Catheters
ERAS
Prevention of
PONV
No Nasogastric
Tubes
Epidural
Anaesthesia
Normothermia
Short-acting
Anaesthetics
Avoidance of
Fluid Overload
Non-opioid
Analgesics
No Drains
Short Incisions
/ Lap
Technique
Preoperative Counselling
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Intensive preoperative patient information facilitates
recovery, improves post-operative self care and has been
shown to reduce anxiety and pain1,2
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Counselling should emphasise the importance of a
patient’s role in their own recovery. Patients should be
given goals to meet during their post-operative period,
for example
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Tolerating diet and fluids
Sitting out of bed
Mobilising several times a day
Social aspects that may delay discharge should be
identified and criteria for discharge should be explained,
this may include
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Oral analgesia adequately controlling pain
Satisfactory wound healing
Independently performing activities of daily living or return to
pre-surgery function
Preoperative Optimisation
 Detecting and modifying comorbidities before major
surgery results in a reduction in morbidity and in the need
for more complex supportive care, such as intensive care3
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Cardiovascular risk
Pulmonary risk
Anaemia
Nutrition and
exercise
Obesity
Diabetes
Smoking and
alcohol intake
Carbohydrate Drinks & Fasting
 Fast from solid food for six hours and
encourage clear fluids up until two hours
before surgery
 Preoperative carbohydrate rich drinks
reduce thirst, hunger and anxiety4
 Reduces postoperative insulin resistance4
 Unpleasant, can be stressful for the patient
Bowel
Preparation
 Increased rates of pre-operative admission
to hospital solely for bowel preparation
 Increased risk for patients with renal
dysfunction and the elderly – can cause
large fluid shifts, dehydration, electrolyte
imbalance and acute renal failure.
Cao, Li & Li (2011): Meta analysis for secondary outcomes including 14 trials shows no significant
effect whether patients had mechanical bowel preparation before surgery5
Bowel Preparation
Cao, Li & Li (2011): Meta analysis for anastomotic leak including 14 trials shows no significant effect
whether patients had mechanical bowel preparation before surgery5
Anaesthetic & Surgery
 Avoid preoperative sedative medications as they can delay post operative
mobility and oral intake
 Recommended use of short acting induction agents and short acting
opioids to allow for rapid awakening
 Multimodal approach to PONV with two or more antiemetic agents given
as prophylaxis intraoperatively
 Avoidance of NGTs, or if used to be removed before reversal of
anaesthetic
 Maintain normothermia >36°C
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prevents wound infection
improves patient pain scores
reduces bleeding
reduces incidence of cardiac
complications
7
Analgesia
 Thoracic epidural anaesthetic is
recommended for open surgery
 Laparoscopic surgeries are performed with
regional/TAP blocks to reduce postoperative
opioid requirement
 Patient controlled analgesia (PCA) is provided
postoperatively with an aim to remove the
PCA by day two at the latest
 Postoperative analgesia should always be
multimodal
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Paracetamol
NSAIDs (depending on surgeon preference)
Fluid Management

Traditionally, patients were given bowel preparation and fasted for prolonged periods of
time before their surgery – potentially leaving them dehydrated and with electrolyte
imbalances
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ERAS patients are better conditioned for surgery as they’re not given bowel prep and are encouraged
to continue clear fluids up until two hours before surgery
Aim to maintain normovolaemia through the use of vasopressors intraoperatively rather
than by multiple fluid boluses
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Hypovolaemia can lead to hypoperfusion of vital organs
Fluid overload can lead to bowel oedema and delay return of gastrointestinal function
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Fluid shifts should be minimised where possible –
by avoiding bowel preparation, encouraging oral
hydration up to two hours before surgery and
minimising bowel handling and blood loss during
surgery
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Intravenous fluids should be ceased as soon as the
patient is tolerating oral hydration. Target for oral
hydration should be 800mLs on day of surgery.
Nutrition
 Oral nutritional supplements commence
two hours post surgery and continue each
day until discharge
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Achieves target intakes of energy and protein
during early postoperative recovery
 Early enteral or oral feeding reduces risk
of infection and length of stay in hospital
and is not associated with risk of
anastomotic dehiscence6
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However, early oral feeding does increase the risk
of vomiting and patients should be assessed for
PONV
Mobilisation
 There is more evidence detailing the detriment of prolonged bed rest
than the benefits of early mobilisation
 Combining forced mobilisation and nutritional support in the early
postoperative phase has been shown to increase muscle strength7
 Prolonged bed rest has been associated with an increase in chest
infections, muscle weakness and an increase in length of stay in hospital
 Failure to mobilise on day one
has been associated with longer
length of hospital stay, likely due
to other factors such as
inadequate pain control, preexisting comorbidities and
patient motivation
Nambour General Hospital
Questions?
References
1
2
3
4
5
6
7
Disbrow EQ, Bennett HL, Owings JT. Effect of preoperative suggestion on postoperative gastrointestinal motility. West J Med.
1993;153(5):438-92
Blay N, Donoghue J. The effect of pre-admission education on domiciliary recovery following laparoscopic cholecystectomy. Aust J Adv
Nurs. 2005;22(4):14-9
Halaszynski TM, Juda R, Silverman DG. Optimizing postoperative outcomes with efficient preoperative assessment and management.
Crit Care Med. 2004;32(4):S76-86
Soop M, Nygren J, Myrenfors P, Thorell A, Ljungqvist O. Preoperative oral carbohydrate treatment attenuates immediate postoperative
insulin resistance. Am J Physiol Metabol 2001;280(4):E576-83
Cao F, Li J, Li F. Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-analysis. Int J
Colorectal Dis. 2012;27:803-810
Lewis SJ, Andersen HK, Thomas S. Early enteral nutrition within 24h of intestinal surgery versus later commencement of feeding: a
systematic review and meta-analysis. J Gastrointest Surg. 2009;13(3):569-575
Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A,
Kennedy RH, Lobo DN, Fearon K, Ljungqvist, O. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After
Surgery (ERAS) Society Recommendations. World J Surg. 2013;13:259-284