Enhanced Recovery Masterclass Pre-op

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  • The overall prevalence of anaemia in the general population increases with age, so that in the elderly (.65 yr old), the prevalence of anaemia as defined by the World Health Organization (WHO)1 is 11% and 10.2% for men and women, respectively.2 Previously undiagnosed anaemia istherefore common in elective surgical patients;3 the preva- lence depending on age and associated co-morbidities such as diabetes, congestive heart failure, and other inflam- matory conditions. In a US national audit of patients under- going elective orthopaedic surgery,4 35% of the patients were found to have haemoglobin (Hb) levels ,13 g dl21 at preadmission testing. Many of these patients are women and approximately one-third of these are the result of iron deficiency.2 5 6 Similarly, in a large single-institution study in Spain, preoperative Hb was ,13 g dl21 in 19.4% of the patients, and the prevalence of haematinic deficiencies was 33% for iron, 12.3% for vitamin B12, and 3% for folate.7 These results were also corroborated by a large series from Egypt and Scotland.8 The remaining anaemias are attributed to chronic inflammatory disease, chronic renal disease (CKD), or unknown causes.2 9Preoperative anaemia is associated with increased mor- bidity10 11 and mortality10 12 13 after orthopaedic surgery, and exposure to allogeneic blood transfusions.14 – 16 Admis- sion Hb levels have also been shown to have an impact on postoperative functional recovery in an elderly population with hip fractures11 17 18 and on the quality of life after total hip arthroplasty.1 The clinical significance of postoperative anaemiaInflammatory cytokines after surgery and trauma invoke a response characterized by, among other effects, decreased iron uptake from the gastrointestinal tract and iron seques- tration in macrophages, along with a diminished erythroid response to erythropoietin and decreased erythropoietin pro- duction.9 Other contributory causes to postoperative anaemia include pre-existing preoperative anaemia and traumatic and surgical blood loss. Added to these is an element of haemodilution occurring as a result of fluid repla- cement before, during, and after surgery. Normovolaemic haemodilution is well tolerated due to compensatory mech- anisms that maintain an adequate myocardial and periph- eral tissue oxygenation. On the other hand, hypovolaemic anaemia must be avoided, as the cardiovascular compensa- tory mechanisms required to maintain oxygen transport in the setting of anaemia are severely compromised
  • Joa Patient Education Before Hip or Knee Arthroplasty Lowers Length of Stay Top of Form Richard S. Yoon , BS, Kate W. Nellans , MD, MPH, Jeffrey A. Geller , MD, Abraham D. Kim , BA, Maiken R. Jacobs , MA, OTR/L, William Macaulay , MD Bottom of Form Received 24 July 2008; accepted 16 March 2009. published online 11 May 2009. Education participants enjoyed a significantly shorter LOS than nonparticipants for both total hip arthroplasty (3.1 ± 0.8 days vs 3.9 ± 1.4 days; P = .0001) and total knee arthroplasty (3.1 ± 0.9 days vs 4.1 ± 1.9 days; P = .001).
  • 1818 patients, operated on 303 separate days Over 50 anaesthetists, and over 30 surgeons


  • 1. Enhanced Recovery – The clinical components• Pre-operative @officialERblog enhancedrecoveryblog.com
  • 2. @officialERblogenhancedrecoveryblog.com
  • 3. @officialERblogenhancedrecoveryblog.com
  • 4. Referral from primary care @officialERblog enhancedrecoveryblog.com
  • 5. Enhanced Recovery Pathways - Thecontribution from Primary Care• Vital that assessment and preparation start in primary care• The GP can play a major role in identifying causes of increased morbidity – anaemia, suboptimal diabetic control, hypertension, obesity, smoking, low levels of physical fitness• Either continue with referral or instigate management plans to optimise the patient’s condition @officialERblog enhancedrecoveryblog.com
  • 6. • Previously undiagnosed anaemia is common in elective surgical patients• Evidence shows that treating even minor degrees of anaemia can reduce the risk of blood transfusion that in turn reduces morbidity, mortality and cost @officialERblog enhancedrecoveryblog.com
  • 7. @officialERblogenhancedrecoveryblog.com
  • 8. Alcohol and smoking• Alcohol abusers can reduce their increased risks of bleeding, wound and cardiopulmonary complications by abstaining preoperatively. Abstaining for a period of one month improves organ function sufficiently to reduce postoperative morbidity.• Smoking cessation for a month preoperatively can reduce the increased risk of wound and respiratory complications. @officialERblog enhancedrecoveryblog.com
  • 9. Nutrition• Patients who are well nourished have appropriate stores to cope with the peri- and postoperative catabolic state that is triggered by major surgery (the ‘stress response’).• Malnourished patients have smaller nutritional stores and have been shown to benefit from preoperative supplementation.• In colorectal enhanced recovery preoperative nutritional supplementation is associated with a reduction in infectious complications and anastomotic leaks. @officialERblog enhancedrecoveryblog.com
  • 10. Orthopaedic out-patients and pre-assessment @officialERblog enhancedrecoveryblog.com
  • 11. Why is thorough pre-operativeassessment needed?• 1:180 000 anaesthesia alone• 1:50 000 anaesthesia related• 1:200 elective surgery• 1:20 emergency surgery Buck N, Devlin HB, Lunn JN. The Report of a Confidential Enquiry into Peri-Operative Deaths. London: Nuffield Provincial Hospitals Trust and the King’s Fund, 1987. 2.Pearce RM et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 2006;10;R81. @officialERblog enhancedrecoveryblog.com
  • 12. Preoperative assessment• A good preoperative assessment service is led by anaesthetists – All necessary preoperative investigations are performed in plenty of time – Patient anxiety is reduced – Time is allowed for planning – Potential problems are flagged up – Patients can be admitted on the day of surgery and not cancelled @officialERblog enhancedrecoveryblog.com
  • 13. Managing patient educationusing a pre-operative education class @officialERblog enhancedrecoveryblog.com
  • 14. Importance of pre-operative education• Reduces the duration of hospitalization• Elevates satisfaction• Minimizes postsurgical complications• Enhances patients’ psychological well-being (Ong et al. 2009)• Pre-operative educational classes are an important aspect to explain the process of hospitalisation, surgical procedure and coping with recovery. (Mohanty 2008)• In addition to reducing anxiety, it also reduces post- operative pain. (Williams 1993) @officialERblog enhancedrecoveryblog.com
  • 15. Patient education before hip or knee arthroplasty improves patient satisfaction• 261 patients were offered voluntary participation in a preoperative educational program.• Education participants enjoyed a significantly shorter LOS than nonparticipants for both total hip arthroplasty and total knee arthroplasty• Higher patient satisfaction Yoon et al. 2009 @officialERblog enhancedrecoveryblog.com
  • 16. The pre-op education class Every patient attends the pre-operative education class. The pathway is explained in detail, exercises are practiced, questions answered, and patient expectations aligned toHip and knee education class what will happen @officialERblog enhancedrecoveryblog.com
  • 17. Education class• Lasts for 1 hour• Manage patient and carer expectations• De-mystify the experience• Clear and concise messages• Information on day to day expectations of their hospitalisation, surgical and anaesthetic process, prosthesis design, exercise and aftercare.• Opportunity for patients to ask questions• Collect social information (RAPT) to help predict their LOS. @officialERblog enhancedrecoveryblog.com
  • 18. RAPT score • An Australian tool which scores patients social factors out of 12. • 0-5 (Red – probable need for social intervention on D/C) • 6-9 (Amber – average social background, may need support) • 10-12 (Green – likely to manage well when home) • Factors scored: • Age • Gender • Pre-operative mobility – distance and walking aids • In receipt of any care pre-operatively • Living alone/with someone to help on discharge @officialERblog enhancedrecoveryblog.com
  • 19. @officialERblogenhancedrecoveryblog.com
  • 20. Pre-operative Discharge plans are made preoperatively. RAPT score predicts which patients will be more likely to have longer length of stays. Increased input can then be given to these patients www.enhancedrecoveryblog.com
  • 21. Does attending the group effectLOS? Overall LOS differences Group Number LOS RAPT Age % Red % Amber % Green DNA 215 4.67 8.3 71.63 14.9% (32) 50.7% (109) 34.4% (74) Attended 1018 4.07 8.78 70.4 7.8% (79) 49.7% (506) 42.5% (433) @officialERblog enhancedrecoveryblog.com
  • 22. Does attending the group effectLOS? - TKR Results Group Number LOS Ext Flex RAPT Age % Red % Amber % Green DC DC DNA 122 4.91 2.25 82.66 8.33 72.15 15.6% 50.8% 33.6% (19) (62) (41) Attended 521 4.14 2.26 84.06 8.84 70.9 8.8% 47.8% 43.4% (46) (249) (226) @officialERblog enhancedrecoveryblog.com
  • 23. TKR – Social breakdown Group Number LOS Ext DC Flex DC RAPT Age TKR Red RAPT DNA 19 7.1 1.58 82.9 4.53 79.47 Attended 46 4.52 2.4 84.57 4.76 77.43 Group Number LOS Ext DC Flex DC RAPT AgeTKR Amber RAPT DNA 62 4.9 1.85 82.02 8.05 74.27 Attended 249 4.34 1.99 83.59 7.99 73.63 Group Number LOS Ext DC Flex DC RAPT Age TKR Green RAPT DNA 41 3.9 3.17 83.54 10.51 65.54 Attended 226 3.85 2.52 84.46 10.62 66.59 @officialERblog enhancedrecoveryblog.com
  • 24. Day of admission @officialERblog enhancedrecoveryblog.com
  • 25. Day of admissionOptimised nutrition and hydration with Patient admitted and walks toEnhanced Recovery Pre-op Drink theatre @officialERblog enhancedrecoveryblog.com
  • 26. Carbohydrate drinks• Use of preoperative iso-osmolar carbohydrate drinks up to two hours preoperatively, reduces anxiety, prevents dehydration, minimizes the stress response to surgery, reduces insulin resistance and obtunds the development of a catabolic state.• By giving a carbohydrate ‘load’, the patient is in the ‘fed’ state at the beginning of surgery. This can help lead to reduced postoperative resistance to insulin and shortened hospital length of stay.• There is no change in gastric emptying time with the ingestion of up to 400ml of a carbohydrate solution up to 2 hours before surgery and so there is unlikely to be any increased risk of aspiration. @officialERblog enhancedrecoveryblog.com
  • 27. Staggered admission times and a predictable theatre list allow for optimal fasting instructions @officialERblog enhancedrecoveryblog.com
  • 28. Preoperative starvation• Preoperative guidelines generally state that patients should be nil by mouth for food for six hours prior to induction and two hours for clear fluids.• However we know that patients are starved for far longer than this, leading to dehydration and increased perioperative fluid requirements.• This period of starvation should be kept as close to that recommended as possible, encouraging patients to eat and drink normally as late as possible, particularly encouraging consumption of clear fluids (water, squash or black tea and coffee) for up to two hours prior to surgery. @officialERblog enhancedrecoveryblog.com