COLORECTAL SURGERY ENHANCED RECOVERY PROGRAMME - Draft Guidelines

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COLORECTAL SURGERY ENHANCED RECOVERY PROGRAMME - Draft Guidelines

  1. 1. 5th Draft Guidelines Enhanced Recovery Programme April 07 COLORECTAL SURGERY ENHANCED RECOVERY PROGRAMME DRAFT GUIDELINES Version Date Purpose of Issue/Description of Change Review Date 1 Oct 06 April 08 Scope Author Approved by Date Margaret Jennings Colorectal Specialist Nurse
  2. 2. 6TH Draft Guidelines Enhanced Recovery Programme April 07 CONTENTS 1. INTRODUCTION............................................................................................. 1 1.1. SUMMARY ........................................................................................... 1 1.2. BACKGROUND AND RATIONALE ...................................................... 1 2. PREOPERATIVE INFORMATION .................................................................. 2 3. PERIOPERATIVE ........................................................................................... 3 4. POSTOPERATIVE.......................................................................................... 4 5. DISCHARGE ................................................................................................... 4 6. CONCLUSION ................................................................................................ 5 7. REFERENCES................................................................................................ 6 APPENDIX 1 - ENHANCED RECOVERY PROGRAMME COLORECTAL SURGERY 8 APPENDIX 2 - PROTOCOL FOR THE USE OF NUTRICIA PRE-OP..................... 11 APPENDIX 3 - OCCUPATIONAL THERAPY.......................................................... 14 APPENDIX 4 EPIDURALS FOR PAIN RELIEF ................................................... 14 APPENDIX 5 ENHANCED RECOVERY PROGRAMME............................... 28 APPENDIX 6 .34 APPENDIX 7 - PONV FLOW CHART ..................................................................... 35
  3. 3. 6TH Draft Guidelines Enhanced Recovery Programme April 07 COLORECTAL SURGERY ENHANCED RECOVERY PROGRAM 1. INTRODUCTION 1.1. SUMMARY This document provides guidelines to support the implementation of the enhanced recovery program at Harrogate District Hospital for patients receiving elective colorectal cancer surgery. The aim is to improve patient recovery after surgery and reduce morbidity; such programs enable the patient to be discharged home earlier, without compromising the patients safety and wellbeing 1.2. BACKGROUND AND RATIONALE A recent development in elective large bowel surgery is the introduction of the enhanced recovery program, also referred to as fast track (Wilmore D; Kehlet H 2005). The enhanced recovery program combines a number of elements, aimed at enhancing patient recovery, and reducing the stress response after surgery, aiding faster recovery and shorter hospital stay (Basse L et al 2000; Kehlet et al 2000). The Enhanced Recovery Program was introduced over a decade ago with favourable early results, based on solid evidence derived from randomized trials (Kehlet H 2005) The main elements to this are · Extensive pre operative counselling · Bowel preparation. There will be no mechanical bowel preparation. If an on table colonoscopy is required then this will be highlighted in pre assessment , as to the need for picoloax · No pre-medication · Avoid preoperative fasting but carbohydrate loaded drinks until 2 hours before surgery (Type 1 and 2 diabetics excluded) · Low residue diet 3 days prior to surgery · Tailored anaesthetics, involving thoracic epidural anaesthesia and reduced intra operative fluids · Perioperative high inspired oxygen concentrations · Avoidance of perioperative fluid overload/ reduced post operative fluids · Tailored abdominal incisions · Non opiod pain management ie only use opiod as a rescue (refer to guidelines) · Avoid routine use of drains, remove early if used Version 1 Page 1 of 35 Review Date April 08
  4. 4. 6TH Draft Guidelines Enhanced Recovery Programme April 07 · Avoidance of naso-gastric tubes · Enforced post-operative mobilisation (see appendix .) · Early removal of bladder catheters · Standard laxatives and prokinetics · Early postoperative feeding The Enhanced Recovery Program requires a team approach from Surgeons, Anaesthetists, Pharmacists, Physiotherapist, Occupational Therapist, Dieticians, Nursing staff and services allied to health in primary care, each will play a vital role in achieving the aims of the program 2. PREOPERATIVE INFORMATION Pre surgery information is crucial in ones assessment of the patient prior to surgery as problems/concerns addressed in this period can reduce the barriers that often delay patient discharge (see appendix 2) The principles that require engagement at this point are the principles of supportive care and include: · Information needs of patients and carers; patients and their carers will be given information on post operative goals i.e. when what will happen, e.g. what will happen on the evening after surgery, what will happen on day 1,2,3,4,etc (see appendix 4) · Being treated with respect · Empowerment · Having choices · Equal access · Continuity of care · Meeting physical/psychological/social/spiritual needs · Risk assessment for when discharged, preventing possible barriers to optimisation These principles have been shown to improve patient compliance with enhanced rehabilitation, reduce anxiety, pain and post operative ileus, and have an important impact on early recovery, and reduced length of hospital stay (Monagle J et al 2003) Within this period a pre-operative assessment, an environment of multidisciplinary team working, patients are assessed with regard suitability for optimization. The pre operative assessment in the context of the enhanced recovery program has two major functions; 1. To recognise preoperative comorbidity, and therefore optimise these conditions 2. Detect other factors, including social and psychological , that may cause a barrier to early recovery and discharge Version 1 Page 2 of 35 Review Date April 08
  5. 5. 6TH Draft Guidelines Enhanced Recovery Programme April 07 Patients at risk of having a stoma as a result of their surgery will require to be seen by the stoma care sister to be assessed and arrangements made for Pre operative stoma education, as not being proficient in stoma management can delay discharge There is evidence that avoiding picolax preparation, prior to surgery, reduces electrolyte imbalances and dehydration This has been reported as avoiding electrolyte imbalances and dehydration, (Beloosesky Y et al 2003).There has been no reported increase in anastomotic leaks and septic complications by not giving bowel prep pre operatively (Guenaga K F et al 2003; Zmora O et al 2003). It has been agreed by the Colorectal surgeons that prior to colonic or rectal resection, patients will receive a phosphate enema 2 hours pre operatively. This may well be an interim measure, and may change in the future when an agreed bowel preparation protocol has been agreed as part of the enhanced recovery program The patient will receive Preop nutritional supplements (see appendix 1) Oral carbohydrate loading has been shown to reduce less postoperative insulin resistance and improved outcomes after surgery (Ljungqvist O, Nygren J 2002). Patients who are Type 1 and 2 diabetics will be excluded from pre op nutricia. 3. PERIOPERATIVE Within this period the patient will receive: High inspired oxygen. This has been shown to increase intestinal intramural oxygenation (Ratnaraj J et al 2004), less risk of wound infection (Grief R et al 2000), and less post operative nausea and vomiting (Grief R et al 1999). Avoid post operative nausea and vomiting (see appendix 5) It is difficult to determine the relevance of nausea and vomiting to overall outcomes measures in colorectal surgery, however in the context of the enhanced recovery program nausea and vomiting may increase postoperative stress and discomfort and therefore become a barrier to the recovery process. A multi modal approach to care is therefore important and needs to be included in ones strategy so that optimisation is achieved. Decision on surgical incision will be made by the surgeon, but a Transverse Incision for a Right Hemicolectomy has been shown to give the patient less pain, fewer chest infections (Lindgren PG et al 2001; Grantcharov TP, Rosenburg J 2001); encourages earlier gut function and feeding, earlier mobilisation resulting in a shorter hospital stay (Kam MH et al 2004; Donati D et al 2002). · Epidural anaesthesia Epidural analgesia is an effective way of treating pain. It is important that patients have confidence in this technique. Patients will receive information pre-operatively on what to expect and this will be supported in the post-operative period by the caring team (see appendix 3) Version 1 Page 3 of 35 Review Date April 08
  6. 6. 6TH Draft Guidelines Enhanced Recovery Programme April 07 It is important that all members of the caring team have a full understanding of epidural analgesia enabling for effective management. This guidance is supported by the Clinical Practice Guidelines for Epidural Analgesia for Adult Acute pain Management (HDFT 2006) · Post epidural management Refer to the clinical practice guidelines for Epidural analgesia for adult acute pain management (HDFT 2006), see appendix 4 · Intravenous fluids Intravenous fluids at an appropriate rate will be given, adjusted to oral intake, fluid loss from stoma, urine output, vital sign recordings, of blood pressure, pulse, central venous pressure, blood biochemistry i.e. Urea and Electrolytes (U+Es), and how the patient is clinically. If the patient has an epidural refer to Clinical practice guidelines (HDFT 2006) · Drains/Naso- gastric tubes Drains and nasogastric tubes will be avoided, as there is no evidence of their benefit of use (Merad F et al 1999; Cheatham ML et al 1995), only that they decrease mobilisation and increase patients distress (Hoffmann S et al 2001). 4. POSTOPERATIVE The aim is to introduce fluid and diet early. This has been shown to be safe (Reissman P et al 1995) resulting in fewer septic complications (Beier-Holgersen R, Boesby S 1998). · Enhanced mobility plan. Early mobilisation has been shown to reduce the incidence of post operative ileus, and shorter hospital stay (Basse L et al 2002). 5. DISCHARGE There will be planned goals for each day (see appendix 5) Target discharge dates for the following are: Right Hemicolectomy 5days Left Hemicolectomy 7 days Sigmoid Colectomy 5 days Anterior resection with stoma 7days Abdomino perineal resection 10 days Anterior resection 5 days Version 1 Page 4 of 35 Review Date April 08
  7. 7. 6TH Draft Guidelines Enhanced Recovery Programme April 07 Outcome measures with regard physiological function, psychological function, gut function and clinical outcome will need to be considered when evaluating this service long term 6. CONCLUSION The enhanced recovery program requires multidisciplinary team work. Evidence shows that the best and most cost effective outcomes for patients are achieved when professionals work together and generate innovation to ensure progress in practice and service (DOH 1993). Version 1 Page 5 of 35 Review Date April 08
  8. 8. 6TH Draft Guidelines Enhanced Recovery Programme April 07 7. REFERENCES BASSE L, HJORT JAKOBSON D ET AL. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000: 232: 51-57 BASSE L, RASKOV HH ET AL. Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg 2002;89: 446-453 BASSE L, THORBOL J E.ET al. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 2004; 47:271-278. BEIR-HOLGERSEN R, BOESBY S. Effect of early postoperative enteral nutrition on postoperative infections. Ugeskr Laeger 1998; 160: 3223-3226 BELOOSESKY Y, GRINBALT J ET AL. Electrolyte disorders following oral sodium phosphate administration for bowel cleansing in elderly patients. Arch intern Med 2003; 163: 803-808 CHEATHAM M L, CHAPMAN W C ET AL. A meta analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995; 221: 469-476 DONATI D, BROWN S R ET AL. Comparison between midline incision and limited right skin crease incision for right sided colonic cancers. Tech Coloproctol 2002; 6: 1-4 GRIEF R, AKCA O ET AL. Supplemental perioperative oxygen to reduce the incidence of surgical wound infection. Outcomes Research Group. N Engl J Med 2000; 342: 161-167 GRIEF R, LACINY S ET AL. Supplemental oxygen reduces the incidence of post operative nausea and vomiting. Anesthesiology 1999; 91: 1246-1252 GUENAGA KF, MATOS D, CASTRO AA ET AL. Mechanical bowel preparation for elective colorectal surgery. Cochrane database Syst Rev 2003; (2) CDOO1544 HOFFMANN S, KOLLER M ET AL. Nasogastric tube versus gastrostomy tube for gastric decompression in abdominal surgery: a prospective, randomized trial comparing patients tube-related inconvenience. Langenbecks Arch Surg 2001; 386: 402-409. KAM M H,SEOW-CHOEN F ET AL. Minilaparotomy left iliac fossa skin crease incision vs midline incision for left sided colon cancer. Tech Coloproctol 2004;8: 85- 88 KEHLET H, DAHL J B. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003; 362: 1921-1928 Version 1 Page 6 of 35 Review Date April 08
  9. 9. 6TH Draft Guidelines Enhanced Recovery Programme April 07 KEHLET H, WILMORE D W.. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183: 630-641. KEHLET H, WILMORE D W. Fast track surgery. Br J Surg 2005; 92: 3-4 LINDGREN P G, NORDGREN S R ET AL. Midline or transverse abdominal incision for right sided colon cancer-a randomized trial. Colorectal Dis 2001;3: 46-50 LJUNGQUIST O, NYGREN J, THORELL A. Modulation of post-operative insulin resistance by pre-operative carbohydrate loading. Proc Nutr Soc 2002; 61: 329-336. MERAD F, HAY J M ET AL. Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. French Association for Surgical Research. Surgery 1999; 125: 529-535 MONAGLE J ET AL 2003. ANZ J Surg 2003 RATNARAJ J, KABON B ET AL. Supplemental oxygen and carbon dioxide each increase subcutaneous and intestinal intramural oxygenation. Anesth Analg 2004; 99: 207-211 WILMORE DW, KEHLET H. Recent advances: management of patients in fast track surgery. BMJ 2001; 322: 473-476 ZMORA O, MAHAJNA A, ET AL. Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial. Ann Surg 2003; 237: 363-367 Version 1 Page 7 of 35 Review Date April 08
  10. 10. 6TH Draft Guidelines Enhanced Recovery Programme April 07 APPENDIX 1 - ENHANCED RECOVERY PROGRAMME COLORECTAL SURGERY Dietary Management Low Fibre Diet and Pre Op Nutritional Supplement Three days before surgery you should eat a low fibre diet. This reduces the stool residue in the bowel. The main sources of fibre in the diet are cereal products, vegetables and fruits. When following a low fibre diet, intake of these foods needs to be reduced. It is important to have regular meals and a varied diet which includes foods such as meat, poultry, fish, eggs and dairy products (milk, cheese, yoghurt). It is important to have a good fluid intake ie at least 8-10 cups (water, tea, squash etc) per day. Foods to avoid Foods to use instead Wholemeal, granary, hi-bran and White bread brown breads White flour Wholemeal flour Pastry (white flour) Wholemeal pastry Wholegrain breakfast cereals eg Corn and rice breakfast cereals Weetabix, Shreddies, eg Corn Flakes, Rice Krispies Branflakes, muesli, porridge, natural bran Brown rice White rice Wholewheat pasta White and tricolour pasta Wholegrain biscuits eg digestive, Biscuits made with white flour Hob Nobs, flapjack, bran eg rich tea, custard creams, biscuits fig rolls crispbreads, shortbreads, cream crackers, oatcakes butter puffs Fruit cakes Cake made with white flour eg Mince pies sponge, Jam tarts (use jelly jams, lemon curd fillings) Dried fruit (including tinned Fresh, peeled fruit prunes) Tinned fruit Seeds & pips (Maximum of 2 portions/day) Nuts Fruit juice (as desired) Version 1 Page 8 of 35 Review Date April 08
  11. 11. 6TH Draft Guidelines Enhanced Recovery Programme April 07 Milk puddings, stewed apple and Desserts eg Sponge & pies made with fruit custard, apple pie, sponge containing skins and pips, eg pudding and custard plums, gooseberries and Mousses, plain or set yoghurts, raspberries jelly Jelly jams and marmalade Preserves Jams and marmalade containing Lemon curd a high fruit content and/or Honey seeds and pips Marmite Mincemeat Peanut butter The day before your operation you will be advised to have clear fluids and Pre Op nutritional drinks. Pre Op is a clear, lemon flavoured carbohydrate drink. It has been specifically designed for patients who are scheduled to have bowel surgery. Taking these drinks has been shown to benefit patients recovery from surgery. They have been shown to improve well-being and may contribute to a reduction in length of hospital stay. In pre-assessment clinic or on the ward you will receive 4 cartons to take the evening before surgery. These will be given at 4.00 pm, 6.00 pm, 8.00 pm and 10.00 pm. On the day of surgery you will receive 2 more cartons to drink on the ward. These should be fully consumed 2 hours prior to you having your anaesthetic. Pre Op should be sipped slowly and is best served chilled. After surgery, you should return to your usual diet unless advised otherwise by the Dietitian, Nurse Specialist or Consultant. If you have any questions, please contact:- Margaret Jennings Jill Gale/Heidi Cobb Colorectal Clinical Nurse Specialist or Specialist Dietitians Harrogate District Hospital Harrogate District Hospital ( (01423) 553340 ( (01423) 553329 Produced by: Nutrition and Dietetic Service, Harrogate District Hospital - March 2007 Version 1 Page 9 of 35 Review Date April 08
  12. 12. 6TH Draft Guidelines Enhanced Recovery Programme April 07 Review date: March 2008 Version 1 Page 10 of 35 Review Date April 08
  13. 13. 6TH Draft Guidelines Enhanced Recovery Programme April 07 APPENDIX 2 - PROTOCOL FOR THE USE OF NUTRICIA PRE-OP INTRODUCTION Recovery after major surgery is significantly delayed by the development of temporary insulin resistance, which is associated with muscle weakness and wasting (1). Recent evidence has suggested that post-operative insulin resistance and the stress response to major abdominal surgery can be significantly attenuated by pre-operative carbohydrate loading (2-5). A carbohydrate drink, Nutricia preOp has been developed specifically for this purpose, in order to provide a sustained hyperinsulinaemia (required to prevent insulin resistance) while ensuring rapid gastric transit (making it safe to take up to 2 hours before induction of anaesthesia) (6). This treatment has been shown to reduce post-operative loss of muscle mass (7) and improve well being (8). Pre-operative oral carbohydrate loading has been incorporated into enhanced recovery programmes for major abdominal surgery in several European countries. The recommended intake of Nutricia preOp ensures that at the time of surgery the patient is in an anabolic, rather than catabolic state, has loaded glycogen stores and an empty stomach. The product is contraindicated for use in emergency surgery, if a patient has delayed gastric emptying (patients with delayed gastric emptying will be identified by the consultant) and Type 1 and 2 Diabetics. The regimen has patient benefits, e.g. less thirst, hunger and anxiety before the operation and may contribute to a reduction in length of hospital stay. PURPOSE OF THE PROTOCOL The purpose of this protocol is to ensure that all patients admitted for elective colorectal resections (unless contra-indicated) will receive a carbohydrate drink (Nutricia preOp) up to 2 hours prior to the anaesthetic being administered. DEFINITIONS Nutricia preOp is a clear, non-carbonated, lemon flavoured, iso-osmolar carbohydrate drink which provides a sustained hyperinsulinaemia while ensuring rapid gastric transit. Each carton contains 200ml, 100 calories, 25g carbohydrate and electrolytes. It is fat, protein, lactose, gluten and fibre free. It is a drink for the medical purpose of pre-operative dietary management of lower gastrointestinal surgical patients. ADMINISTRATION The initial loading dose is 4 x 200ml the evening before surgery. The final dose is 2 x 200ml to be fully consumed two hours prior to anaesthesia. The dose should be written on the drug chart by the pharmacist in pre-assessment clinic. Every patient will be given an information leaflet and will consent to this part of their surgical pathway. Version 1 Page 11 of 35 Review Date April 08
  14. 14. 6TH Draft Guidelines Enhanced Recovery Programme April 07 FLOW CHART FOR THE USE OF NUTRICIA PRE-OP Lower GI patient identified by consultant, pharmacist or nursing staff in pre-assessment unit as a candidate for preOp. (Colorectal Nurse Specialist will already be aware of patient and will discuss with the dietitian). Pharmacist writes patient up for preOp drinks on the drug chart (4 x 200ml evening before surgery, and 2 x 200ml to be fully consumed two hours pre anaesthesia) Cartons given to patient to take home. Information leaflet given to patient to explain rationale for treatment and directions for use. (Leaflet Patient given contact number for CNS and dietitians in case of queries. Patient admitted for surgery. CNS marks patient as receiving preOp on colorectal patient database. Patient takes second dose on ward. Protocol to be reviewed/ audited after six months Version 1 Page 12 of 35 Review Date April 08
  15. 15. 6TH Draft Guidelines Enhanced Recovery Programme April 07 REFERENCES 1. Insulin resistance: a marker of surgical stress. Thorell A, Nygren J, Ljungqvist O. Curr Opin Clin Nutr Metab Care. 1999 Jan:2(1):69-78 2. Randomised clinical trial of the effects of immediate enteral nutrition on metabolic responses to major colorectal surgery in an enhanced recovery protocol. Soop M et al Br J Surg 2004 Sept;91: 1138-1145 3. Preoperative oral carbohydrate treatment attenuates immediate post operative insulin resistance. Soop M et al. Am J Physiol Endocrinol Metab. 2001 April; 280(4):E576-583 4. Preoperative oral carbohydrate administration reduces postoperative insulin resistance. Nygren J et al. Clin Nutr 1998 April;17(2):65-71 5. Can post traumatic insulin resistance be attenuated by prior glucose loading? Byrne CR, Carlson GL. Nutrition 2001;17:354-355 6. Preoperative gastric emptying. Effects of anxiety and oral carbohydrate administration. Nygren J et al. Ann Surg 1995 Dec;222(6):728-734 7.The administration of an oral carbohydrate containing fluid prior to major elective upper gastrointestinal surgery preserves skeletal muscle mass post operatively a randomised clinical trial. Yuill KA et al Clin Nutr 2005 Feb;24(1):32-37 8. Randomised clinical trial of the effects of oral preoperative carbohydrates on post operative nausea and vomiting after laparoscopic cholecystectomy. Hausel J et al. Br J Surg. 2005 Feb 28 (E pub) Jill Gale and Heidi Cobb Specialist Dietitians September 2006 With acknowledgement to Kirstine Farrer, Consultant Dietitian, Salford Royal Hospitals NHS Trust Version 1 Page 13 of 35 Review Date April 08
  16. 16. 6TH Draft Guidelines Enhanced Recovery Programme April 07 APPENDIX 3 - OCCUPATIONAL THERAPY Pre Surgery Information Occupational Therapists (OTs) work as part of the team on the ward. We aimtoh elp you to become as independent as possible with all the tasks that you need to do during the day such as personal care. In order to help us plan the treatement that you require, enabling you to return home as quickly, safely and independently as possible, please complete the following questionnaire which the OT will then discuss with you whilst you are on the ward. Social Information 1. What type of accommodation do you have? (house, flat, bungalow) 2. Is this privately owned/council/rented? 3. Describe the access to your property. (steps? rails?) 4. Do you have a toilet upstairs/downstairs/both? 5. Do you have any stairs to go up and if so, as you are going upstairs is the rail on the left/right/both sides? 6. If necessary do you have a spare bed and would there be room to have it downstairs? 7. Do you live alone or if not, who do you live with? 8. Is the person you live with reasonably fit? Version 1 Page 14 of 35 Review Date April 08
  17. 17. 6TH Draft Guidelines Enhanced Recovery Programme April 07 9. Do you have any formal support at present? (Homecare/Meals on Wheels/Cleaner?) l0. Do you have any informal support? (Family/Friends) Can you describe how (if at all) they help you with everyday activities? 11. Please describe your current level of mobility. Do you use a walking aid? 12. Please describe how you currently manage personal and domestic tasks. (washing, dressing, cooking, housework, shopping) 13. Do you have any difficulty getting on or off you bed, chair or toilet? 14. Where do you eat your meals? 15. Do you have any equipment that helps you with everyday tasks? (raised toilet seat, commode, kitchen stool, trolley, helping hand) 16. Do you have any concerns about managing at home following your operation? Thank you for completing this questionnaire. Version 1 Page 15 of 35 Review Date April 08
  18. 18. 6TH Draft Guidelines Enhanced Recovery Programme April 07 APPENDIX 4 EPIDURALS FOR PAIN RELIEF Epidurals for pain relief after surgery This leaflet is for anyone who may benefit from an epidural for pain relief after surgery. We hope it will help you to ask questions and direct you to sources of further information. Version 1 Page 16 of 35 Review Date April 08
  19. 19. 6TH Draft Guidelines Enhanced Recovery Programme April 07 This booklet explains what to expect when you have an epidural anaesthetic for pain relief after your operation. It is part of a series about anaesthetics and related topics written by a partnership of patient representatives, patients and anaesthetists. You can find more information in other leaflets in the series. You can get these leaflets, and large print copies, from www.youranaesthetic.info. They may also be available from the anaesthetic department in your hospital. The series will include the following: l Anaesthesia explained l You and your anaesthetic (a summary of the above) l Your child s general anaesthetic l Your spinal anaesthetic l Headache after an epidural or spinal anaesthetic l Your child's general anaesthetic for dental treatment l Local anaesthesia for your eye operation l Your tonsillectomy as day surgery l Your anaesthetic for aortic surgery l Anaesthetic choices for hip and knee replacement Throughout this booklet we use these symbols To highlight your options or choices. To highlight where you may want to take a particular action. To point you to more information. Version 1 Page 17 of 35 Review Date April 08
  20. 20. 6TH Draft Guidelines Enhanced Recovery Programme April 07 Introduction This leaflet describes what happens when you have an epidural, together with any side effects and complications that can occur. It aims to help you and your anaesthetist make a choice about the best method of pain relief for you after your surgery. What is an epidural? The nerves from your spine to your lower body pass through an area in your back close to your spine, called the quot;epidural spacequot;. l To establish an epidural an anaesthetist injects local anaesthetics through a fine plastic tube called an epidural catheter into this epidural space.. As a result, the nerve messages are blocked. This causes numbness, which varies in extent according to the amount of local anaesthetic injected. l An epidural pump allows local anaesthetic to be given continuously. l Other pain relieving drugs can also be added in small quantities. l The amounts of drugs given are carefully controlled. l You may be able to press a button to give a small extra dose from the pump. Your anaesthetist will set the pump to limit the dose which you can give, so overdose is extremely rare. l When the epidural is stopped, full feeling will return. l Epidurals may be used during and/or after surgery for pain relief. Version 1 Page 18 of 35 Review Date April 08
  21. 21. 6TH Draft Guidelines Enhanced Recovery Programme April 07 How is an epidural done? Epidurals can be put in: l when you are conscious l when you are under sedation (when you have been given a drug which will make you drowsy and relaxed, but still conscious) l or during a general anaesthetic. These choices can be discussed further with your anaesthetist. 1. A needle will be used to put a thin plastic tube (a cannula ) into a vein in your hand or arm for giving fluids (a drip ). 2. If you are conscious, you will be asked to sit up or lie on your side, bending forwards to curve your back. It is important to keep still while the epidural is put in. 3. Local anaesthetic is injected into a small area of the skin of your back. 4. A special epidural needle is pushed through this numb area and a thin plastic catheter is passed through the needle into your epidural space. The needle is then removed, leaving only the catheter in your back. Your epidural Version 1 Page 19 of 35 Review Date April 08
  22. 22. 6TH Draft Guidelines Enhanced Recovery Programme April 07 What will I feel? l The local anaesthetic stings briefly, but usually allows an almost painless procedure. l It is common to feel slight discomfort in your back as the catheter is inserted. l Occasionally, an electric shock-like sensation or pain occurs during needle or catheter insertion. If this happens, you must tell your anaesthetist immediately. l A sensation of warmth and numbness gradually develops, like the sensation after a dental anaesthetic injection. You may still be able to feel touch, pressure and movement. l Your legs feel heavy and become increasingly difficult to move. l You may only notice these effects for the first time when you recover consciousness after the operation, particularly if your epidural was put in when you were anaesthetised. l Overall, most people do not find these sensations to be unpleasant, just a bit strange. l The degree of numbness and weakness gradually decreases over the first day after the operation. What are the benefits? l Better pain relief than other methods, particularly when you move. l Reduced complications of major surgery, e.g. nausea/vomiting, leg/lung blood clots, chest infections, blood transfusions, delayed bowel function. l Quicker return to eating, drinking and full movement, possibly with a shorter stay in hospital compared to other methods of pain relief. How do the nurses look after me on the ward with an epidural? Version 1 Page 20 of 35 Review Date April 08
  23. 23. 6TH Draft Guidelines Enhanced Recovery Programme April 07 l At regular intervals, the nurses will take your pulse and blood pressure and ask you about your pain and how you are feeling. l They may adjust the epidural pump and treat side effects. l They will check that the pump is functioning correctly. They will encourage you to move, eat and drink, according to the surgeon s instructions. l The Pain Relief Team doctors and nurses may also visit you, to check your epidural is working properly. When will the epidural be stopped? l The epidural will be stopped when you no longer require it for pain relief. l The amount of pain relieving drug being given by the epidural pump will be gradually reduced. l A few hours after the pump is stopped, the epidural tubing will be removed, as long as you are still comfortable. l The epidural catheter will be removed if it is not working properly. Another epidural catheter can be re-inserted if necessary. Can anyone have an epidural? No. An epidural may not always be possible if the risk of complications is too high. The anaesthetist will ask you if: l you are taking blood thinning drugs, such as warfarin l you have a blood clotting abnormality l you have an allergy to local anaesthetics l you have severe arthritis or deformity of the spine l you have an infection in your back Version 1 Page 21 of 35 Review Date April 08
  24. 24. 6TH Draft Guidelines Enhanced Recovery Programme April 07 Side effects and complications l All the side effects and complications described can occur without an epidural. l Side effects are common, are often minor and are usually easy to treat. Serious complications are fortunately rare. l For major surgery, the risk of permanent nerve damage is probably about the same, with or without an epidural. l The risk of complications should be balanced against the benefits and compared with alternative methods of pain relief. Your anaesthetist can help you do this. Version 1 Page 22 of 35 Review Date April 08
  25. 25. 6TH Draft Guidelines Enhanced Recovery Programme April 07 Very common or common side effects and complications Inability to pass urine. The epidural affects the nerves that supply the bladder, so a catheter ( tube ) will usually have to be inserted to drain it. This is often necessary anyway after major surgery to check kidney function. With an epidural, it is a painless procedure. Bladder function returns to normal when the epidural wears off. Low blood pressure. The local anaesthetic affects the nerves going to your blood vessels, so blood pressure always drops a little. Fluids and/or drugs can be put into your drip to treat this. Low blood pressure is common after surgery, even without an epidural. Itching. This can occur as a side effect of morphine-like drugs used in combination with local anaesthetic. It is easily treated with anti-allergy drugs. Feeling sick and vomiting. These can be treated with anti- sickness drugs. These problems are less frequent with an epidural than with most other methods of pain relief. Backache. This is common after surgery, with or without an epidural and is often caused by lying on a firm flat operating table. Inadequate pain relief. It may be impossible to place the epidural catheter, the local anaesthetic may not spread adequately to cover the whole surgical area, or the catheter can fall out. Overall, epidurals usually provide better pain relief than other techniques. Other methods of pain relief are available if the epidural fails. Headaches Minor headaches are common after surgery, with or without an epidural. Occasionally a severe headache occurs after an epidural because the lining of the fluid filled space surrounding the spinal cord has been inadvertently punctured (a dural tap ). Version 1 Page 23 of 35 Review Date April 08
  26. 26. 6TH Draft Guidelines Enhanced Recovery Programme April 07 The fluid leaks out and causes low pressure in the brain, particularly when you sit up. Occasionally it may be necessary to inject a small amount of your own blood into your epidural space. This is called an epidural blood patch . The blood clots and plugs the hole in the epidural lining. It is almost always immediately effective. The procedure is otherwise the same as for a normal epidural. For more information please see Headache after an epidural or spinal anaesthetic . Uncommon complications Slow breathing. Some drugs used in the epidural can cause slow breathing and/or drowsiness requiring treatment. Catheter infection. The epidural catheter can become infected and may have to be removed. Antibiotics may be necessary. It is very rare for the infection to spread any further than the insertion site in the skin. Rare or very rare complications Other complications, such as convulsions (fits), breathing difficulty and temporary nerve damage are rare whilst permanent disabling nerve damage, epidural abscess, epidural haematoma (blood clot) and cardiac arrest (stopping of the heart) are very rare indeed. In comparison, you are more likely to die from an accident on the roads or in your own home every year than suffer permanent damage from an epidural. These risks can be discussed further with your anaesthetist and more detailed information is available. (All risks quoted are approximate and assume best practice). Version 1 Page 24 of 35 Review Date April 08
  27. 27. 6TH Draft Guidelines Enhanced Recovery Programme April 07 What if I decide not to have an epidural? It is your choice. You do not have to have an epidural. l There are several alternative methods of pain relief with morphine that work well; injections given by the nurses or by a pump into a vein which you control by pressing a button (Patient Controlled Analgesia, PCA ). l There are other ways in which local anaesthetics can be given. l You may be able to take pain relieving drugs by mouth. l Every effort will always be made to ensure your comfort. How do I ask further questions? l Ask the nursing staff or your anaesthetist. l Future sources of information about epidural anaesthesia available from the website. www.youranaesthetic.info. l Most hospitals have a team of nurses and anaesthetists who specialise in pain relief after surgery. You can ask to see a member of the pain team at any time. They may have leaflets available about pain relief. Version 1 Page 25 of 35 Review Date April 08
  28. 28. 6TH Draft Guidelines Enhanced Recovery Programme April 07 Useful organisations Royal College of Anaesthetists 48-49 Russell Square London WC1B 4JY. Phone: + 44 20 7813 1900 Fax: + 44 20 7813 1876 E-mail:info@rcoa.ac.uk Website: www.rcoa.ac.uk The organisation responsible for the standards in anaesthesia, critical care and pain management throughout the UK. Association of Anaesthetists of Great Britain and Ireland 21 Portland Place London WC1B 1PY Phone: +44 20 7631 1650 Fax: +44 20 7631 4352 E-mail: info@aagb.org Website: www.aagbi.org This organisation works to promote the development of anaesthesia and the welfare of anaesthetists and their patients in Great Britain and Ireland. Version 1 Page 26 of 35 Review Date April 08
  29. 29. 6TH Draft Guidelines Enhanced Recovery Programme April 07 Questions you may like to ask your anaesthetist Q Who will give my anaesthetic? Q Do I have to have this type of pain relief? Q Have you often used this type of pain relief? Q What are the risks of this type of pain relief? Q Do I have any special risks? Q How will I feel afterwards? Tell us what you think Second edition March 2003 We welcome any suggestions to improve this booklet. You should send these to: The Patient Information Unit, 48 Russell Square, The Association of Anaesthetists of Great Britain and Ireland (AAGBI) London WC1B 4JY E-mail: admin@youranaesthetic.info The Royal College of Anaesthetists (RCA) © The RCA and AABGI agree to the copying of this document for the purpose of producing local leaflets in the United Kingdom and Ireland. Please quote where you have taken the information from. The Patient Information Unit must agree to any changes if the AAGBI and RCA crests are to be kept. Version 1 Page 27 of 35 Review Date April 08
  30. 30. Patient Sticker 6TH Draft Guidelines Enhanced Recovery Programme April 07 APPENDIX 5 ENHANCED RECOVERY PROGRAMME EVENING POST-SURGERY FLUID BALANCE AND URINE FREE ORAL FLUIDS Record On Fluid Chart TOTAL FLUID INTAKE 2000ML IV MAINTENANCE Record On Fluid Chart Hourly Catheter Measurements Record on Fluid Chart Maintain 0.3 ml/kg/h (Ave. over 4 hours) IF LESS, INFORM DOCTOR CHEST Oxygen Promote Deep Breathing Exercises Encourage Cough MOBILITY (commence 6 hours post-op) Out Of Bed For 2 Hours Circulatory Exercises Ted Stockings NUTRITION High Protein Drink 1 High Protein Drink 2 REMEMBER: PATIENT IS ALLOWED FREE ORAL FLUIDS PAIN AND NAUSEA Epidural In-Situ Yes / No Effective Yes / No Antiemetic Prescribed As Necessary Post-op Assessment Pain Team STOMA CARE Inspect Stoma for good circulation Ensure the patient has a good fitting, drainable appliance TODAY S GOALS ACHIEVED? Yes / NO IF NO, REASON . ................................................................................................................................................... SIGNATURE Date Version 1 Page 28 of 35 Review Date April 08
  31. 31. Patient Sticker 6TH Draft Guidelines Enhanced Recovery Programme April 07 DAY 1 POST-SURGERY GENERAL MANAGEMENT Ted Stockings Dalteparin FLUID BALANCE AND URINE FREE ORAL FLUIDS Record On Fluid Chart TOTAL FLUID INTAKE 2000ML IV MAINTENANCE Record On Fluid Chart Hourly Catheter Measurements Record on Fluid Chart IF LESS, INFORM DOCTOR Maintain 0.3 ml/kg/h (Ave. over 4 hours) CHEST Oxygen Promote Deep Breathing Exercises Encourage Cough MOBILITY Out Of Bed For 8 Hours IF NOT ACHIEVED, WHY? ............................................ ................................... Ambulate x 2 ............................................ ................................... Circulatory Exercises NUTRITION High Protein Drink 1 High Protein Drink 2 High Protein Drink 3 High Protein Drink 4 PAIN AND NAUSEA Epidural In-Situ Yes / No Effective Yes / No Antiemetic Prescribed As Necessary Post-op Assessment Pain Team STOMATHERAPY The patient is encouraged to look at the Stoma Pouch emptying procedure is explained including the use of Velcro fastener Renew the pouch Reassurance given regarding colour, odour, etc TODAY S GOALS ACHIEVED? YES / NO IF NO, REASON .......................................... .. SIGNATURE Date . Version 1 Page 29 of 35 Review Date April 08
  32. 32. Patient Sticker 6TH Draft Guidelines Enhanced Recovery Programme April 07 DAY 2 POST-SURGERY GENERAL MANAGEMENT Ted Stockings Dalteparin Nutrition Stomatherapy Goals FLUID BALANCE AND URINE FREE ORAL FLUIDS Record On Fluid Chart TOTAL FLUID INTAKE 2000ML IV MAINTENANCE Record On Fluid Chart Hourly Catheter Measurements Record on Fluid Chart Maintain 0.3 ml/kg/h (Ave. over 4 hours) IF LESS, INFORM DOCTOR CHEST Oxygen Promote Deep Breathing Exercises Physiotherapist Assess MOBILITY IF NOT ACHIEVED, WHY? Out of bed for 8 hours Ambulate x 4 6 Circulatory Exercises NUTRITION High Protein Drink 2 High Protein Drink 1 High Protein Drink 3 High Protein Drink 4 BREAKFAST .......................................... DINNER ............................... SNACKS .............................. LUNCH ................................................... PAIN Epidural Stopped Today If no, why? ................................ Oral Analgesia Prescribed Contra-indication ....................... (Paracetamol + NSAID or Tramadol if NSAID contra-indicated) STOMA CARE Patient is emptying pouch Reassurance given regarding the appearance of the stoma. This may be a little unsightly/oedematous at this time Complete pouch change explained and undertaken TODAY S GOALS ACHIEVED? YES / NO IF NO, REASON .. .. SIGNATURE . Date Version 1 Page 30 of 35 Review Date April 08
  33. 33. 6TH Draft Guidelines Enhanced Recovery Programme April 07 Patient Sticker DAY 3 POST-SURGERY GENERAL MANAGEMENT Ted Stockings Dalteparin Nutrition Stomatherapy Goals CHECK DISCHARGE ARRANGEMENTS HAVE BEEN ADDRESSED FLUID BALANCE AND URINE FREE ORAL FLUIDS Record On Fluid Chart TOTAL FLUID INTAKE 2000ML STOP IV MAINTENANCE IF POSSIBLE Hourly Catheter Measurements Record on Fluid Chart Maintain 0.3 ml/kg/h (Ave. over 4 hours) IF LESS, INFORM DOCTOR RECTAL RESECTIONS: Remove Urethral Catheter if epidural/PCA down CHEST Physiotherapist Assessment MOBILITY Self caring IF NOT ACHIEVED, WHY? ............................................ Out Of Bed For 8 Hours ................................... Ambulate x 6 ................................... Circulatory Exercises NUTRITION High Protein Drink 1 High Protein Drink 2 High Protein Drink 3 High Protein Drink 4 BREAKFAST .......................................... DINNER ............................... LUNCH ................................................... SNACKS .............................. PAIN Epidural stopped Oral Analgesia Prescribed (Paracetamol + NSAID or Tramadol if NSAID contra-indicated) TODAY S GOALS ACHIEVED? YES / NO IF NO, REASON......................................... ................................................................................................................................................ FIT FOR DISCHARGE? YES / NO IF NO, REASON ..................................................... ............................................................................................... SIGNATURE . Date Version 1 Page 31 of 35 Review Date April 08
  34. 34. Patient Sticker 6TH Draft Guidelines Enhanced Recovery Programme April 07 DAY 4 POST-SURGERY GENERAL MANAGEMENT Ted Stockings Dalteparin Nutrition Stomatherapy Goals ) IS PATIENT FIT FOR DISCHARGE? YES / NO (If No, reason FLUID BALANCE AND URINE FREE ORAL FLUIDS Record on Fluid Chart TOTAL FLUID INTAKE 2000ML IV MAINTENANCE SHOULD BE STOPPED Hourly Catheter Measurements Record on Fluid Chart Maintain 0.3 ml/kg/h (Ave. over 4 hours) IF LESS, INFORM DOCTOR CATHETER SHOULD BE OUT CHEST Physiotherapist Assessment MOBILITY Self caring IF NOT ACHIEVED, WHY? Out Of Bed For 8 Hours ............................................ ................................... Ambulate x 6 ................................... Limb Exercises NUTRITION High Protein Drink 1 High Protein Drink 2 High Protein Drink 3 High Protein Drink 4 BREAKFAST .......................................... DINNER ............................... LUNCH ................................................... SNACKS .............................. PAIN Oral Analgesia Prescribed (Paracetamol + NSAID or Tramadol if NSAID contra-indicated) STOMA · The patient should be participating in the pouch change procedure · The patient will need to change their chosen pouch daily for practice and to become confident the patient may have chosen an appliance prior to admission · Explanation of the changing nature of output should be given TODAY S GOALS ACHIEVED? YES / NO. IF NO, REASON ........................... ...................................................................................................................................... FIT FOR DISCHARGE? YES / NO IF NO, REASON ................................................ ..................................................................................................................................... SIGNATURE .. Date Version 1 Page 32 of 35 Review Date April 08
  35. 35. Patient Sticker 6TH Draft Guidelines Enhanced Recovery Programme April 07 DAY 5 POST-SURGERY GENERAL MANAGEMENT Ted Stockings Dalteparin Nutrition Stomatherapy Goals IS PATIENT FIT FOR DISCHARGE? YES / NO (If No, reason ) FLUID BALANCE AND URINE FREE ORAL FLUIDS Record On Fluid Chart TOTAL FLUID INTAKE 2000ML IV MAINTENANCE SHOULD BE STOPPED Hourly Catheter Measurements Record on Fluid Chart Maintain 0.3 ml/kg/h (Ave. over 4 hours) IF LESS, INFORM DOCTOR CHEST Physiotherapist Assessment MOBILITY Self caring IF NOT ACHIEVED, WHY? ............................................ Out Of Bed For 8 Hours ................................... Ambulate x 6 ................................... Limb Exercises NUTRITION High Protein Drink 1 High Protein Drink 2 High Protein Drink 3 High Protein Drink 4 BREAKFAST .......................................... DINNER ............................... LUNCH ................................................... SNACKS .............................. PAIN Oral Analgesia Prescribed (Paracetamol + NSAID or Tramadol if NSAID contra-indicated) STOMA CARE The patient should be: - Changing the pouch unaided in the bathroom - Disposing of soiled pouch and contents - Be aware of methods of obtaining supplies The patient should have knowledge of: - Skin care - Complications that may occur - Dietary implications - The effect of medication on stoma output TODAY S GOALS ACHIEVED? YES / NO IF NO, REASON .......................................................... .................................................................................................................................................................. FIT FOR DISCHARGE? YES / NO IF NO, REASON ................................ . SIGNATURE .. Date .. Version 1 Page 33 of 35 Review Date April 08
  36. 36. 6TH Draft Guidelines Enhanced Recovery Programme April 07 APPENDIX 6 Day of operation Epidural Fentonyl and Bupivocaine Regular IV Paracetamol 1st post operative day Epidural and regular IV Paracetamol 2nd post operative day Evening of 2nd post Epidural and regular operative consider oral Paracetamol commencing NSAID and PPI 3rd post operative day Prescribe PRN doses of Contraindications to Buscopan 20mg IV first suspend epidural for 6 NSAIDS line (100mg maximum in hours at 8.00 am, give >Heart Failure 24 h ours) Morphine 10 regular Paracetamol >Renal Failure mgs sc/po >GI Bleed >Proven allergy to NSAIDS Recommence epidural if pain score is <3/10 for If contraindications further 24 hours commencing Codeine administering loading or Tramadol doses prior to this. Give regular Paracetamol and consider NSAID and PPI 4th post operative day suspend epidural for 6 hours and repeat pain assessment Version 1 Page 34 of 35 Review Date April 08
  37. 37. 6TH Draft Guidelines Enhanced Recovery Programme April 07 APPENDIX 7 - PONV FLOW CH ART PONV Routine Score ÞÞ Observations NO 1 or 2 YES 1. CYCLIZINE 25-50MG If given IV administer slowly over 3-5mins Review in 1 hr PONV Score 1 or 2 Routine Observations 1.1.1. Y 1.1. NO E S Contraindicated with patients with Parkinson s disease. PROCHLOPERAZINE BUCCAL 3 - 6mg 12 hourly prn Max. 12mg / 24 hours Review in 1 hour PONV Routine Score Observation 1.1.2. NO Consider regular Cyclizine and 1 or 2 PRN Prochloperazine · Consider referral to senior medical cover, anaesthetist or acute pain nurse · Reconsider causes ?abdominal obstruction · Ondansetron 4 - 8mg IV/Oral Version 1 Page 35 of 35 Review Date April 08

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