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Enhanced Recovery after Surgery its relevance - Evidence Based


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Enhanced recovery programs are evidence-based protocols designed to standardize medical care, improve outcomes, and lower health care costs. These protocols include evidence-based techniques to minimize surgical trauma and postoperative pain, reduce complications, improve outcomes, and decrease hospital length of stay, while expediting recovery following elective procedures.Protocols have been developed for colorectal surgery patients to reduce physiological stress and postoperative organ dysfunction through optimization of perioperative care and recovery

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Enhanced Recovery after Surgery its relevance - Evidence Based

  1. 1. Dr. Deep Goel, FACS (USA), FRCS (England) Director Department of Surgical Gastro-oncology, Bariatric & Minimal Access Surgery Centre for Digestive and Liver Disease BLK Super Specialty Hospital, New Delhi. ERAS Protocols and Its Relevance - Evidence Based
  2. 2. Disclosure • Consultant and mentor- J & J • Advisory consultant- Medtronics
  3. 3. Pub med Search • Key words – ERAS – Enhance recovery – Colon surgery – Newer guidelines – Colon cancer treatment – Laparoscopic colonic surgery
  4. 4. Pub Med Search + Guidelines + Recommendations • The European Society for Clinical Nutrition and Metabolism • The International Association for Surgical Metabolism and Nutrition 2012 • American Society for Colon and Rectal Surgery • World Journal of Surgery
  5. 5. N Engl J Med 270:825–827 Reduction of postoperative pain by encouragement and instruction of patients. a study of doctor-patient rapport. Egbert LD, Battit GE, Welch CE, Bartlett MK (1964) Surg Endosc 26(6):1730–1736 The effect of perioperative psychological intervention on fatigue after laparoscopic cholecystectomy: a randomized controlled trial. Kahokehr A, Broadbent E, Wheeler BR, Sammour T, Hill AG (2012) Br J Surg 86(7):869–874 Preoperative alcoholism and postoperative morbidity. Tonnesen H, Kehlet H (1999) Dis Colon Rectum 47(8):1397–1402 Physiologic effects of bowel preparation. Holte K, Nielsen KG, Madsen JL, Kehlet H (2004) BMC Surg 7:5 Preoperative mechanical preparation of the colon: the patient’s experience. Jung B, Lannerstad O, Pahlman L, Arodell M, Unosson M, Nilsson E (2007) Acta Anaesthesiol Scand 40(8 Pt 2):971–974 Fasting guidelines in different countries. Eriksson LI, Sandin R (1996) Anesth Analg 93(5):1344–1350 A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. Hausel J, Nygren J, Lagerkranser M, Hellstrom PM, Hammarqvist F, Almstrom C et al (2001) Dis Colon Rectum 53(10):1355–1360 How much do we need to worry about venous thromboembolism after hospital discharge? A study of colorectal surgery patients using the National Surgical Quality Improvement Program database. Fleming FJ, Kim MJ, Salloum RM, Young KC, Monson JR (2010) Cochrane Database Syst Rev 3:CD001484 Elastic compression stockings for prevention of deep vein thrombosis. Amaragiri SV, Lees TA (2003) J Am Coll Surg 213(5):596–603 603 e1 Perioperative pharmacologic prophylaxis for venous thromboembolism in colorectal surgery. Kwon S, Meissner M, Symons R, Steele S, Thirlby R, Billingham R et al (2011) Ann Surg 250(1):10–16 Timing of antimicrobial prophylaxis and the risk of surgical site infections: results from the trial to reduce antimicrobial prophylaxis errors. Steinberg JP, Braun BI, Hellinger WC, Kusek L, Bozikis MR, Bush AJ et al (2009) Arch Surg 142(7):657–661 Randomized, multicenter trial of antibiotic prophylaxis in elective colorectal surgery: single dose vs 3 doses of a second-generation cephalosporin without metronidazole and oral antibiotics. Fujita S, Saito N, Yamada T, Takii Y, Kondo K, Ohue M et al (2007) JAMA 290(18):2455–2463 Efficacy of postoperative epidural analgesia: a meta-analysis. Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr, Wu CL (2003) Cochrane Database Syst Rev 8(12):CD007705 Perioperative transversus abdominis plane (TAP) blocks for analgesia after abdominal surgery. Charlton S, Cyna AM, Middleton P, Griffiths JD (2010) Ann Surg 254(6):868–875 Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF et al (2011) Int J Colorectal Dis 26(4):423–429 The role of nasogastric tube in decompression after elective colon and rectum surgery: a meta-analysis. Rao W, Zhang X, Zhang J, Yan R, Hu Z, Wang Q (2011) N Engl J Med 334(19):1209–1215 Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. Kurz A et al (1996) JAMA 277(14):1127–1134 Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events.A randomized clinical trial. Frank SM et al (1997) Lancet 347(8997):289–292 Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Schmied H et al (1996) Br J Surg 94(4):421–426 Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Wong PF, et al (2007) Proc Nutr Soc 69(4):488–498 A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open Ann Surg 240(6):1074–1084 discussion 1084-5 Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta- analyses. Petrowsky H, Demartines N, Rousson V, Clavien PA (2004) Reg Anesth Pain Med 34(6):542–548 Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic epidural analgesia. Zaouter C, Kaneva P, Carli F (2009) Colorectal Dis 8(5):375–388 Systematic review on the short-term outcome of laparoscopic resection for colon and rectosigmoid cancer. Tjandra JJ et al(2006) Dis Colon Rectum 50(12):2149–2157 Use of chewing gum in reducing postoperative ileus after elective colorectal resection: a systematic review. Chan MK, Law WL (2007) Cochrane Database Syst Rev 1:CD004088 Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra- abdominal surgery. Werawatganon T, Charuluxanun S (2005) Colorectal Dis 12(2):119–124 The evolution of analgesia in an ‘accelerated’ recovery programme for resectional laparoscopic colorectal surgery with anastomosis. Zafar N, Davies R, Greenslade GL, Dixon AR (2010) Acta Anaesthesiol Scand 50(9):1152–1160 Patterns in current anaesthesiological peri-operative practice for colonic resections: a survey in five BMJ 323(7316):773–776 Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta- analysis of controlled trials. Lewis SJ, Egger M, Sylvester PA, Thomas S (2001) Br J Surg 94(5):555–561 Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery. Han-Geurts IJ, Hop WC, Kok NF, Lim A, Brouwer KJ, Jeekel J (2007) Ann Surg 255(6):1060–1068 A meta-analysis of the effect of combinations of immune modulating nutrients on outcome in patients undergoing major open gastrointestinal surgery. Marimuthu K, Varadhan KK, Ljungqvist O, Lobo DN (2012) N Engl J Med 345(19):1359–1367 Intensive insulin therapy in the critically ill patients. van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M et al (2001) Ann Surg 254(6):868–875 Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF et al (2011) Arch Surg 146(5):571–577 Adherence to the Enhanced Recovery After Surgery protocol and outcomes after colorectal cancer surgery. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J (2011) Clin Nutr 29(4):434–440 The Enhanced Recovery After Surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials.
  6. 6. What is ERAS • Stands for Enhanced Recovery after Surgery • The immediate challenge to improve the quality of surgical care by not discovering new knowledge but by integrating what we already know • Initiated by Professor Henrik Kehlete in 1990’s
  7. 7. Enhanced Recovery is …… • Evidence-based clinical pathways • Multidisciplinary in scope • Outcome driven • Better for patients • Better for healthcare organizations • “Complex” task to implement upto 20 elements
  8. 8. Recommendation's of ERAS Society Based on quality of evidence – High – Moderate – Low – Very low Recommendation's – Strong recommendation- Means panel is confident that desirable effects outweigh the undesirable effects – Weak recommendation’s-Panel is less confident that desirable effects outweigh undesirable effects.
  9. 9. Recommendations • Pre-operative • Intra operative • Post operative
  10. 10. – Diminishes fear and anxiety – Improve post-op recovery – Quicken hospital discharge – Improves wound healing and recovery after lap surgery Evidence Low Recommendation Strong Pre-admission information, education and counseling
  11. 11. Pre-operative Medical Optimization • It is necessary • Alcohol abuse – wound and cardio pulmonary complications • One month of abstinence improve results Evidence Low to High Recommendation Strong
  12. 12. Pre-op Bowel Preparation • Mechanical bowel preparation – Causes dehydration – Spillage of bowel contents – Prolonged ileus – Bowel preparation should be avoided Evidence High Recommendation Strong
  13. 13. Pre-op Fasting & Carbohydrate Treatment • Clear and high carb liquid should be allowed up to 2 hrs prior to surgery • Solid food up to 6 hrs prior to surgery Evidence Moderate Recommendation Strong
  14. 14. • Long acting sedative premedication should be avoided within 12 hrs of surgery because it affects immediate post-op recovery by impairing mobility and oral intake. • Short acting anesthetic drugs combined with regional anesthetic procedures like spinal anesthesia & field blocks should be encouraged. Evidence High Recommendation Strong Pre-anesthetic Medication
  15. 15. Prophylaxis against Thrombo-Embolism • The incidence of asymptomatic DVT in colorectal surgery is 30% and fatal pulmonary embolism in 1%. • All colorectal patients should receive mechanical thrombo prophylaxis to reduce DVT. • Use of LMWH reduces DVT and VTE. Evidence High Recommendation Strong
  16. 16. Antimicrobial Prophylaxis • IV antibiotics - 30-60 min before the incision • Repeat doses during prolonged procedures may be beneficial. Evidence High Recommendation Strong
  17. 17. Standard Anesthesia Protocol • Tri-modal approach – A regional anesthesia block used in addition to GA • Reduced post-op use of opiates • Rapid awakening from anesthesia • Early enteral intake and mobilization • Use of epidural analgesia is superior to opioids Evidence Low to High Recommendation Strong
  18. 18. Post-op Nausea and Vomiting (PONV) • Regional anesthesia technique like epidural TAP block has reduced the opiates use and thus PONV. • Use of NSAIDS as an alternative to opiate is well established Evidence Low Recommendation Strong
  19. 19. Laparoscopy and Modifications of Surgical Access • Laparoscopic surgery for colonic resection is recommended if expertise is available Evidence Low to High Recommendation Strong
  20. 20. Naso-gastric Intubation • Post operative NG should not be used routinely • NG tube should be removed before reversal of anesthesia. Evidence High Recommendation Strong
  21. 21. Preventing Intra-op Hypothermia • Hypothermia (<36 degree C) can cause cardiac events, bleeding and wound infection. • Normothermia to be maintained with warming device and warm IV fluid. Evidence High Recommendation Strong
  22. 22. Peri-operative Fluid Management • Fluid overload can cause bowel and lung edema. • Fluid shift should be minimized by – Avoid bowel preparation – Maintain hydration upto 2 hrs before surgery – Avoid blood loss Evidence High Recommendation Strong
  23. 23. Drainage of Peritoneal Cavity after Colonic Resection • Routine drainage is discouraged Evidence High Recommendation Strong
  24. 24. Urinary Drainage • Routine transurethral bladder drainage for 1-2 days is recommended. • Catheter should be removed early. Evidence Low Recommendation Strong
  25. 25. Post-operative Recommendation • Lap colonic resection leads faster return of bowel function. • Fluid overload to be avoided to prevent ileus • Peri-operative chewing gum reduces ileus. Evidence High Recommendation Strong
  26. 26. Post-operative Analgesia • Optimal analgesia should give - Good pain relief - Allow early mobilization - Early return of gut function and feeding Evidence High Recommendation Strong
  27. 27. Post-op Analgesia • Low dose epidural local anesthetic with short acting opiates gives good analgesia decreases risk of hypotension due to sympathetic block. Evidence High Recommendation Strong
  28. 28. Peri-operative Nutritional Care • Under ERAS protocol early enteral feeding – Reduce risk of infection – Reduce hospital stay – No anastomotic dehiscence Evidence High Recommendation Strong
  29. 29. Peri-operative Nutritional Care • Immuno-nutrition containing arginine, glutamine, Omega-3 fatty acids are used. Evidence Low Recommendation Weak
  30. 30. Post-operative Control of Glucose • Hyperglycemia is a risk factor for complication. Patients with higher pre-op HBA1C level has more complications. • Control of hyperglycemia showed improved results • ERAS protocol improves insulin action. Evidence Moderate Recommendation Strong
  31. 31. Early Mobilization • Reduce chest complication • Counteract insulin resistance • Improves muscle strength Evidence Low Recommendation Strong
  32. 32. Audit • Periodic auditing is a key element in ERAS programme and improves quality of healthcare. Evidence Moderate Recommendation Strong
  33. 33. Outcomes of ERAS • ERAS versus traditional peri-operative care – Early recovery & discharge from hospital – Morbidity – Re-admission – cost Evidence Low to High Recommendation Strong
  34. 34. GIS Team