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Enhanced Recovery After Surgery

Enhanced Recovery Programmes

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Enhanced Recovery After Surgery

  1. 1. ENHANCED RECOVERY PROGRAMMES DR.MASUMAHAQUE SHARMIN MS RESIDENT- GENERALSURGERY SU - III
  2. 2. 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.
  3. 3. …but Evidence always trumps Dogma
  4. 4. Evolution of surgical principles brought about the concept of E R A S This concept was first described in 1990s by Henrik Kehlet, MD, PhD, Surgical Gastroenterologist.
  5. 5. What is ERAS and ERPs? ERAS stands for Enhanced Recovery After Surgery also Known as Fast Track Surgery ERAS consists of Enhanced Recovery Programs which is a multimodal perioperative care pathway that aims at reducing stress response to surgery and acceleration of recovery.
  6. 6. 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
  7. 7. Team Members for Successful ERP Nurses Dietitians Physiotherapists Occupational therapists Pain team Theatre staff Anesthetists Surgeons Hospital management Audit team
  8. 8. Pre-Admission Optimization Counseling Oral Supplements Pre-Operative Admission on the day of surgery Preoperative fasting and Carbohydrate Loading No Mechanical Bowel Preparation Prophylaxis: DVT, Antibiotic Perioperative opioid sparing analgesia Anesthesia Normothermia Mid Thoracic Epidural Analgesia Avoidance of fluid overload Surgical Approach: Laparoscopy/ Short Incision/ Transverse Incision Avoid Surgical Drains or Nasogastric tubes Post-Operative Hydration Active, Multimodal and preventive pain control Aggressive management of nausea and vomiting Early oral feeding and mobilization Nutritional support Remove urinary catheters and drains Discharge criteria ERP Components
  9. 9. 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
  10. 10. 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.
  11. 11. 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.”
  12. 12. ERP - Key Elements 4. Avoid pre anesthetic sedatives or anxiolytics if possible 5. 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.
  13. 13. ERP - Key Elements 6. 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
  14. 14. 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)
  15. 15. ERP - Key Elements 8. Individualized perioperative fluid administration: Avoid Na and Fluid overload Goal directed fluid therapy via Oesophageal Doppler(OD) monitoring Fluid overload is associated with delayed gut function and increased complication rates.
  16. 16. ERP - Key Elements 9. 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
  17. 17. ERP - Key Elements 10. 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.
  18. 18. ERP - Key Elements 12. 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.
  19. 19. ERP - Key Elements 13. 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
  20. 20. ERP - Key Elements 14. Early mobilization Bed 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.
  21. 21. ERP - Key Elements 15. Non-opiate Analgesics/NSAIDs Opiates are associated with decreased gut motility. Short term NSAIDs use can avoid Gastric irritation.
  22. 22. Day of Surgery
  23. 23. 1st POD TWOC- Trial Without Catheter NMBM- No Meal by Mouth
  24. 24. 2nd POD
  25. 25. 3rd POD
  26. 26. ERP – Discharge Criteria Patients 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.
  27. 27. 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

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