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ERAS Protocol
- 1. Enhanced Recovery AfterSurgery The ERAS protocol Ankit Raj Postgradutate Student(2nd Year) Unit-III Dept. of General Surgery LHMC & associated Dr RML Hospital New Delhi-110001
- 2. THE DOGMA What Isa Dogma? /ˈdɒɡmə/ noun ‘a principle or set of principles laid down by an authority as incontrovertibly true’;applies to some strong belief whose adherents are not willing to rationally discuss it Dogmas in General Surgery- • Preoperative prolonged fasting • MBP • NGT’s • Drains • Prolonged bed rest
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- 5. What is ERAS? •Proposed by Dr. Henrik Kehlet, a Danish Surgical Gastroenterologist in 1990’s “Why is the patient in hospital today?” • “Patient-centered,evidence based,outcome driven,multidisciplinary team developed pathways for a surgical specialty and facility culture to maintain pre-operative organ function and reduce the profound stress response following surgery,optimize their physiologic function,and facilitate recovery” • Fast Track Surgery • These form an integrated continuum, as the patient moves from home through the pre-hospital / preadmission, preoperative, intraoperative, and postoperative phases of surgery and home again
- 6. Objectives of ERAS •Reducing complications and LOS • Reducing variability • Reducing cost • Improving quality of care • Increasing value = quality/cost
- 7. Traditional Care VS •Provider focused • High variability • Physician driven ERAS® Care • Patient focused • Outcome ddriven • Standardised • Evidence based • Interdisciplinary
- 8. Recommendations of ERAS®Society • Based on quality of evidence – High – Moderate – Low – Very low 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. Enhanced Recovery inPractice Referral from Primary Care Pre- Operative Admission Operative Post- Operative Follow-up • Fluid management • Postoperativ glycaemic control • Postoperative nutrition • Early mobilisation • Rapid hydration / nourishment • Appropriate iv therapy • Catheters removed early • Regular oral analgesia • Avoid opiates • Antimicrobial prophylaxis • Multimodal analgesia • PONV • Optimal fluid therapy • Hypotermia prophylaxis • Optimised medical conditions • Nutrition • Fasting time • Carbohidrate drinking • Pre-anesthestic medication • Anti-thrombotic prophylaxis
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- 11. Preoperative ERAS Components •Patient information • Health/medical optimisation • Nutrition • Fasting time • Carbohydrate drinking • Pre-anesthestic medication • Anti-thrombotic prophylaxis
- 12. Intraoperative ERAS Components •Antimicrobial prophylaxis • Anesthesia protocol • PONV • Fluid management • Hypotermia prophylaxis
- 13. Postoperative ERAS Components •Postoperative analgesia • Fluid management • Postoperative glycaemic control • Postoperative nutrition • Early mobilisation
- 15. ERAS Epidural Anaesthesia Prevention of ileus/ prokinetics CHO-loading/ no fasting Early mobilisation Peri-opfluid management DVT prophylaxis Pre-op councelling Remifentanyl No premed No bowel prep Perioperative nutrition Bairhugger Oral analgesics/ NSAID’s Incisions No NG tubes Early removal of catheters/drains
- 16. Preoperative ERAS components •Patient information • Health/medical optimisation • Nutrition • Fasting time • Carbohidrate drinking • Pre-anesthestic medication • Anti-thrombotic prophylaxis
- 17. Patient information Preadmission educationand counselling • Decrease fear and anxiety • Improve wound healing perioperative feeding postoperative mobilisation pain control • Reduce the prevalence of complications Enhance Postoperative Recovery and Discharge Evidence Low Recommendation High
- 18. Preoperative ERAS components •Patient information • Health/medical optimisation • Nutrition • Fasting time • Carbohidrate drinking • Pre-anesthestic medication • Anti-thrombotic prophylaxis
- 19. Preoperative Alcohol Consumption? PreoperativeSmoking Cessation? • Does it make any difference? • If yes for how long? Alcohol consumption should be stopped 4 weeks before surgery Smoking should be stopped 4 weeks Before surgery Smoking should be stopped 4 weeks before surgery Smoking should be stopped 4 weeks before surgery
- 20. Preoperative ERAS components •Patient information • Health/medical optimisation • Nutrition • Fasting time • Carbohidrate drinking • Pre-anesthestic medication • Anti-thrombotic prophylaxis
- 23. Questions regarding perioperative nutrition •TNP vs EN ? • Pre vs post-operative ? • Standard vs immunonutrition ?
- 24. Who should receivepreoperative nutrition support? • moderately/severely malnutrished • nutrition support has been shown to improve outcome – thoraco-abdominal surgery • elective surgery and safe to delay for 7-10 days • enteral route is always prefered (when possible) • combination with postoperative nutrition • immune-enhancing formulas
- 25. Preoperative ERAS components •Patient information • Health/medical optimisation • Nutrition • Fasting time • Carbohidrate drinking • Pre-anesthestic medication • Anti-thrombotic prophylaxis
- 26. Preoperative fasting • Standardpractice – fasting from midnight reduce the volume and acidity of stomach contents decrease the risk of pulmonary aspiration But … • Cochrane review of 22 RCTs-fasting from midnight no reduction in gastric content no rise in pH of gastric fluid Clear fluids until 2h before anesthesia Thirst, headaches, hunger
- 27. Why challange fasting bymidnight? • Normal physiology • Is no guarantee of an empty stomach • The same gastric volume with/without clear fluids • Improved well being
- 28. Preop Fasting andPeriop Fluids • If fasted – risk of dehydration • Dehydration and anesthesia --> hypotension • Hypotension --> more fluids infused • Overload of fluids • Preop clear fluids --> less iv fluids --> improved outcomes Gustafsson et al Arch Surg, 2011
- 29. Metabolic effects ofovernight fasting Day Night Hormones Insulin + Insulin – Glucagon Cortizol Substrates Storage Breakdown Utilization CHO > Fat Fat > CHO
- 30.
- 31. Insulin resistance causecomplications Complications increase with insulin resistance: 50% reduction in insulin sensitivity: • 5-6 fold increase risk of complications • 10 fold risk for infections Sato et al, JCEM 2010, 95; 4338-44
- 32. Preoperative ERAS components •Patient information • Health/medical optimisation • Nutrition • Fasting time • Carbohydrate drinking • Pre-anesthestic medication • Anti-thrombotic prophylaxis
- 33. Carbohydrate treatment • 20%glucose iv • 12.5% carbohydrate drink – 400 ml 2h before anesthesia + 800 ml evening before • Induce insulin release
- 34. Effects of PreoperativeCarbohydrates • Reduces the metabolic stress of surgery • Effectively reduces insulin resistance • Improves pre/postoperative well being • Improves postoperative muscle function • Reduce lean body mass losses • May result in faster recovery
- 35. Preoperative ERAS components •Patient information • Health/medical optimisation • Nutrition • Fasting time • Carbohidrate drinking • Pre-anesthestic medication • Anti-thrombotic prophylaxis
- 36. Pre-anesthetic medication Education Short-acting ivdrugs Prior epidural/spinal analgesia No sedative medication before surgery Avoid starvation CHO loading U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
- 37. Preoperative ERAS components •Patient information • Health/medical optimisation • Nutrition • Fasting time • Carbohidrate drinking • Pre-anesthestic medication • Anti-thrombotic prophylaxis
- 38. Anti–thrombotic prophylaxis Mechanical Pharmacological Compression stockingsin all patients Intermitent pneumatic compression LMWH 2hr before Surgery Risk in major surgery patients DVT – 30% PE – 1% U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
- 39. Intraoperative ERAS components •Antimicrobial prophylaxis • Anesthesia protocol • Multimodal analgesia • PONV • Fluid management • Hypotermia prophylaxis
- 40. Antimicrobial prophylaxis • Imperativeto reduce the risk of surgical infections • Time • 30-60 min before the incision • repeated doses during prolonged procedure (≥3h)/Massive blood loss/fluid loading • Route intravenous • Spectrum Suspected germs (aerobic ± anaerobic bacteria)
- 41. Intraoperative ERAS components •Antimicrobial prophylaxis • Anesthesia protocol • PONV • Fluid management • Hypotermia prophylaxis
- 42. Anesthesia Protocol • Tri-modalapproach -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
- 43.
- 44. Intraoperative ERAS components •Antimicrobial prophylaxis • Anesthesia protocol • Multimodal analgesia • PONV • Fluid management • Hypotermia prophylaxis
- 45. Multimodal analgesia Epiduralanalgesia i/v analgesia Wound catheters/infiltration Peripheral blocks
- 46. Benefits of EpiduralAnalgesia • Dynamic pain control • Obtunds stress response • Reduction of ileus • Reduced post-operative pulmonary complications • Reduced myocardial ischaemia • Reduced incidence of DVT/PE
- 47. Causes of Ileus •Degree of surgical manipulation • Magnitude of inflammatory and stress response • Sympathetic reflexes • Opioids • Fluid overload/ bowel oedema
- 48. Intraoperative ERAS components •Antimicrobial prophylaxis • Anesthesia protocol • Multimodal analgesia • PONV • Fluid management • Hypotermia prophylaxis
- 49. PONV • Risk factors Patient:female, non smokers, motion sickness Anestetic: volatile agents, iv opioids, nitrous oxide Surgical: major abdominal surgery • PONV scoring systems • Multimodal approach Pharmachological Non-pharmachological techniques: TIVA, minimal fasting, CHO loading, adequate hydration, epidural, NSAIDS
- 50. Intraoperative ERAS components •Antimicrobial prophylaxis • Anesthesia protocol • Multimodal analgesia • PONV • Fluid management • Hypotermia prophylaxis
- 51. Perioperative fluid management What type of fluid ? Is there an indication for vasopressors ? When iv fluids should be discontinued ? Apparently, fluid management is an art of medicine and based on personal judgments. Is fluid therapy vital for outcome ? Are the fluid requirements the same ? What about fluid shifts ? What amount ?
- 52. Perioperative fluid management •Type of fluid • Vasopressors are indicated in hypotensive normovolemic patients • Iv fluids should be discontinued as soon as practicable Goal directed Therapy • Fluid therapy is vital for outcome • Fluid requirements are different • Fluid shifts should be minimised • Fluid administration must be goal directed
- 53. Intraoperative ERAS components •Antimicrobial prophylaxis • Anesthesia protocol • Multimodal analgesia • PONV • Fluid management • Hypotermia prophylaxis
- 54. • Hypothermia –central temperature < 36 C • Risk factor for wound infections, prolonged cicatrisation cardiac events shivering – increase O2 consumption bleeding coagulation disorders trombocites dysfunction postoperative ileus increase pain prolonge emergence time • Methods - warming devices (forced air warming blankets) warmed iv fluids warm gases in laparoscopic surgery Hypothermia Prophylaxis
- 55. Postoperative ERAS components •Postoperative analgesia • Fluid management • Postoperative glycaemic control • Postoperative nutrition • Early mobilisation
- 56. Postoperative analgesia • Optimaleanalgesic regimen – Good pain relief – Reduction of cardiovascular, cognitive, endocrino – metabolic complications in at risk patients – Decrease the risk of chronic pain – Allow early mobilisation – Allow early return of gut function and feeding
- 57. Postoperative analgesia • Principlesof Multimodal Analgesia – Avoidance of iv opioids – Regional anesthesia techniques • Thoracic epidural analgesia (TEA) • Spinal analgesia – Local anesthetic techniques • Transversus abdominis plane (TAP) block • The analgesic regimen is specific to the type of surgery/incision
- 58. Postoperative ERAS components •Postoperative analgesia • Fluid management • Postoperative glycaemic control • Postoperative nutrition • Early mobilisation
- 59. Postoperative ERAS components •Postoperative analgesia • Fluid management • Postoperative glycaemic control • Postoperative nutrition • Early mobilisation
- 60. Hyperglycemia in SurgicalStress • Insulin resistance is the key • Traditional belief Hyperglycemia in the acutely stressed patient is ”not dangerous” Glucose levels treated > 200 mg/dl
- 61. • Elective majorsurgery-opportunity to prevent /attenuate metabolic responses to surgeryrather than having to treat them with insulin. • Several stress-reducing interventions in ERAS attenuate insulin resistance as single interventions: •preoperative oral carbohydrate treatment •epidural blockade •minimally invasive surgery • If interventions are combined in ERAS protocol, hyperglycaemia can be avoided even during full enteral feeding starting immediately after major colorectal surgery.
- 62. Postoperative ERAS components •Postoperative analgesia • Fluid management • Postoperative glycaemic control • Postoperative nutrition • Early mobilisation
- 63. Postoperative early enteralnutrition Lewis et al BMJ 2001;323(7316):773-6
- 64. Postoperative ERAS components •Postoperative analgesia • Fluid management • Postoperative glycaemic control • Postoperative nutrition • Early mobilisation
- 65.
- 66. Surgeon No bowel prep Foodafter surgery No drains or KAD No iv fluids, no lines Early discharge All evidence based! Anesthetist Carbohydrates No fasting No premedication Epidural Anesthesia Balanced fluids Vasopressors No or short acting opioids
- 67. BOWEL PREPARATION • PRO –Avoids massive contamination !?! – Minor inconvenience to the patient !?! – Looks better inside !?! • CON – Preoperative dehydration !!! – Modification of enteral flora !!! – Delayed gut motility !!!
- 68. Rectal cancer –TME (total mesorectum excision) • Standardised Enhanced Recovery Programme for the EnROL Trial Day before surgery avoidance of oral bowel preparation except in patients undergoing total mesorectal excision (TME) and reconstruction. Kennedy et al. BMC Cancer 2012, 12:181
- 69. Reduce surgical injury Minimallyinvasive surgery • FAST TRACK Surgery • Early postoperative recovery – Decreased stress response – Decreased inflammatory response – Decreased pain – Early bowel movement
- 70. NO routine NGT •28 multicenter trials >4000 pts – Decreased duration of postoperative ileus – Decreased risk of postoperative pulmonary complications – Increased patient QOL – No increase in anastomotic leak Nelson, R. at all Systematic review of prophylactic nasogastric decompression after abdominal operations. Br. J. Surg., 2005, 92, 673–680.
- 71. No drains • Rationaleof drains: • A surgical tradition • Difficult to be abandoned • For how long? 24h / 48h / 7days ??? • In majority of cases – serous drained fluid (physiological reabsorption) “When in doubt, drain” Lawson Tait, english surgeon “The drain= the surgeon eye in the patients abdomen”
- 72. No drains • RCTs: –Unreliable indication of anastomotic leak – Underestimates the significance of anastomotic leak – Underestimates the postoperative bleeding – Does not influence the rate of anastomotic leak – Increases the contamination risk – Prolongs the duration of postoperative ileus – Prolongs the hospital lenght of stay Petrowsky, H. at all: Evidence-based value of prophylactic drainage in gastrointestinal surgery: A systematic review and meta-analyses. Ann. Surg., 2004, 240, 1074–1085.
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- 75. Examples • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC32 02008/table/t1-cuaj-5-342/?report=objectonly • https://www.clinicalnutritionjournal.com/article/S0 261-5614(12)00178-1/fulltext#sec3.25 •https://link.springer.com/article/10.1007/s00268- 016-3492-3