Lecture notes for medical students

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2. Enhanced Recovery After
Surgery (ERAS®)

3. Enhanced Recovery After
Surgery (ERAS®)
• Guidelines for Perioperative Care in
Elective Colonic Surgery: Enhanced
Recovery After Surgery (ERAS®) Society
Recommendations

4. Aims and Objects

5. Aims and Objects
• This review aims to present a consensus for
optimal perioperative care in colonic
surgery and to provide graded
recommendations for items for an
evidenced-based enhanced perioperative
protocol.

6. Method

7. Method
• Studies were selected with particular
attention paid to meta-analyses, randomised
controlled trials and large prospective
cohorts. For each item of the perioperative
treatment pathway, available English-
language literature was examined, reviewed
and graded. A consensus recommendation
was reached after critical appraisal of the
literature by the group.

8. • The delay until full recovery after major
abdominal surgery has been greatly
improved by the introduction of a series of
evidence-based treatments covering the
entire perioperative period and formulated
into a standardised protocol.

9. counseling

10. counseling
• Patients should routinely receive dedicated
preoperative counseling

11. • Increasing exercise preoperatively may be
of benefit.
• Smoking should be stopped 4 weeks before
surgery and
• Alcohol abusers should stop all alcohol
consumption 4 weeks before surgery

12. Mechanical Bowel Preparation

13. Mechanical Bowel Preparation
– should not be used routinely in colonic surgery.
• Evidence level:
– High
• Recommendation grade:
• Strong

14. • Clear fluids should be allowed up to 2 h and solids
up to 6 hrs prior to induction of anaesthesia. In
those patients were gastric emptying may be
delayed (duodenal obstruction etc.) specific safety
measures should at the induction of anaesthesia.
Preoperative oral carbohydrate treatment should
be used routinely. In diabetic patients
carbohydrate treatment can be given along with
the diabetic medication.

15. – Patients should wear well-fitting compression
stockings, have intermittent pneumatic
compression, and receive pharmacological
prophylaxis with LMWH. Extended
prophylaxis for 28 days should be given to
patients with colorectal cancer.

16. Antibiotics

17. Antibiotics
• Routine prophylaxis with intravenous antibiotics
should be given 30–60 min before initiating
colorectal surgery. Additional doses should be
given during prolonged procedures according to
the half-life of the drug used.
• Post op antibiotics - NO

18. Laparoscopy

19. Laparoscopy
• Laparoscopic surgery for colonic resections is
recommended if the expertise is available.

20. Ryle’s tube

21. Ryle’s tube
– Postoperative nasogastric tubes should not be
used routinely. Nasogastric tubes inserted
during surgery should be removed before
reversal of anaesthesia.

22. Temperature

23. Temperature
• Intraoperative maintenance of
normothermia with a suitable warming
device (such as forced-air heating blankets,
a warming mattress or circulating-water
garment systems) and warmed intravenous
fluids should be used

24. • Balanced crystalloids should be preferred to 0.9 %
saline. In open surgery, patients should receive
intraoperative fluids (colloids and crystalloids)
guided by flow measurements to optimise cardiac
output.
• The enteral route for fluid postoperatively should
be used as early as possible, and intravenous fluids
should be discontinued as soon as is practicable.

25. Drainage

26. Drainage
– Routine drainage is discouraged because it is an
unsupported intervention that probably impairs
mobilisation.
• Evidence level:
– High
• Recommendation grade:
– Strong

27. • Routine transurethral bladder drainage for
1–2 days is recommended

28. SPC

29. SPC
• A meta-analysis has shown that suprapubic
bladder catheterisation in abdominal
surgery is associated with lower rates of
bacteriuria and lower patient discomfort
than transurethral drainage

30. Postoperative analgesia in open
surgery

31. Nutrition

32. Nutrition
• In enhanced-recovery programmes, oral
nutritional supplements (ONS) have been
used on the day before surgery and for at
least the first 4 postoperative days to
achieve target intakes of energy and protein
during the very early postoperative phase

33. Nutrition
• In the postoperative phase, patients
undergoing ERAS can drink immediately
after recovery from anaesthesia and then eat
normal hospital food and, in doing so,
spontaneously consume ≈1,200–
1,500 kcal/day .
• This is safe. RCTs of early enteral or oral
feeding versus ‘nil by mouth’ show that
early feeding reduces the risk of infection
and LOSH, and is not associated with an
increased risk of anastomotic dehiscence

34. Take Home Message
1. Preop counseling, exercise, smoking,
alcohol.
2. Mechanical Bowel Preparation –NO
3. Preop antibiotic –Yes
4. Post op antibiotics –NO
5. Intraabdomina drainage –NO
6. SPC in place of urethral catheter
7. NG tube – NO
8. Post of NPO for 4 hours only.

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