A presentation by Olle Ljungqvist at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Russian Call Girls Lucknow ₹7.5k Pick Up & Drop With Cash Payment 8923113531 ...
The role of ERAS society
1. The role of
Olle Ljungqvist MD PhD
Professor Surgery
Örebro University Hospital & Karolinska
Institutet
Sweden
Improving Perioperative Care Worldwide
2. VERBAL DISCLOSURE
• Co-founder ERAS Society
• Founder, stock owner Encare AB
• Advisor Nutricia A/S The Netherlands
• Advise Abbot, USA & Merck, USA
• Speakers honoraria: Fresenius-Kabi, BBraun,
Nutricia, Nestle, Merck
6. 2010
0
5
10
15
20
25
Colectomy:Mean LOS by Provider Oct - Dec 2010
Provider Organisations
Meanlengthofstay(days)
Source: Hospital Episodes Statistics (Provisional)
Variations in a single country
Courtesy M Scott
13. Started in 2001
Collaboration
Grew over time
Several studies
Tromsö: A Revhaug
Stockholm: O Ljungqvist
Copenhagen: H Kehlet
Maastricht: M v Meyenfeldt, C deJong
Edinburgh: KFC Fearon
2010 ERAS Society
ERAS Study Group
14. Review of the literature
Compare with our own practice
ERAS Study Group
15. Review of the literature
Compare with our own practice
Not aligned – very different
Move all to ERAS care
Audit of the process
ERAS Study Group
16. Review of the literature
Compare with our own practice
Not aligned – very different
Move all to ERAS care
Audit of the process
The next surprise
Not what we believed
ERAS Study Group
17. Review of the literature
Compare with our own practice
Not aligned – very different
Move all to ERAS care
Audit of the process
The next surprise
Not what we believed
Audit to get control
ERAS Study Group
18. ERAS
Epidural
Anaesthesia
Prevention
of ileus/
prokinetics
CHO - loading/
no fasting
Early
mobilisation
Peri-op fluid
management
DVT
prophylaxis
Pre-op
councelling
Short acting
anestetics
No - premed
No bowel prep
Perioperative
Nutrition
Body heating
devises
Oral analgesics/
NSAID’s
Incisions
No NG tubes
Early removal
of catheters/drains
Fearon et al, Clin Nutr 2005
20. Why ERAS Society?
We had a better care plan
We could teach others
Interest was growing
Networking society
21. A Non profit Multi-professional Multi-disciplinary
Medical Society
Founded in 2010
Mission statement: Enhancing Recovery After Surgery
The mission of the Society is to develop perioperative care
and to improve recovery through
• Research,
• Education,
• Implementation of evidence based practice.
• Audit
Improving Perioperative Care Worldwide
23. ERAS® compliance:
Length of stay & Readmissions
Gustafsson et al, Arch Surg 2011
n = 953
p < 0.05
Compliance with ERAS protocol elements
Colorectal cancer
24. ERAS® compliance:
Complications
Gustafsson et al, Arch Surg, 2011
n = 953
p < 0.05
0
5
10
15
20
25
30
35
40
45
50
<50% >70% >80% >90%
Complica ons
Compliance with ERAS protocol elements
Percentpatientsaffected
Colorectal cancer
25. ERAS® compliance:
Complications 13 hospitals 7 countries
ERAS Compliance group Ann Surg, 2015
n = 2352
Compliance with ERAS protocol elements
Multi center study, consecutive patients
Percentpatientsaffected
Colorectal cancer
0
10
20
30
40
50
<50% 75-90% >90%
Major complication
Any complication
26. ERAS® compliance:
5 year mortality
Gustafsson et al, WJS 2017
Compliance with ERAS protocol elements
5yearoverallmortality
<70% >70%
Postop days
42% risk reduction, p<0.001
30. ERAS 2005
Securing modern care: colon resection
Surgeon:
No bowel prep
Food after surgery
No drains
Early removal u-
catheter
No iv fluids, no lines
Early discharge
All evidence based!
Anesthetist:
Carbohydrates no fasting
No premedication
Thoracic Epidural
Anesthesia
(open)
Balanced fluids
Vasopressors
No or short acting
opioids
Nursing:
Structured preoperative
information
Preop CHO
Remove Iv lines and
drains
Support mobilisation
Serve normal food
Follow up
Fearon et al, Clin Nutr 2005
31. ERAS flow chart
Pre admission
nutritional support
Cessation of smoking
Control alcohol intake
Medical optimization
Preoperative
information
Selective
Bowel
preparation
Preoperative
carbohydrates
No NPO
PONV
prophylaxis
Minimal invasive surgery
Minimize drains and
tubes
Regional analgesia
Opioid sparing anesthesia
Balanced fluids
Temperature control
Early removal of
drains and tubes
Stop iv fluids
Multimodal opioid
sparing pain control
Early mobilization
Early oral intake of
fluids and solids
Post discharge follow
up
Pre admission Preoperative Intraoperative Postoperative
Surgery
Anesthesia
Nursing
Ljungqvist, Scott, Fearon, JAMA Surgery, 2017 152(3):292-298
32. Seefeld 2013: ≈ 100 colorectal specialists & SAGES USA 2014 ≈ 250 surgeons
Hong Kong 2016: 1500 anesthesiologists
Who is aware of ERAS?
Martin Hübner 2013, O Ljungqvist/ L Feldman 2014, Ljungqvist 2016
ERAS obstacle – wish vs. reality
33. ERAS obstacle – wish vs. reality
Who has an ERAS protocol?
Seefeld 2013: ≈ 100 colorectal specialists & SAGES USA 2014 ≈ 250 surgeons
Hong Kong 2016: 1500 anesthesiologists
Martin Hübner 2013, O Ljungqvist/ L Feldman 2014, Ljungqvist 2016
34. ERAS obstacle – wish vs. reality
Who could provide data on compliance?
Seefeld 2013: ≈ 100 colorectal specialists & SAGES USA 2014 ≈ 250 surgeons
Hong Kong 2016: 1500 anesthesiologists
Martin Hübner 2013, O Ljungqvist/ L Feldman 2014, Ljungqvist 2016
36. ERAS
Epidural
Anaesthesia
Prevention
of ileus/
prokinetics
CHO - loading/
no fasting
Early
mobilisation
Peri-op fluid
management
DVT
prophylaxis
Pre-op
councelling
Short acting
anestetics
No - premed
No bowel prep
Perioperative
Nutrition
Body heating
devises
Oral analgesics/
NSAID’s
Incisions
No NG tubes
Early removal
of catheters/drains
Fearon et al, Clin Nutr 2005
37. ERAS
Epidural
Anaesthesia
Prevention
of ileus/
prokinetics
CHO - loading/
no fasting
Early
mobilisation
Peri-op fluid
management
DVT
prophylaxis
Pre-op
councelling
Short acting
anestetics
No - premed
No bowel prep
Perioperative
Nutrition
Body heating
devises
Oral analgesics/
NSAID’s
Incisions
No NG tubes
Early removal
of catheters/drains
Fearon et al, Clin Nutr 2005
Anaesthesia
38. ERAS
Epidural
Anaesthesia
Prevention
of ileus/
prokinetics
CHO - loading/
no fasting
Early
mobilisation
Peri-op fluid
management
DVT
prophylaxis
Pre-op
councelling
Short acting
anestetics
No - premed
No bowel prep
Perioperative
Nutrition
Body heating
devises
Oral analgesics/
NSAID’s
Incisions
No NG tubes
Early removal
of catheters/drains
Fearon et al, Clin Nutr 2005
Anaesthesia
Surgery
39. ERAS
Epidural
Anaesthesia
Prevention
of ileus/
prokinetics
CHO - loading/
no fasting
Early
mobilisation
Peri-op fluid
management
DVT
prophylaxis
Pre-op
councelling
Short acting
anestetics
No - premed
No bowel prep
Perioperative
Nutrition
Body heating
devises
Oral analgesics/
NSAID’s
Incisions
No NG tubes
Early removal
of catheters/drains
Fearon et al, Clin Nutr 2005
Anaesthesia
Surgery
ORPreop
PACU/ward
40. ERAS
Epidural
Anaesthesia
Prevention
of ileus/
prokinetics
CHO - loading/
no fasting
Early
mobilisation
Peri-op fluid
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
Fearon et a al 2005, Lassen et al Arch Surg 2009
45. ERAS Implementation plan
S 1
26-27 sept 2011
Introduction to
ERAS
Present status
Start data entry
Strategies for
implementation
Active work periods
S 2
28-29 nov 2011
Report of
Results (pre ERAS)
Goals, measures &
Outcomes
Planning for local
ERAS implementation
S 3
2 feb 2012
Video follow-up
Reporting results
S 3
7maj 2012
New situation
Reporting results
Summary of what has
Been learned
Planning for
the future
Successively start
using ERAS in patients
Work group meetings,
develop a new way of
auditing
Support by the Coach
Preparations Follow-
up
Alumni
Develop methods to
enter data into EIAS
Work group meetings
Support by the Coach
Dec 2011j-
Jan 2012
Half day
visit by
EIP-coach
Routine use of ERAS
for all patients
Work group meetings
for regular interactive
audit
Support by the Coach
4 Interactive work shops over 8 – 10 months
3 active working periods at home
46. ERAS Implementation
ERAS Center of Excellence (KOL)
ERAS Symposia & other local events
ERAS Implementation Program
New surgical disciplines; Colorectal,
Orhopedics, Gynecology, Urology etc.
47. ERAS in the world today
Castiglione, S.A. & Ritchie, J.A. (2011). Moving into action: We know what we want to change, now what?
An implementation guide for health care practitioners. Canadian Institutes of Health Research.
Courtesy F Carli
My view
49. 49
ERAS®Society 2010
A few leading academic centers forms the Society
More than one Implementation program
ERAS Center in place
ERAS center discussions
Implementation program running/announced
ERAS center in training
50. 50
ERAS®Society 2012 Cannes
a few ERAS centers, implementation just starting
More than one Implementation program
ERAS Center in place
ERAS center discussions
Implementation program running/announced
ERAS center established in 2012
51. 51
ERAS®Society May 2014
Growing…
More than one Implementation program
Implementation program running/announced
ERAS Center in place
ERAS center established
ERAS center discussions
52. 52
ERAS®Society growth in 2016/2017
100+ units in 20+ countries
More than one Implementation program
Implementation program running/announced
ERAS Center in place
ERAS center in training
ERAS center discussions
Manilla
Singapore
Guadalajara
Bogota
Lisbon
Tokyo
Nanjing, Bejing
Krakau
Cape town
Buenos Aires
Auckland
Mayo Clinic
Alberta HS
Hamburg
CT, Charlotte
Soeul
Sao Paolo
Porto Allegro
Ankara
Groningen
Tel Aviv
Teheran
Santiago
Montevideo
RomeERAS USA
Melbourne
64. ERAS & Cost savings single units
• New Zealand – $4,500
– 4,000€ / patient in the first 50 patients. Study
visits & full time included
• Switzerland - $1,650
– 1,500€ / patient per first 50 patients. Training &
full time nurse included
• Canada - $2,985
– 2985 $/ patient (colorectal surgery)
– 2,200 €/ patient (esophageal surgery).
Roulin et al, BJS 2013, Sammour NZJS 2010, Lee BJS 2013, Lee Ann Surg 2014
S Africa: ≈20% uncomplicated
≈24% complication
R Oodit, personal communication
65. 2.4 – 5.1 Return on Investment
Thanh et al, Can J Surg 2016
66. Research developments
• Already more than 25 studies published on
the systems (15 in the last year)
• Research Support Unit – Audit System data
• Audit studies – 40,000 patients
• Prospective studies
• Örebor University & Industries
67. ERAS® Experiences
• Issues are similar everywhere
• Variation in delivery
• Variation in outcomes
• Poor control of the entire process
• Pressure for better results at lower cost
• Very similar model works everywhere
• ERAS team work
• Audit
• Continuous improvement work
• Cost saving
68. ERAS® Society role
• Gather expertize and develop guidelines
• Multi professional – multi disciplinary
• Guidelines
• Platforms for
• Education
• Meeting places – congress – regional - national
• Implementation – via Centers of Excellence
• Research – ERAS Audit database