ENHANCED

RECOVERY

DFOB

A Standard of care….

RECOVERY

One of the first comprehensive reviews

2005

Definition

Components

My experience

Review of the literature

ExamplesExamples

ERAS groupERAS group

Consensus on the ‘elements’

Summary of core protocol elements

Beginnings of ‘Translational Research

Definition

Enhanced recovery

‘Enhanced Recovery After Surgery

(ERAS) pathways areFrom expertise silos to patient-

centric outcomes(ERAS) pathways are

multidisciplinary, coordinated,

standardized care plans that

integrate evidence-based

interventions addressing multiple

aspects and phases of the patient’s

perioperative trajectory.’

centric outcomes

Functional recovery both physical

and psychological versus clinical

outcomes

Adherence to pathways and

compliance

Definition

IHI

Care bundle is

‘a small set of interventions, when ‘a small set of interventions, when

implemented together for a defined

care setting, result in better

outcomes than when implemented

individually’

Resar 2012

Elements

Defined population

Customization

Multidisciplinary

Compliance

Definition

Expanded ( Feldman

2015)Based on specifics and outcomes

AVLOS

GI function

Pain and MobilizationBased on specifics and outcomes

‘Postoperative recovery is defined as a multidimensional

construct that follows a particular trajectory.’

Physical

Physiological

Psychological

Social

Economical

Pain and Mobilization

Less than half post discharge functional

measures

¼ measures of HRQOL

Preoperative assessment

Risk factor identification,

modulation ,

(both long and short term)

Fasting

Fluids

Food

Information ( Patient , Peri-

operative team )

Anaesthesia

Pain

PONV

Intra-operative management

Communal attention to a common goal

Post-operative Management

Pharmacology

• Opiates

• PONVPONV

• Thrombophylaxis ( HATS )

• Anti-microbial Prophylaxis

( +/-)

Regional Anaesthesia

• Stress response

• Functional recovery

Physiologic/Psychological

Stress response

•NeuroendocrinePhysiologic/Psychological

• Mobilisation

• Respiratory Function

•Neuroendocrine

•Catabolic phase

•Sepsis

•GI funciton

Anaesthesia

Pain

PONV

Intra-operative management

Post-operative Management

Fluid management

• Goal Directed fluid Therapy (Like the porridge) , just right

• Too much is bad• Too much is bad

• Hypotension and low UOP common but may not predict outcome

• Consider surgery and patient as combined risk

• Vasopressors ?

Fluid management

Outcome measurement

AVLOS

Functional recovery

Intra-operative Surgical factors

Minimally invasive*******

Incisions

Avoid hypothermia

Postoperative NG tubes and catheters

Mobilisation

Discharge planning

Contact informaiton

Preoperative counsellingPreoperative counselling

Consensus 5 P’s

•Primary care ‘fitness for referral’ for

common conditions e.g. anaemia –

managing the risk

• Patient involvement: shared decision • Patient involvement: shared decision making , information

• Pre-habilitation, assessment and care , planning

• Pain relief, fluid management,

Anaesthetics

• Preparation for and effective discharge.

AVLOS

Patient Experience

Whistlestop

Elements

Defined population

CustomizationCustomization

Multidisciplinary

Compliance

Literature

Evidence assessmentEvidence assessment

Hypothermia

TEDS

Pneumatic compression

LiteratureBased upon the unit’s own experience

Components collated from other disciplines

Time to develop the programme

Programme development3 years

Whistlestop

DFOB

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