ENHANCED RECOVERY PROGRAMMES

DR. MASUMA HAQUE SHARMINMS RESIDENT - GENERAL SURGERY

SU - III

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.

…but Evidence always trumps Dogma

DOG

M

A

EVIDENCE

Evolution of surgical principles brought about the

concept of

E R A SThis concept was first described in 1990s by Henrik Kehlet, MD, PhD, Surgical Gastroenterologist.

What is ERAS and ERPs?

ERAS stands for Enhanced Recovery After Surgery

also Known as

Fast Track SurgeryERAS consists of Enhanced Recovery Programs which is a multimodal perioperative care pathway that aims at reducing stress response to surgery and acceleration of recovery.

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

Team Members for Successful ERPNurses

DietitiansPhysiotherapists

Occupational therapistsPain team

Theatre staffAnesthetists

SurgeonsHospital management

Audit team

Pre-AdmissionOptimizationCounseling

Oral Supplements

Pre-OperativeAdmission on the day of surgery

Preoperative fasting and Carbohydrate LoadingNo Mechanical Bowel Preparation

Prophylaxis: DVT, AntibioticPerioperative opioid sparing analgesiaAnesthesia

NormothermiaMid Thoracic Epidural Analgesia

Avoidance of fluid overload 

SurgicalApproach: Laparoscopy/ Short Incision/ Transverse Incision

Avoid Surgical Drains or Nasogastric tubes

Post-OperativeHydration

Active, Multimodal and preventive pain controlAggressive management of nausea and vomiting

Early oral feeding and mobilizationNutritional support

Remove urinary catheters and drainsDischarge criteria

ERP Components

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

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.

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.”

ERP - Key Elements4. Avoid pre anesthetic sedatives or anxiolytics if possible5. 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.

ERP - Key Elements6. 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

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)

ERP - Key Elements

8. Individualized perioperative fluid administration:

Avoid Na and Fluid overloadGoal directed fluid therapy via

Oesophageal Doppler(OD) monitoring Fluid overload is associated with delayed gut function and increased complication rates.

ERP - Key Elements9. 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

ERP - Key Elements10. 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.

ERP - Key Elements12. 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.

ERP - Key Elements13. 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

ERP - Key Elements14. Early mobilizationBed 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.

ERP - Key Elements15. Non-opiate Analgesics/NSAIDs

Opiates are associated with decreased gut motility.

Short term NSAIDs use can avoid Gastric irritation.

Day of Surgery

1st POD

TWOC- Trial Without Catheter

NMBM- No Meal by Mouth

2nd POD

3rd POD

ERP – Discharge CriteriaPatients 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.

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

Thank You All