ERAS: Enhanced Recovery After Surgery

Christopher L. Wu, M.D. Professor of Anesthesiology

The Johns Hopkins University; Baltimore, Maryland

Overview • History and basic principles of ERAS • Review published ERAS data • Anesthesiology ERAS topics

– Goal-directed fluid therapy (GDFT) – Multimodal analgesia – Regional anesthesia-analgesia

• ERAS at Hopkins

History of ERAS

• Previously known as “fast-track surgery” – Studies in 1990s (Kehlet – Denmark) showed ↓ LOS for

colon resection from 9-10 d → 2 d – Also known as “enhanced recovery programs (ERP)”

• “ERAS”: acronym started in 2001 (academic surgeons) – Intent: develop optimal evidence-based perioperative

care pathway to facilitate patient recovery – Changed name from “fast-track” (implied focus on faster

d/c only) to ERAS (focus on overall patient recovery)

Br J Surg 1999;86:227-30 JPEN 2014;38:559-66

Philosophy of ERAS

• Traditional hospital works in silos → need to be removed to optimize patient care – One team may have little insight if the treatment they

use for their purpose is beneficial hrs or days later – Team taking over patient care may have little insight

into what occurred before their part of the care process • ERAS pathways designed everyone involved in the

entire chain of events during patient’s care – True multidisciplinary effort: improves communication;

allows team members to understand each other roles

JPEN 2014;38:559-66

JPEN 2014;38:559-66

ERAS: General Goals

• Get patient back to normal preoperative function as quickly as possible – Normal gastrointestinal function – Pain control – Mobilization – Minimize complications – Improve patient experience

ERAS: Basic Principles

• Multidisciplinary and collaborative approach – Optimize perioperative nutrition – Standardized perioperative anesthestic plan to

minimize pain/opioid usage/stress response – Early mobilization and oral intake – Patient education and participation

Clin Nutr 2005;24:466-77

Preoperative

• Information, education and counseling • Medical optimization • Standardized bowel preparation • Preoperative fasting and carbohydrate treatment • Preanesthetic medication • Prophylaxis against thromboembolism

World J Surg 2013;37:259-84

Intraoperative • Antimicrobial prophylaxis and skin preparation • Standardized anesthetic protocol • Multimodal approach to PONV prophylaxis • Laparoscopy and modifications of surgical access (if

applicable) • Postoperative nasogastric tubes should not be used

routinely (removed at end of surgery) • Prevent intraoperative hypothermia • Optimize perioperative fluid management

World J Surg 2013;37:259-84

Postoperative

• Urinary drainage (limit to 1-2 days) • Prevention of postoperative ileus • Multimodal analgesia – minimize opioids • Perioperative nutritional care • Postoperative glucose control • Early mobilization

World J Surg 2013;37:259-84

Does ERAS Work?

• Several meta-analyses of existing RCTs to suggest that ERAS (vs. traditional care) implementation will: – ↓ Length of hospital stay (LOS) – ↓ Complication rate – ↓ Urinary tract infection – ↓ Pneumonia, respiratory complications – ↓ Cardiovascular complications – No difference in mortality or readmission rate

Cochrane Data Syst Rev 2011: CD007635 World J Surg 2014;38:1531-41 Int J Colorectal Dis 2012;27:1549-54

Decrease in Length of Stay

World J Surg 2014;38:1531-41

World J Surg 2014;38:1531-41

Decrease in Respiratory Complications

Decrease in UTI

Yang D, Grant M et al (submitted)

World J Surg 2014;38:1531-41

Decrease in Cardiovascular Complications

World J Surg 2014;38:1531-41

Decrease in Morbidity

World J Surg 2014;38:1531-41

No Difference in Readmission

Int J Colorectal Dis 2012;27:1549-54

No Difference in Mortality

Anesthesiology ERAS Topics

• Goal-directed fluid therapy – Anesthesiology providers have generally given too

much IV fluids intraoperatively • Multimodal analgesia

– Concurrent use of non-opioid analgesic agents will result in additive/synergistic analgesia while providing an opioid-sparing effect

• Regional anesthesia-analgesia – Local anesthetic based technique may provide superior

analgesia and physiologic benefits to facilitate patient recovery

Goal-directed Fluid Therapy • Excessive IV crystalloids ⇒ cardiac/pulmonary fxn, ↓ tissue

oxygenation (SSI), paralytic ileus • ERAS fluid management ⇒ continuum through the pre-/intra-

/post-operative phases” (TE Miller, Duke) • Preoperative: to OR in a hydrated and euvolemic state

– Avoid prolonged fasting; carbohydrate drink 2-3 h before surgery • Intraoperative: maintain central euvolemia, avoid excess NaCl

– Individualized fluid management plan using balanced crystalloid solution (LR) to provide maintenance fluid therapy.

– Low-risk patients/surgery = "zero-balance" probably sufficient – Higher risk patients/major surgery = consider GDFT

Br J Anaesth 2002;89:622-32

Can J Anaesth 2015;62:158-68

Goal-directed Fluid Therapy • Meta-analysis of 13 RCT (1399 patients)

– GDFT = ↓ first bowel motion (p=0.02), oral intake (p= 0.03), PONV (p = 0.01)

– GDFT = more effective outside ERAS, colorectal patients • RTC (n = 100): GDFT vs. routine care

– GDFT = ↑ SV/CO, ↓ LOS (mean 5 vs 7 days, p=0.03), earlier oral intake of solid food (p=0.01)

• Meta-analysis (29 RCTs): preemptive hemodynamic intervention – 4805 patients with an overall mortality of 7.6% – Preemptive HD ⇒ ↓ mortality (OR = 0.48 [0.33-0.78], p=0.0002),

surgical complications (OR = 0.43 [0.34-0.53], p<0.0001) Br J Surg 2015;102:577-86

Anesthesiology 2002;97:820-6 Anesth Analg 2011;112:1392-402

Br J Surg 2015;102:577-86

Multimodal Analgesia • Optimal pain control in ERAS is critical to facilitate recovery • Multimodal analgesia (improve pain control, ↓ opioid-related

side effects) is a key component of most ERAS programs – Acetaminophen, NSAIDs, NMDA antagonists, local anesthetics,

gabapentanoids, alpha-2 agonists, glucocorticoids • Opioids ⇒ sedation, PONV, urinary retention, ileus, RD • Combining acetaminophen and NSAID ⇒ superior analgesia

compared with either drug alone – Meta-analysis (21 RCTs, 1909 patients) – Pain intensity 35% and 38% less for the combination versus

acetaminophen alone and NSAID alone, respectively

Can J Anaesth 2015;62:203-18 Anesth Analg 2010;110:1170-9

http://www.medicine.ox.ac.uk/bandolier/booth/painpag/acutrev/analgesics/leagtab.html

Drug Mean NNT 95% CI Celecoxib PO 400mg 2.1 1.8 - 2.5 Codeine 60mg/Acetam PO 1000mg 2.2 1.7 - 2.9 Oxycodone PO 15mg 2.4 1.5 - 4.9 Ibuprofen PO 400mg 2.5 2.4 - 2.7 Ibuprofen PO 200mg 2.7 2.5 - 2.9 Meperidine IM 100mg 2.9 2.3 - 3.9 Morphine IM 10mg 2.9 2.6 - 3.6 Ketorolac IM 30mg 3.4 2.5 - 4.9 Celecoxib PO 200mg 3.5 2.9 - 4.4 Acetaminophen PO 1000mg 3.8 3.4 - 4.4 Tramadol PO 100mg 4.8 3.4 - 8.2

Single-Dose Analgesics: >50% Relief for Moderate-Severe Postoperative Pain

Regional anesthesia-analgesia • Neuraxial (epidural, spinal) or peripheral (TAP,

paravertebral, wound infiltration) blocks/catheters – TAP block meta (10 RCTs, 633 subjects): TAP vs. control

• TAP block: ↓ pain at rest at 4 and 24 h, postoperative opioid consumption

• Preoperative (vs. postoperative) TAP block ⇒ ↓ early pain, opioid consumption

– Analgesic efficacy of wound catheters (infusion of LA via catheters placed in surgical wounds) is uncertain

• Meta-analysis (32 RCTs): no difference in side effects or analgesia at rest or on activity, except in OB-GYN patients

• ↓ Morphine consumption, wound breakdown, LOS (p=0.04)

Anesth Analg 2014;118:454-63 Acta Anaesthesiol Scand 2011;55:785-96

Anesth Analg 2014;118:454-63

Acta Anaesthesiol Scand 2011;55:785-96

Pain at rest-24 h

Pain at rest-48 h

Role of Epidural in ERAS? • TEA ⇒ superior analgesia, ↓ some pulmonary/cardiac

morbidity, facilitate earlier return of GI function • Overall benefits of TEA in laparoscopic procedures uncertain

– Meta-analysis of 7 RCTs (n=378): epidurals vs. alternative analgesic methods

• No significant difference in complication rate (OR=1.14 [0.49, 2.64], p=0.76) or LOS; EA faster return of GI fxn, ↓ pain scores

– Meta-analysis (6 RCTs): epidural analgesia on laparoscopic colorectal surgery

• TEA = ↓ first bowel motion (p=0.02) and pain scores (p=0.04) but no difference in LOS hospital, OR time, side effects

JAMA Surg 2014;149:1224-3 Surg Endosc 2013;27:2581-91

• Goal: normal function as soon as possible – Superior analgesia to facilitate recovery – Minimize analgesic (opioid) side effects

• Short-term goals: ↓ LOS/pain, ↑satisfaction • Long-term goal: preservation of perioperative immune

function: ↓ SSI/cancer recurrence • Perioperative period creates a vulnerable period of

immunosuppression for our surgical patients

ERAS at Hopkins (Anesthesiology)

Perioperative Period: High Risk

Brain Beh Immun 2007;21:881-7

• Multiple systematic/literature reviews to examine available evidence for various aspects of care

• Incorporate appropriate evidence to meet both short-term and long-term goals

• Create a preliminary pathway – feedback from ERAS anesthesiology members

• Pathway trial – further modifications based on clinical experiences

• Continued modification of pathway: new evidence or clinical experience warrants discussion/modification

ERAS at Hopkins (Anesthesiology)

ERAS at Hopkins (Anesthesiology)

• For open procedures = EA + TIVA • For lap. procedures = TIVA + IV lidocaine + TAP • Preserve immune fxn: avoid opioids, inhalation

agents; ketamine, blood transfusions, hypothermia • Epidural analgesia: integral part of ERAS pathways

– Superior analgesia vs. opioids – Faster return of gastrointestinal function – Attenuation of neuroendocrine stress response – Preserve immune function/↓ opioid use

Epidural Anesthesia & Immunosuppression

Eur J Canc Prevent 2008;17:269-72

Preoperative (Hopkins)

• Preoperative holding area (day of surgery) – Oral celebrex (200 mg) – Oral gabapentin (600 mg) – Oral acetaminophen (1000 mg) – Scopolamine patch (avoid dexamethasone) – Insertion of thoracic epidural catheter (open

cases)

Standardized Anesthetic (Hopkins) • GOALS: maintain normothermia; avoid blood tnxs;

minimize hypotension/hypoxia; maintain normocarbia • Epidural anesthesia + TIVA (propofol)

– TEA: 2% lidocaine w/ 1:200K epi as bolus (∼10ml) to obtain T4 level + infusion of 2% lidocaine (no epinephrine) at 4-6ml/hr

• If no epidural, TIVA + IV Lidocaine gtt • Adjuvants

– Acetaminophen 1gm IV x1 (if not given preop) – Ketorolac 30 mg IV at end of case (↓ 15 mg IV for age >75) – Ondansetron 8 mg IV 30 min prior to end of case

Postoperative (Hopkins)

• When NPO: – PCEA: 0.0625% bupivacaine only (no fentanyl)

• Continue 1 day after tolerating oral intake/analgesics

– Assuming no contraindications • Acetaminophen 1 gm IV/PO q8h • Ketorolac 15-30 mg IV q6h or ibuprofen 400 mg

PO q6h – Breakthrough pain: hydromorphone IV prn

Postoperative (Hopkins)

• When taking PO: – Acetaminophen 1000mg PO q8h – Gabapentin 100 mg PO tid – Ibuprofen 400 mg PO q6h – Lidoderm patch – Tramadol 50 mg PO q4-6h prn (before opioid) – Breakthrough pain: prn opioid of choice

Hopkins CR ERAS: Results • Prior to ERAS: Hopkins (major large and small bowel)

mean LOS = 8.6 d (NSQIP: 10th decile) • Colorectal ERAS started February 2014 • Prelim analysis: colorectal d/c since 1/1/14 = median

LOS of 2 days less than last 6 m of CY 2013 – Equivalent of freeing up 4 additional beds every day

• Our own data analysis since 2/1/14 = – Mean LOS = 5.3 d; median LOS = 4 d

• ↑ Marburg 2 patient satisfaction survey scores

Armstrong Institute for Patient Safety and Quality

ERAS Baseline Net

Savings Patients 330 310

Mean

Length of Stay

5.3 days 7.2 days (-)1.9 days (26.4%)*

Variable Direct Cost

$9,036 $10,933 (-1)$1,897 (17.3%)**

*p<0.001

J Am Coll Surg 2015;221:669-77

Hopkins CR ERAS: LOS and Cost

**p=0.013

Metric Pre ERAS Post ERAS Improvement

Patients 42 56

Case Mix Index

2.6 2.5 (0.1)

Length of Stay

7.9 5.8 (2.1)

Cost $12,761 $10,450 ($2,311)

Complications 9.5% 0.0% (9.5%)

Readmissions 21.4% 19.6% (1.8%)

Early results: ERAS Expansion Liver Resection (Hopkins)

Baseline 27%

Post-ERAS 6%

Colorectal Operating Room CUSP ERAS

Hospital Target 15%

Armstrong Institute for Patient Safety and Quality

Hopkins CR ERAS: SSI

Costs of Implementation: $552,783 Reduction in Direct Hospital Costs: $948,500 Net Savings: $395,717

Data from Johns Hopkins Hospital show a net savings of ∼$400,000 in the first year of implementation

Hopkins CR ERAS: Results

Johns Hopkins

Armstrong Institute for Patient Safety and Quality

NSQIP Report: 2015

Hopkins ERAS: Practical Considerations

• Attempted to develop an opioid-free ERAS pathway – Opioids are ordered as a PRN (as needed) dose – ∼50% pts will still receive opioids during their hospital

stay but the overall amounts of opioids given are less • With an accepted pathway, we were able to truly

administer multimodal analgesia (ERAS ordersets) – NSAIDs, acetaminophen, tramadol, gabapentin, epidural

analgesia, lidocaine, opioid PRN for breakthrough pain – Previously, some were reluctant to accept certain

modalities (e.g., NSAIDs, gabapentin, epidural)

Final Thoughts • Not a rigid or fixed protocol:

– Clinicians should feel free to do whatever they need to do to care for our patients

– Overall pathway continues to be modified based on updated evidence or clinician input

• Low volume ventilation, magnesium, acetaminophen • Benefits:

– Focuses care around the patient – ↑ Collaboration/communication among services – true

multidisciplinary effort – Breaks down silos; ↑ staff morale; enhances SSI efforts