Rehabilitation in

surgery

Rehabilitation after surgery

Enhanced Recovery After Surgery

What is ERAS?

• Or Fast-track

• Developed by Kehlet in Denmark in colonic

surgery

• Gradually has gained world-wide acceptance

• Originally described in Open Surgery but same

advantages seem to apply for Laparoscopy

Enhance (vb) (tr) to intensify or increase in quality, value,

power, etc.; improve; augment

In practice, usually equated and quantified in terms of

time/speed: Length of Stay

Hot topic for NHS managers Can be applied to colorectal, urology, gynae and musculosketal surgery

What is Enhanced

Recovery?• Minimise stress

responses during & after

surgery

• Optimise pre-op condition

• Optimise peri-operative

care

• Optimise post-op

rehabilitation

Time

Function

Traditional care

Enhanced Recovery

• Pre-operatively: Other health

problems are identified & managed to

enable the patient to be in the best

possible condition for surgery

• Intra-operatively: Best possible

evidence based management is given

to the patient during and after surgery

• Post-operatively: Patients are

encouraged with early mobilisation

and timely discharge for the best

rehabilitation with support

Goals of FAST TRACK SURGERY

• Lower risk, better outcome

• Accelerate recovery

• Reduce morbidity, complications

(pulmonary, cardiac, thromboembolic,

infectious)

• Shorten convalescence

• Less expensive healthcare

Factors influencing

patient recoveryPre-op informationOptimised organ functionNo nutritional defectsNo alcohol pre-opStop smoking pre-opNeuraxial blockadeMinimally invasive surgeryNormothermiaNausea preventionIleus preventionEarly feedingGood oxygenationGood sleepOpioid sparingEvidence-based post-op care

Referral from

Primary Care

Pre-

Operative

Admission

Operative

Post-

Operative

Follow-up

•Optimising pre-operative

haemoglobin levels

•Managing pre-existing co-

morbidities eg Diabetes

•Discharge on

planned day

•Therapy input

(stoma / physio /

dietician)

•Audit & outcome

measures

•Planned mobilisation

•Rapid hydration & nourishment

•Appropriate iv therapy

•No wound drains

•No NGT (bowel surgery)

•Catheters removed early

•Regular oral analgesia

•Avoid opiates

•Day of surgery

admission

•Reduced starvation

/ CHO load

•Optimise fluid

hydration

•No pre-med/bowel

prep

•Minimally invasive surgery

•Transverse incisions

•Avoid nasogastric tubes

•Use of LA/ Regional

analgesia with sedation

•Epidural (thoracic)

•Optimised fluid therapy

•Optimised health /

medical conditions

•Informed decision-

making

•Pre-operative health

& risk assessment

•Patient well-informed

/ expectations

managed

•Stoma training

•Discharge planning

(EDD)

What is ERAS?

Patient Information

• At the clinic

Carbohydrate drinks

• 4 night before surgery if having bowel prep

• 2 morning of the surgery

No mechanical bowel preparation

Patients admitted on the morning of surgery

Pre-op

Thoracic Epidural Analgesia

Incision choice

• Transverse for R) sided

• Mid-line or Laparoscopic for L) sided

Avoidance of Drains and NGT post-operatively

Limited Intra-Operative fluid therapy

• Aiming to max of 1.5-2 L

Surgery

IVF

• unless clinically indicated

• Pressors for epidural hypotension

Regular pre-emptive antiemetics

• ondansetron as first line

On arrival to the departement

Patient sits up

• Starts drinking protein drinks (Resource/Fortisip etc)

After surgery

• Solids until 6 hours before surgery

• Clear fluids until 2 hours before surgery

• Safe

• Beneficial

• Carbohydrate-loaded liquid pre-op

• post-op catabolism

• insulin resistance, hyperglycemia

• muscle loss

Early Feeding

• Start clear fluids 2h post-op

• Aim > 800mL fluids on day of surgery

• Routine nutritional supplements

• IV appropriately, avoid fluid overload,

• Length of time a patient can remain NPO

after surgery without complications is

uknown, however depends on:

• Severity of operative stress

• Patient’s preexisting nutritional status

• Nature and severity of illness

• Two types of nutritional support

• Enteral

• Parenteral

Day 1

• Urine catheter removed in the morning

• 8 hrs of enforced mobilisation

• Resumes normal diet

• Pre-emptive oral analgesia is started

• Paracetamol and NSAIDs

• Avoid Opioids

Day 2

• Epidural infusion is stopped in the morning

• Epidural Catheter is removed if pain controlled, and

timed with Clexane dose

Day 3/4 - discharge criteria:

• Return of GI function

• Able to eat and drink without discomfort

• Passing flatus

• Pain controlled with oral analgesia

• Adequate home support

Discharge date is an important target for

patients and staff but flexibility is vital

What is Cardiac

Rehabilitation? • It is defined as, “all measures used to help

cardiac patients return to an active and

satisfying life and to prevent re-ocurrence

of cardiac events”.

• Cardiac Rehabilitation includes exercise,

education, and social and emotional

support.

• Rehabilitation can be hospital or home

based.

Rehabilitation Outcome and Quality of

Life• The benefits include psychological well being, reduction in mortality, improvement in quality of life, and lowering of hospital re-admission rates, with the prevention of reoccurrence of future cardiac events

• Cardiac rehabilitation lowers the risk of death in survivors by 20-25%

• Cardiac rehab also decreases the need for medication

• Improves exercise tolerance, coronary risk factors, physiological well being and health related quality of life, as well as reducing long term mortality

Complication due to Non-

Rehabilitation• Reoccurrence of cardiac events

• Re-hospitalization due to re-occurrence of

cardiac event with high cost of treatment

• Decreased quality of life

• Increased need for medication

• Increased risk of death

• Increased risk for co-morbidity

• Predisposition to blood clotting from stasis

Standard Interventions

• Cardiac rehab staff nurse will meet patient prior to discharge from hospital and address the rehabilitation program protocol.

• rehabilitation consists of forty exercise sessions; 24 sessions (3/per week) endurance training on a cycle ergometer ( with 5 minute warm up) 20 min training with constant workload, 5 minute cool down, and 5 min post exercise monitoring. In addition 16, (2/per week) 1 hour sessions of stretching and flexibility exercises.

Goals for Rehabilitation Focus on 4 aspects of activities of daily

living:

i) Somatic goals – Teaching individuals

to

learn one’s optimal exercise limits

ii) Social goals – helping individuals to

reintegrate into family life with

optimal

reintegration regarding working,

household, hobbies and leisure

activities.

Goals for Rehabilitation (Con’t)

iii). Psychosocial goals – empowering

individuals by evaluating anxiety levels

and concerns towards cardiac exertion

during exercise, that may lead to negative

emotions.

iv). Secondary prevention goals – helping

individuals to modify risk behavior &

reinforce compliance to therapy

regimen

Give “advanced anticipatory guidelines”

towards expectations including advantages,

outcomes, side effects, possible

complications, how to monitor their own

pulse rates and maximum heart rates, and

how to recognize symptoms of over-exertion

(ex: muscle cramps, short of breath).

Assess patient’s stress level, emotional status,

and functional status every time the nurse

calls

Outcome measuring tools• Establish a baseline evaluation for cardiac rehabilitation.

• vital signs, pulse ox

• EKG

• BMI

• pulse ox with activities to monitor the need for oxygen.

• Re-hospitalization do to reoccurrence of a cardiac event.

• Establish daily patient journal to monitor patient

impression of daily improvement and level of

performance of ADL.

• Pre, intra, post –echocardiogram to evaluate ejection

fraction.

ERAS Results

Type of Operation Duration of stay

Carotid endarterectomy 1-2 days

Lung lobectomy 1-2 days

Prostatectomy 1-2 days

Colectomy 1-3 days

Aortic Aneurysm 3-4 days

Fast-track surgeryPersonal experience

• Day surgery/One day surgery

- hernia

- laparoscopy (diam< 3 cm)

- hemorrhoids

- thoracocenthesis

Fast-track surgery

Cholecystectomy

Fast-track surgeryPersonal experience

• Cholecystectomy

- medical history!

- admittance day of operation

- early mobilization: I°day

- drain: II°day

- discharge: II°-III° day

Pre-operative examinations

• Hemocromo – PT- PTT

• ECG > 40 years

• X ray chest > 60 years

• Electrolyte-urea -creatinina > 60 years

• Glycemia > 60 years

• Urine: only specific indication

Fast-track surgery

Thyroidectomy

Fast-track surgeryThyroidectomy

'Same-day' thyroid surgery. Results

after 805 thyroidectomies in a fast-

track program

Fast-track surgeryThyiroidectomy

…conclusions:

• Specialized centre

• Lobectomy or sub-total

• No total thyroidectomy

• No ASA 3

Fast-track surgeryPersonal experience• Thyiroydectomy

- Admittance day of operation

- Free nutritional intake until midnight

- Free oral fluid intake

- Drains: I°-II°day

- Discharge: II°-III° day

Fast-track surgery

Breast surgery

William Stewart Halsted1852 - 1922

Surgeon-in-chief Johns Hopkins Hospital

1890-1922

Fast-track surgeryPersonal experience.

• Brest surgery:

- Free oral intake

- Admittance day of operation

- Mobilization: I° day

- Drains: I°-V° day

- Discharge: I°-V° day

Fast-track surgery

Colon surgery

Fast-track surgeryColon

The “Coast trial” is an important multicentric randomized and controlled trial that shows an

hospital stay significantly decreased after laparoscopic surgery (5 days) respect to open

surgery (6 days)

Basse L et al. – Dis Colon Rectum 2004; 47: 271“Colonic surgery with accelerated rehabilitation or conventional care”

•Post-op. stay: II°-III° day

•Readmission: 20%

Morbility

Traditional Care 20-35%

Fast-track Rehabilitation < 10%

Wolfgang Schwenk – TATM 2007; 9: 43-44

“Editorial: principles of fast-track rehabilitation in

elective colonic surgery”

Fast-track surgery

Gastric surgery

Gastic surgery

• Free nutritional oral intake until midnight

• Naso-gastric tube: II°-III° day

• Urinary catheter: I° day

• Oral nutritional intake: IV°-VI° day

• Mobilization: I° day

• Discharge: VI°-VIII° day

Fast-track surgeryPersonal experience

• Lung surgery:

pneumothorax: II°-III° day

- VATS

wedge-resection: II°-III° day

- TAC-guidate needle biopsy: ambulat.

- Lobectomy: VII° day

- Pneumonectomy: IX°-X° day

La Fast-track surgery demands a motivated team:

- Anaesthesist- Surgeon- Dietician

- Physiologist- Nursing staff

- Home/Ambulatory care