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Enhanced Recovery After Surgery The ERAS protocol Prof. Ioana Grigora Anesthesia and Intensive Care Department University of Medicine and Pharmacy, Gr.T.Popa.

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Presentation on theme: "Enhanced Recovery After Surgery The ERAS protocol Prof. Ioana Grigora Anesthesia and Intensive Care Department University of Medicine and Pharmacy, Gr.T.Popa."— Presentation transcript:

1 Enhanced Recovery After Surgery The ERAS protocol Prof. Ioana Grigora Anesthesia and Intensive Care Department University of Medicine and Pharmacy, Gr.T.Popa Regional Institute of Oncology Iasi, Romania

2 Enhancing Recovery after GI surgery Factors influencing patient recovery Pre-op information Optimised organ function No nutritional defects No alcohol pre-op Stop smoking pre-op Neuraxial blockade Minimally invasive surgery Normothermia Nausea prevention Ileus prevention Early feeding Good oxygenation Good sleep Opioid sparing Evidence-based post-op care Anxiety, fear Pre-op organ dysfunction Surgical stress response Hypothermia Nausea, vomiting Ileus Semi-starvation Hypoxaemia Poor sleep Drains & tubes Catheters Accelerated recovery Delayed recovery

3 What is ERAS ? Standardized protocol for perioperative care Function al capacity Days Weeks Traditional Care Enhanced Recovery Henrik Kehlet, Br J Anaesth 1997; 78 : 606  Multi-modal intervention  Reduce operative stress  Support organ function  Reduced morbidity  Accelerate convalescence

4 What is ERAS ? Standardized protocol for perioperative care Henrik Kehlet, Br J Anaesth 1997; 78 : 606 preop information stress attenuation pain relief exerciseenteral nutrition nursessurgeonsanesthesistsdieticiankinesitherapist Multi-modal intervention Multi-disciplinary approach

5 ERAS EpiduralAnaesthesia 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 Lassen et al, Arch Surg, 2009

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7 Outline Anesthetist approach Surgeon approach Protocolization

8 Outline Anesthetist approach Surgeon approach Protocolization

9 Enhanced Recovery in practice Referral from Primary Care Pre- Operative Admission Operative Post- Operative Follow-up Fluid management Postoperativ glycaemic control Postoperative nutrition Early mobilisation Rapid hydration / nourishment Appropriate iv therapy Catheters removed early Regular oral analgesia Avoid opiates Antimicrobial prophylaxis Multimodal analgesia PONV Optimal fluid therapy Hypotermia prophylaxis Optimised medical conditions Nutrition Fasting time Carbohidrate drinking Pre-anesthestic medication Anti- thrombotic prophylaxis

10 Preoperative ERAS components  Patient information  Health/medical optimisation  Nutrition  Fasting time  Carbohidrate drinking  Pre-anesthestic medication  Anti-thrombotic prophylaxis U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

11 Preoperative ERAS components  Patient information  Health/medical optimisation  Nutrition  Fasting time  Carbohidrate drinking  Pre-anesthestic medication  Anti-thrombotic prophylaxis U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

12 Patient information Preadmission education and counselling  Decrease fear and anxiety  Improve  wound healing  perioperative feeding  postoperative mobilisation  pain control  Reduce the prevalence of complications U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800 Enhance Postoperative Recovery and Discharge

13 Preoperative ERAS components  Patient information  Health/medical optimisation  Nutrition  Fasting time  Carbohidrate drinking  Pre-anesthestic medication  Anti-thrombotic prophylaxis U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

14 Prehab Preoperative improvement of physiological function Increasing exercise preoperatively  WALK  Training programs

15 Prehab Preoperative improvement of physiological function Increasing exercise preoperatively  WALK  Increasing distance  Increasing duration  Increasing frequency Easier to implement Psychological preparation Motivation – adherence to exercise Less efficient

16 Prehab Preoperative improvement of physiological function Increasing exercise preoperatively  Training programs

17 Prehab Hulzebos EH, JAMA. 2006;296(15):1851-1857

18 Prehab Hulzebos EH et al. JAMA. 2006;296(15):1851-1857  RCT, n=279 high risk pts  single centre, 2002-2005  prehospitalization period before CABG surgery may be used to improve a patient’s pulmonary condition

19 Prehab Hulzebos EH, JAMA. 2006;296(15):1851-1857 postoperative pulmonary complication time of postoperative hospitalization

20 Preoperative alcohol consumption  Increase (x 3) in postoperative morbidity  Cardiopulmonary complications  Bleeding  Wound infections Tønnesen et al. Br J Surg 1999;86:869-74

21 Preoperative alcohol consumption  Abstinence from alcohol for 1 month before surgery reduces postoperative morbidity after colorectal surgery U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800 Does it any difference???!!???

22 Preoperative alcohol consumption Tønnesen et al. BMJ 1999; 318:1311–6 Postoperative ECG and pulse oxymetry Mean HR Ischemia % Arrhythmias SpO2 Hypoxemic episodes

23 Preoperative alcohol consumption Tønnesen et al. BMJ 1999; 318:1311–6 Responses to surgical stress Mean BP Mean HR Serum cortisol Plasma glucose Plasma noradrenaline Plasma adrenaline Plasma IL-6

24 Preoperative alcohol consumption Alcohol consumption should be stopped 4 weeks before surgery U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

25 Preoperative smoking  Increased postoperative morbidity  Cardiopulmonary complications  Wound infections Lindström D. et al. Ann Surg 2008, 248:739-45. Anaesthesia, 2009

26 Preoperative smoking  RCT n = 117 (Blinded outcome assessment) Hernia, Cholecystectomy, Hip/knee replacement Smoking cessation 4 weeks before surgery Postoperative complications  41% vs. 21% Smoking abstinent after 1 yr  33% vs. 15% Lindström D. et al. Ann Surg 2008, 248:739-45. Anaesthesia, 2009

27 Preoperative smoking  Meta – analysis, 11 RCTs, 1194 pts T. Thomsen et al. Br J Surg 2009; 96: 451–461

28 Preoperative smoking Any complication T. Thomsen et al. Interventions for preoperative smoking cessation Cochrane Database of Systematic, 2010, 7. CD002294

29 Preoperative smoking Wound complications T. Thomsen et al. Interventions for preoperative smoking cessation Cochrane Database of Systematic, 2010, 7. CD002294

30 Preoperative smoking Smoking should be stopped 4 weeks before surgery U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

31 Preoperative ERAS components  Patient information  Health/medical optimisation  Nutrition  Fasting time  Carbohidrate drinking  Pre-anesthestic medication  Anti-thrombotic prophylaxis U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

32 Bozzetti, Nutrition, 2002, 18:953

33 Norman, Clinical Nutrition, 2008,27, 5/15

34 Questions regarding perioperative nutrition: TNP vs EN ? Pre- vs post- vs pre- and postoperative ? Standard vs immunonutrition ?

35 All malnourished patients All cancer patients Scheduled for upper gastro-intestinal surgery No matter the nutritional status ESPEN RECOMMENDATIONS Preoperative Preoperative enteral (immuno)nutrition for 10–14 days RECOMMENDATION GRADE A

36 Only moderately/severely malnourished patients scheduled for elective surgery Imposibility of meeting nutritional needs > 7-14 days ASPEN RECOMMENDATIONS Perioperative Early postoperative enteral (delayed PN) nutrition

37 Rationale for PREOPERATIVE NUTRITIONAL SUPPORT PRO –Malnourished pts → at risk of postoperative complications –Reduced nutrient intake →frequent in cancer pts and correlates with nutrition status and complications –Although malnutrition usually develops over weeks/months → a short course of nutrition support can improve physiologic functions –Preoperative nutrition support →better tolerance for postoperative nutrition –Preoperative glucose → reduced postoperative insulin resistance

38 Rationale for PREOPERATIVE NUTRITIONAL SUPPORT CON –The nutritional status of cancer patients correlates with disease stage and cancer control –If nutritional depletion is the result of metabolic use of nutrients → the benefit ?? –Short-term refeeding → reversal of long-term malnutrition?? –Preoperative nutrition increases the length of preoperative stay and increases the costs

39 Who should receive preoperative nutrition support? The patient should be moderately/severely malnutrished The procedure should be one in which nutrition support has been shown to improve outcome – thoraco-abdominal surgery Surgery should be elective and safe to delay for 7- 10days The enteral route is always prefered (when possible) Combination with postoperative nutrition Immune-enhancing formulas

40 Preoperative nutrition  Malnourished patients should receive nutritional support  oral supplements  enteral nutrition  Immunonutrition 5 -7 days preoperatively  reduce the prevalence of infectious complications in patients undergoing major open abdominal surgery K. Lassen et al. Clin Nutr 2012, 31: 817- 830

41 Preoperative ERAS components  Patient information  Health/medical optimisation  Nutrition  Fasting time  Carbohidrate drinking  Pre-anesthestic medication  Anti-thrombotic prophylaxis U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

42 Preoperative fasting “While it is desirable that there should be no solid matter in the stomach when chloroform is administered, it will be found very salutary to give a cup of tea about 2 h previously.” Joseph Lister. On anaesthetics, Holmes' system of surgery. Vol 3, 3rd ed. London: Longmans Green and Company, 1883

43 Preoperative fasting  Standard practice – fasting from midnight  reduce the volume and acidity of stomach contents  decrease the risk of pulmonary aspiration But … Ljungqvist & Söreide, Br J Surg, 2003; 90: 400-406

44 Preoperative fasting  Standard practice – fasting from midnight  reduce the volume and acidity of stomach contents  decrease the risk of pulmonary aspiration But …  Cochrane review of 22 RCTs fasting from midnight  no reduction in gastric content  no rise in pH of gastric fluid clear fluids until 2h before anesthesia Brady M, et al. Cochrane Database Syst Rev 2003;(4). CD004423. Thirst, headaches, hunger

45 Why challange fasting by midnight?  Normal physiology  Is no guarantee of an empty stomach  The same gastric volume with/without clear fluids  Improved well being

46 Preoperative fasting  Standard practice Fasting from midnight  Reduce the volume and acidity of stomach contents  Decrease the risk of pulmonary aspiration  Modern fasting guidelines Clear fluids 2 h before anaesthesia –Exclusions  Emergency surgery

47 Eur J Anaesthesiology 2011;28:556-569

48 What are the effects of the preoperative fasting ?

49 Preoperative fasting and perioperative fluids If fasted – risk of dehydration Dehydration and anesthesia -> hypotension Hypotension -> more fluids infused Overload of fluids Preop clear fluids -> less iv fluids -> improved outcomes Gustafsson et al Arch Surg, 2011

50 Metabolic effects of overnight fasting DayNight HormonesInsulin +Insulin – Glucagon Cortizol SubstratesStorageBreakdown UtilizationCHO > FatFat > CHO Ljungqvist O.et al. Scand J Nutr 2004; 48 (2): 77-82

51 Surgical stress Insulin resistance

52 Insulin sensitivity falls with the magnitude of surgery Percentage (%) Thorell A et al, Curr Opin Clin Nutr Metab Care 1999; 2: 69 More Insulin Resistance

53 Insulin resistance cause complications Elective cardiac surgery, n= 273 Diabetics and non diabetics Complications increase with insulin resistance: 50% reduction in insulin sensitivity: 5-6 fold increase risk of complications 10 fold risk for infections Sato et al, JCEM 2010, 95; 4338-44

54 Can we change the metabolism ?

55 Preoperative ERAS components  Patient information  Health/medical optimisation  Nutrition  Fasting time  Carbohidrate drinking  Pre-anesthestic medication  Anti-thrombotic prophylaxis U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

56 Carbohydrate treatment  20% glucose iv  12.5% carbohydrate drink – 400 ml 2h before anesthesia + 800 ml evening before  Induce insulin release

57 What is the effect of the carbohydrate drink ?

58 Setting before surgery FastedCHO fed Hyperglycemia - + Insulin sensitivity - + 50% Glucose production+ - - - Peripheral glucose uptake - + + + Ljungqvist et al, Clin Nutr 2001, Svanfeldt et al Clin Nutr 2005

59 Carbohydrate treatment  20% glucose iv  12.5% carbohydrate drink – 400 ml 2h before anesthesia + 800 ml evening before  Safety ???

60 Carbohydrate treatment Nygren et al, Ann Surg, 1995 Minutes after intake Isotope activity in the stomach (%) 120906030 0 0 20 40 60 80 100 120 * * * * * CHO, n=6 Water, n=6 Gastric emptying is complete in 90 min for CHO / water

61 Oral intake of CHO does not increase gastric volumes Gastric volume (ml) Acidity (pH) Overnight fast (n=89) 6-411.6-4.0 Placebo (n=86) 12-351.6-2.5 CHO 12.5 % (n=80) 7-411.6-2.7 Hausel et al, Anesth Analg 2001

62 Carbohydrate treatment  20% glucose iv  12.5% carbohydrate drink – 400 ml 2h before anesthesia + 800 ml evening before  Safe – fast gastric emptying

63 Preop CHO reduces postoperative insulin resistance Per cent change from preop **** *P < 0.05 Nygren et al: Curr Opin Clin Nutr Metab Care 2001 CHO Control More resistance

64 Preop CHO activates muscle insulin signalling pathways p=0.02 Wang et al, BJS 2010

65 Preop CHO maintains postoperative muscle anabolic pathways P<0.001 Wang et al, BJS 2010

66 Preoperative CHO retains lean body mass (MAC) Yuill et al, Clin Nutr 2005 P <0.05 [cm]

67 Effects of preoperative carbohydrates  Reduces the metabolic stress of surgery  Effectively reduces insulin resistance  Improves pre/postoperative well being  Improves postoperative muscle function  Reduce lean body mass losses  May result in faster recovery

68 What type of carbohydrates ? Clear carbohydrate drink ONS 400 (70g ONS dissolved in water to 400 ml) ONS 300 (70g ONS dissolved in water to 300 ml) Amount ingested400 ml 300 ml Amount of carbohydrate 50g Amount of protein0g15g glutamine

69 What type of carbohydrates ?

70 Eur J Anaesthesiology. 2011;28:556-569 Preoperative carbohydrates

71

72 Preoperative carbohydrates Meta analysis Length of Stay One day shorter length of stay for major abdominal surgery, n = 762 No difference in minor short stay surgeries (<3 days), n =380 No difference in orthopedic surgery, n = 32 Awad et al, ClinNutr 2013; 32 : 34-44

73 All recent Guidelines recommend oral carbohydrate loading Germany2003: Major surgery Anaesthesist. 2003 Nov;52(11):1039-45. Scandinavia 2005: Major surgery Acta Anaesthesiol Scand. 2005 Sep;49(8):1041-7 ESPEN 2005: Major surgery Clin Nutr. 2006 Apr;25(2):224-44 ESPEN 2009: Major surgery Clin Nutr. 2009 May 20 United Kingdom 2009: Elective surgery J Intensive Care Society. 2009;10(1):13-5 European Soc Anesthesiology 2011: Elective surgery Eur J Anaesthesiology. 2011;28:556-569

74 Preoperative ERAS components  Patient information  Health/medical optimisation  Nutrition  Fasting time  Carbohidrate drinking  Pre-anesthestic medication  Anti-thrombotic prophylaxis U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

75 Pre-anesthetic medication Education Short-acting iv drugs Prior epidural/spinal analgesia No sedative medication before surgery Avoid starvationCHO loading U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

76 Preoperative ERAS components  Patient information  Health/medical optimisation  Nutrition  Fasting time  Carbohidrate drinking  Pre-anesthestic medication  Anti-thrombotic prophylaxis U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

77 Anti – thrombotic prophylaxis MechanicalPharmacological Compression stockings in all patients Intermitent pneumatic compression LMWH for 28 days in cancer patients Risk in colorectal surgical patients DVT – 30% PE – 1% U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800

78 Intraoperative ERAS components  Antimicrobial prophylaxis  Anesthesia protocol  PONV  Fluid management  Hypotermia prophylaxis

79 Intraoperative ERAS components  Antimicrobial prophylaxis  Anesthesia protocol  Multimodal analgesia  PONV  Fluid management  Hypotermia prophylaxis

80 Antimicrobial prophylaxis  Imperative to reduce the risk of surgical infections  Time  30-60 min before the incision  repeated doses  during prolonged procedure (≥3h)  Massive blood loss/fluid loading  Route  intravenous  Spectrum  Suspected germs (aerobic ± anaerobic bacteria)

81 Intraoperative ERAS components  Antimicrobial prophylaxis  Anesthesia protocol  PONV  Fluid management  Hypotermia prophylaxis

82 Anesthetic protocol  Target – rapid awake of the patient  Anesthesia technique  Balanced anesthesia  TIVA  Short acting agents  Hypnosis – propofol, sevoflurane, desflurane  Analgesia – sufentanil, remifentanil  Myorelaxant – cisatracurium

83 Intraoperative Monitoring Hypnosis Muscle relaxation Cardiac output GlucoseAnalgesia ERAS BIS Algiscan Oesophageal doppler Glucometer TOF

84 Intraoperative ERAS components  Antimicrobial prophylaxis  Anesthesia protocol  Multimodal analgesia  PONV  Fluid management  Hypotermia prophylaxis

85 Multimodal analgesia Epidural analgesia iv analgesia Wound catheters/infiltration Peripheral blocks

86 Benefits of Epidural Analgesia Dynamic pain control Obtunds stress response Reduction of ileus Reduced post-operative pulmonary complications Reduced myocardial ischaemia Reduced incidence of DVT/PE

87 Causes of ileus Degree of surgical manipulation Magnitude of inflammatory and stress response Sympathetic reflexes Opioids Fluid overload/ bowel oedema

88 Epidural analgesia vs iv opiates GI function EDA results in less GI paralysis Jorgensen Cochr Database Syst Rev 2004

89 Intraoperative ERAS components  Antimicrobial prophylaxis  Anesthesia protocol  Multimodal analgesia  PONV  Fluid management  Hypotermia prophylaxis

90 PONV  Risk factors  Patient: female, non smokers, motion sickness  Anestetic: volatile agents, iv opioids, nitrous oxide  Surgical: major abdominal surgery  PONV scoring systems  Multimodal approach  Pharmachological  Non-pharmachological techniques: TIVA, minimal fasting, CHO loading, adequate hydration, epidural, NSAIDS

91 Intraoperative ERAS components  Antimicrobial prophylaxis  Anesthesia protocol  Multimodal analgesia  PONV  Fluid management  Hypotermia prophylaxis

92 Perioperative fluid management  What type of fluid ?  Is there an indication for vasopressors ?  When iv fluids should be discontinued ?  Is fluid therapy vital for outcome ?  Are the fluid requirements the same ?  What about fluid shifts ?  What amount ?

93 Post-op Weight Gain Following Colorectal Resection Lobo et al, Lancet Brandstrup et al, 2002; 359: 1812-18 Annals Surg 2003; 238: 641-8 3-6kg KCH Fearon 2004

94 Perioperative fluid management DO2 = CO (SV x HR) x CaO2 x 10 Bundgaard-Nielsen,et al. Acta Anaesth Scand 2009, 53: 843–851

95 Preoperative carbohydrates, fluids and outcomes Main factors for better outcomes: Preop carbohydrates & fluid balance Preop carbohydrates -> Less fluid overload (450 ml) For every litre extra*: 32% increased risk of complications (cardiovascular) * Limit: Day of surgery: Colonic 3,000 ml, Rectal 3,500 ml Gustafsson et al, Arch Surg 2011

96 Fluid requirements are different Open laparatomy Increase fluid shifts Bowel handling SIRS Laparoscopy CO reduction Head-down position Pneumoperitoneum

97 Fluid shifts should be minimised  Avoid bowel preparation  Maintain hydration till 2 hours before surgery  Minimise bowel handling  Avoid blood loss

98 Goal Directed Therapy The use of cardiac output / surrogate to guide iv fluid alone or in combination with inotropics during the perioperative period.

99 Goal directed intra-operative fluid therapy Noblett et al. BJS 2009

100 Varadhan K, Proc Nutr Soc, 2010 2.75 liters/24h Meta analysis based on amount of fluid given

101 Rahbari NN, BJS 2009: 96: 331 Fluids – recent meta ‐ analysis

102 Types of fluids cristaloids and coloids

103 Varadhan K, Proc Nutr Soc, 2010 59% reduced risk for complications 3.4 days reduction in hospital stay

104 Perioperative fluid management  The types of fluids – cristaloids and coloids  Vasopressors are indicated in hypotensive normovolemic patients  Iv fluids should be discontinued as soon as practicable  Fluid therapy is vital for outcome  Fluid requirements are different  Fluid shifts should be minimised  Fluid administration must be goal directed

105 Intraoperative ERAS components  Antimicrobial prophylaxis  Anesthesia protocol  Multimodal analgesia  PONV  Fluid management  Hypotermia prophylaxis

106 Hypothermia prophylaxis  Hypothermia – central temperature < 36 C  Risk factor for wound infections, prolonged cicatrisation cardiac events shivering – increase O2 consumption bleeding coagulation disorders trombocites dysfunction postoperative ileus increase pain prolonge emergence time

107 Hypothermia prophylaxis Hypothermia – central temperature < 36 C Methods warming devices (forced air warming blankets) warmed iv fluids warm gases in laparoscopic surgery

108 Postoperative ERAS components  Postoperative analgesia  Fluid management  Postoperative glycaemic control  Postoperative nutrition  Early mobilisation

109 Postoperative analgesia Optimale analgesic regimen –Good pain relief –Reduction of cardiovascular, cognitive, endocrino – metabolic complications in at risk patients –Decrease the risk of chronic pain –Allow early mobilisation –Allow early return of gut function and feeding

110 Postoperative analgesia Principles of Multimodal Analgesia –Avoidance of iv opioids –Regional anesthesia techniques Thoracic epidural analgesia (TEA) Spinal analgesia –Local anesthetic techniques Transversus abdominis plane (TAP) block The analgesic regimen is specific to the type of surgery/incision

111 Postoperative analgesia in open surgery  Thoracic epidural anesthesia (TEA) –Middle thoracic (T7-T10) –Superior analgesia in the first 72 h –Earlier return of gut function

112 Postoperative analgesia in open surgery  Thoracic epidural anesthesia (TEA) –Low dose concentration of local anesthetic –Short acting opiate –Maintained for 48 -72 h postoperative

113 Efficacy of Postoperative Epidural Analgesia: A Meta-analysis Block BM et al, JAMA. 2003;290(18):2455-2463

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115

116 Epidural analgesia vs opiates GI function EDA results in less GI paralysis (vs iv opiates) Jorgensen Cochr Database Syst Rev 2004

117 Postoperative analgesia in laparoscopic surgery Spinal analgesia –Low dose long acting opioid- morphine

118 Modification of ERAS in lap surgery ? RCT EDA vs Spinal vs PCA, n=91 –Lap colorectal surgery –LOS EDA (3.7 d) longer than PCA and Spinal (2,8 and 2,7 d) –Spinal Faster return of bowel function (vs EDA and PCA) Earlier tolerance of food (vs EDA) –Levy, BJS, 2011

119 ERAS and Lap colorectal resection One center (North Bristol, UK), –n=606, 2004-2009 –Primary anastomosis –ERAS formally after 2008 –Transversus abdominis plane (TAP) or rectus sheath block –No EDA or PCA –KAD withdrawn in theatre –46% discharged within 3 days (Median LOS 4 days) 2 same day, 70 within 24 hrs, 116 within 48 hrs, 91 within 72 hrs Readmission rates 4 %, –Gash KJ, Colorectal Dis, 2012

120 Early removal of KAD during EDA ? During thoracic epidural anesthesia –Removal of KAD in the morning after surgery Or after removal of EDA RCT, N=205 No increased need for recatheterization Transient increase in post-void residual volume (UL Scanning) –Zaouter, Acta Anasth Scand, 2012

121 Postoperative ERAS components  Postoperative analgesia  Fluid management  Postoperative glycaemic control  Postoperative nutrition  Early mobilisation

122 Varadhan K, Proc Nutr Soc, 2010 59% reduced risk for complications 3.4 days reduction in hospital stay

123 Postoperative ERAS components  Postoperative analgesia  Fluid management  Postoperative glycaemic control  Postoperative nutrition  Early mobilisation

124 Postoperative glycaemic control

125 Hyperglycemia in surgical stress  Insulin resistance is the key  Traditional belief  Hyperglycemia in the acutely stressed patient is ”not dangerous”  Glucose levels treated > 200 mg/dl

126 Elective major surgery opportunity to prevent /attenuate metabolic responses to surgery rather than having to treat them with insulin. Several stress-reducing interventions in ERAS attenuate insulin resistance as single interventions: preoperative oral carbohydrate treatment epidural blockade minimally invasive surgery If interventions are combined in ERAS protocol, hyperglycaemia can be avoided even during full enteral feeding starting immediately after major colorectal surgery.

127 Postoperative ERAS components  Postoperative analgesia  Fluid management  Postoperative glycaemic control  Postoperative nutrition  Early mobilisation

128 Postoperative nutrition Fluids immediately after recovery from anesthesia Normal hospital food on day 1  traditional care  enhanced-recovery protocol Nygren Clin Nutr 2003

129 Postoperative early enteral nutrition Lewis et al BMJ 2001;323(7316):773-6

130 Postoperative ERAS components  Postoperative analgesia  Fluid management  Postoperative glycaemic control  Postoperative nutrition  Early mobilisation

131 Early mobilisation EFFECTS Early return of bowel function Improved digestive tolerance Enhanced anabolism Decreased risk of venousthromboembolism Deacreased risk of pulmonary complications Enhanced recovery !!! CONDITIONS Good analgesia No ventilatory support No postoperative somnolence Psycological support

132 Outline Anesthetist approach Surgeon approach Protocolization

133 ”It is ironic that the American Society of Anesthesiologists, whose members are critical observers of surgical procedures, evolved the best index of “operative risk”. Arthur S. Keats, Anesthesiology 1978

134 ” Perhaps the American Surgical Association, whose members are critical observers of anesthetic procedures, will provide us with a meaningful index of “anesthetic risk”. Arthur S. Keats, Anesthesiology 1978

135 Surgeon: No bowel prep Food after surgery No drains or KAD No iv fluids, no lines Early discharge All evidence based! Anesthetist: Carbohydrates No fasting No premedication Epidural Anesthesia Balanced fluids Vasopressors No or short acting opioids

136 SURGEONS!! TRADITION EVIDENCE BASED MEDICINE

137 BOWEL PREPARATION PRO –Avoids massive contamination !?! –Minor inconvenience to the patient !?! –Looks better inside !?! CON –Preoperative dehydration !!! –Modification of enteral flora !!! –Delayed gut motility !!!

138 Arch Surg.Arch Surg. 2004 Dec;139(12):1359-64; discussion 1365. Mechanical bowel preparation for elective colorectal surgery: a meta-analysis. Bucher PBucher P, Mermillod B, Gervaz P, Morel P.Mermillod BGervaz PMorel P CONCLUSIONS: 7 trialuri 1300 pt There is no evidence to support the use of MBP in patients undergoing elective colorectal surgery. Available data tend to suggest that MBP could be harmful with respect to the incidence of anastomotic leak and does not reduce the incidence of septic complications.

139 Rectal cancer – TME (total mesorectum excision) Standardised Enhanced Recovery Programme for the EnROL Trial Day before surgery avoidance of oral bowel preparation except in patients undergoing total mesorectal excision (TME) and reconstruction. Kennedy et al. BMC Cancer 2012, 12:181

140 Reduce surgical injury Minimally invasive surgery FAST TRACK Surgery Early postoperative recovery –Decreased stress response –Decreased inflammatory response –Decreased pain –Early bowel movement

141 FAST TRACK Early rehabilitation Minimally invasive surgery NOT MANDATORY for FAST TRACK surgery but shortens hospitalization

142 NO routine nasogastric tube 28 multicenter trials >4000 pts –Decreased duration of postoperative ileus –Decreased risk of postoperative pulmonary complications –Increased patient QOL –No increase in anastomotic leak Nelson, R. at all Systematic review of prophylactic nasogastric decompression after abdominal operations. Br. J. Surg., 2005, 92, 673–680.

143 No drains Rationale of drains: A surgical tradition Difficult to be abandoned For how long? 24h / 48h / 7days ??? In majority of cases – serous drained fluid (physiological reabsorption) “When in doubt, drain” Lawson Tait, english surgeon “The drain= the surgeon eye in the patients abdomen”

144 No drains RCTs: –Unreliable indication of anastomotic leak –Underestimates the significance of anastomotic leak –Underestimates the postoperative bleeding –Does not influence the rate of anastomotic leak –Increases the contamination risk –Prolongs the duration of postoperative ileus –Prolongs the hospital lenght of stay Petrowsky, H. at all: Evidence-based value of prophylactic drainage in gastrointestinal surgery: A systematic review and meta-analyses. Ann. Surg., 2004, 240, 1074–1085.

145 Day of surgery – postoperative period IV fluids, if clinically indicated pressors for epidural hypotension regular pre-emptive antiemetics (ondansetron as first line) Early mobilization (patient sits up) Starts drinking protein drinks COLONIC SURGERY

146 Day 1 –Urinnary 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 at 14.00 if pain controlled and timed with anticoagulant dose COLONIC SURGERY

147 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 COLONIC SURGERY

148 THE SURGEON the cornerstone of FAST TRACK and ERAS programs

149 Outline Anesthetist approach Surgeon approach Protocolization

150 Preventing hypotermia Postoperative nutrition Preoperative Fasting Carbohydrates Treatment Properative prophylaxys Early mobilisation PONV Analgesia Preoperative optimisation Analgesia Fluid management Preoperative nutrition Fluid management

151 Results? Randomised trials Meta analysis 1. ERAS

152

153 ERAS compliance & outcomes 953 consecutive colorectal surgery patients Multi variate analysis – ERAS factors Carbohydrate treatment 44% reduced risk of symptoms delaying discharge (PONV, pain, GI sympoms, dizziness ) 16% reduced risk of wound dehiscence Fluid balance: For each extra Liter 16% increased risk of symptoms delaying discharge 32% increased risk of complications Gustafsson et al Arch Surg, in press 2011

154 ERAS - clinical outcome Complications K K. Varadhan et al. Clin Nutr, 2010: 29 ;434–440  Review of 6 RCTs (n=452) Reduce complications by 50%

155 ERAS - clinical outcome Mortality K K. Varadhan et al. Clin Nutr, 2010: 29 ;434–440  Review of 6 RCTs (n=452)

156 ERAS - clinical outcome Length of stay K K. Varadhan et al. Clin Nutr, 2010 : 29 ;434–440  Review of 6 RCTs (n=452) Shorter length of stay by 2.5 days

157 Readmissions (days) Experimental group= Enhanced Recovery After Surgery (ERAS) Control = Traditional Care (TC)

158 JAMA Surgery 2011

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160 Ciaran O’Hare “Fast-track” rehabilitation after colonic surgery in elderly patients—is it feasible? International Journal of Colorectal Disease Volume 22, Number 12 / December, 2007 M. Scharfenberg1, W. Raue1, T. Junghans1 and W. Schwenk1 Conclusion Using the “fast-track” rehabilitation programme on elderly patient is not only feasible but may also lower the number of general complications and the duration of the hospital stay.

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167 World J Surg.World J Surg. 2011 Sep 1. Fast-Track Concepts in Major Open Upper Abdominal and Thoracoabdominal Surgery: A Review. Fagevik Olsén MFagevik Olsén M, Wennberg E.Wennberg E 15 articles: gastric (n = 2), pancreatic (n = 5), hepatic (n = 2), esophageal (n = 3), aortic surgery (n = 3).

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170 Sipos P, HMJ, 2007 Vol.1, Number 2,165–174

171 Anesth Analg 2007;104:1380-1396 © 2007 International Anesthesia Research Society doi: 10.1213/01.ane.0000263034.96885.e1 International Anesthesia Research Society AMBULATORY ANESTHESIA The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care Paul F. White, PhD, MD *, Henrik Kehlet, MD, PhD, and the Fast-Track Surgery Study Group CONCLUSION: The decisions of the anesthesiologist as a key perioperative physician are of critical importance to the surgical care team in developing a successful fast-track surgery program.

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174 ORIGINAL ARTICLE Current perioperative practice in rectal surgery in Austria and Germany Till HasenbergTill Hasenberg, Friedrich Längle, Bianca Reibenwein, Karin Schindler, Friedrich LängleBianca ReibenweinKarin Schindler Stefan PostStefan Post, Claudia Spies,Wolfgang Schwenk and Edward ShangClaudia SpiesWolfgang SchwenkEdward Shang INTERNATIONAL JOURNAL OF COLORECTAL DISEASEINTERNATIONAL JOURNAL OF COLORECTAL DISEASE 2010 Volume 25, Number 7Volume 25, Number 7, 855-863, DOI: 10.1007/s00384-010-0900-2 Results The response rate - 63% A (76 centers) + 30% G (385 centers). Mechanical bowel preparation - abandoned by 2% G and 7% A surgeons. Nasogastric decompression tubes - rarely used; 4/5 of the questioned surgeons - use intra-abdominal drains. Half of the surgical centers - intake of clear fluids on the day of surgery. Mobilization - in half of the centers on the day of surgery. Epidural analgesia - three-fourths of the institutions. Institutions which have implemented fast track rehabilitation discharge earlier.

175 “Surgery and peri-operative care remains heavily based in tradition” Practice varies substantially internationally survey of UK general surgeons: ‘there is inadequate multidisciplinary and community support’ to initiate ERAS ‘never heard of it’. survey regarding practice across European countries: ‘nil by mouth’ almost abandoned in others This is the biggest challenge facing the wide implementation and acceptance of ERAS programs. Hill, Andrew (2008, December 10). Enhanced Recovery after Surgery. SciTopics. http://www.scitopics.com/Enhanced_Recovery_after_Surgery.html

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177 Current evidence supports the potential role of multi-modal care programmes in the promotion of early recovery from major surgical trauma. To achieve the desired outcome targets, all elements of the protocol must function, a committed, multidisciplinary approach is essential and a simple, but effective implementation and reinforcement strategies are necessary. Implementation in Practice (C.H.C. Dejong, Netherlands) http://www.jspen.jp/doc6/sec7.html

178 Implementation of the ERAS protocol  select a target  invite participation to create a team  explain what you are trying to achieve  select an “expert group”  create change concept and priorities  implement strategy  regular review to measure and evaluate change  review strategy Implementation in Practice (C.H.C. Dejong, Netherlands) http://www.jspen.jp/doc6/sec7.html

179 “There is nothing new under the sun but there are lots of old things we don’t know.” Ambrose Bierce.


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