Enhanced Recovery after Surgery (ERAS) Colette Burford Advanced Nurse Consultant ERAS Project 2017

ERAS Goals Reduction of stress response after surgery Acceleration of Recovery Return to pre admission function or better… A happy patient at discharge who has felt well informed and involved in their care

ERAS Components Preoperative Postoperative Outpatients Surgeon & patient discussion Preadmission Optimisation Counselling Discharge planning Oral Supplements Limited fasting Admission day of surgery Preventative & active pain control Hydration (Avoid fluid overload) Aggressive management of N&V Early oral feeding EARLY MOBILISATION Early removal of IDC’s & drains Early discharge planning

Preoperative discussion/counselling Clear explanations of what will happen periop Explanation of the role of the patient with regards to preop activity, food intake, oral nutritional drinks, limited fasting. Expectations of patient postop; early eating, fluid intake, MOBILISATION, pain management, discharge planning.

Preoperative carbohydrate loading Reduces preoperative thirst, hunger and anxiety. Significantly reduces postoperative insulin resistance.

Postoperative Pain Control opioids in postoperative analgesic regimens results in adverse effects, such as sedation, postoperative nausea and vomiting, urinary retention, ileus, and respiratory depression, which can delay discharge. Multimodal analgesia, i.e., the use of more than one analgesic modality to achieve effective pain control while reducing opioid-related side effects, has become the cornerstone of enhanced recovery. 

Postoperative Hydration/ feeding Encourage early oral intake Facilitates early return of bowel function Allows stopping of IVT’s Aids mobilisation Avoid IV fluid overload…. Excess fluid administration would result in several kilos in weight gain and even oedema. This was shown to be a major cause for postoperative ileus and delayed gastric emptying and development of complications

Prevention of Postoperative Nausea and Vomiting (PONV) PONV is unpleasant, delays gut function, affects mobility and has metabolic consequences. Strict post-operative nausea and vomiting prophylaxis.

Early Mobilisation Prolonged bed rest Increased risk of thromboembolism Decrease in muscle strength, pulmonary function and tissue oxygenation ERAS Patients get out of bed on day of surgery and increase activity daily with planned structured walks. IDC’s and drains out early Patients should be getting dressed in day clothes as so0n as possible.

Discharge Planning The earlier discharge planning is undertaken the better It’s all been said before…… Good planning requires anticipation of potential problems by good information gathering, early resolution of potential barriers to discharge, and timely referral to the multidisciplinary team Planning involves close collaboration between the patient, the family, and the multidisciplinary team; this leads to improved patient and carer satisfaction

Team Members for Successful ERAS Nurses Dietitians Physiotherapists Pain Team Theatre staff Anaesthetists Surgeons Hospital management Audit team Anyone not mentioned who is involved in the care of the patient….. WIDESPREAD STAFF AND PATIENT EDUCATION PRIOR TO ROLL OUT IS PIVOTAL TO A SUCCESSFUL OUTCOME OF ERAS PATHWAYS

Some patients will fall off the pathway The challenge for the team is to reassess the needs for each patient and optimise the recovery within the changed pathway.

THE END