ENhanced recovery after surgery Jasna Coralic MD Colon and rectal surgery/general surgery Madison medical affiliates COlumbia St. Mary’s Hospital

Disclosure

Overview PREOPERATIVE MANAGEMENT Preoperative patient education and optimization Preoperative bowel preparation Preoperative fasting and carbohydrates INTRAOPERATIVE MANAGMENT Anesthesia practice Surgical practice Infection prevention POSTOPERATIVE MANAGMENT Postoperative analgesia Maintain euglycemia Early mobility Prevent postoperative ileus

Background We do not have to reinvent the wheel! The Enhanced Recovery After Surgery (ERAS) Society has issued guidelines for perioperative care in colon and rectal surgery This care model has been embraced in Europe for a number of years and is now gaining popularity in the Unites States There are increasing number of articles in well respected peer- reviewed medical journals that showing the benefits of various aspects of this approach

Preoperative management Preadmission education/counseling Dedicated education Smoking cessation Nutrition Exercise

Preoperative management Preoperative bowel preparation Surgeon specific PO antibiotics

Preoperative management Preoperative fasting and carbohydrate loading Stop solids 6 hours prior to surgery Stop clear liquids 2 hours prior to surgery High carbohydrate drinks At bedtime 2-3 hours prior to surgery

INtraoperative management Anesthesia Minimize sedation Goal directed fluid therapy Local and regional anesthesia

INtraoperative management Surgery Minimally invasive approach Drainage of peritoneal cavity discouraged Early urinary catheter removal

INtraoperative management Infection prevention Prevent hypothermia CHG showers and prep Timely antibiotics

Postoperative management Postoperative analgesia Gabapentin Locoregional analgesia PO or IV acetaminophen PO NSAIDS (no ketorolac)

Postoperative management Maintain euglycemia High carbohydrate drinks Treat hyperglycemia

Postoperative management Early mobility Prevent pneumonia Aid insulin resistance Aid muscle weakness

Postoperative management Prevent ileus postoperatively NGT not used Early feeding Gum chewing (no evidence) POD#0 - Modified clear liquid diet + clear Ensure POD#1 - Full liquids POD#2 - Soft (low-residue) diet

COnclUSion The ERAS guidelines provide an established standardized care plan for this patient population which will help us to achieve the goals of the VCO bowel initiative of decreasing complications, lowering cost, reducing length of stay, and improving overall care and patient satisfaction Success will be most evident if we implement a structured program involving most if not all of the ERAS guideline recommendations WE ABSOLUTELY NEED BUY IN FROM ALL OF THE PLAYERS OR THIS WILL NOT BE THE SUCCESS THAT IT COULD BE

THANK YOU Marc Eiseman MD Sherie Ponting Jean Strobel Kevin Kluesner Greg Bruder Kathy McEwen

THank you