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

2. Disclosure

3. 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

4. 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

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

7. Preoperative management
Preoperative bowel preparation
Surgeon specific
PO antibiotics

8. 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

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

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

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

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

13. Postoperative management
Maintain euglycemia
High carbohydrate drinks
Treat hyperglycemia

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

15. 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

16. 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

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

19. THank you