What is Enhanced Recovery After Surgery?
Principles of ERAS
• Multimodal stress minimizing approach
• Maintain post operative physiological function
• Enhance mobilization after surgery
Results in
• Reduced Morbidity & Mortality
• Faster recovery
• Shorter length of stay
• Reduced re-admission rates
• Reduced pain scores
These are small changes in patient care which help enhance the recovery of the patient, length of hospitalisation, recovery and morbidity.
ERAS guidelines exist for every field of surgery. These are only the colorectal surgery guidelines.
Timing of ERAS
I. Pre-admission
II. Pre-operative workup
III. Intra-operative measures
IV. Post-operative care
I. PRE-ADMISSION
1. Preadmission information, education & counselling
2. Preoperative optimisation
a. Risk assessment –
i. Nutritional &
ii. Controlling systemic diseases – Heart, Lung, Kidney, Diabetes, Hypertension
b. Smoking Cessation for 4-8 weeks.
Counselling & Nicotine patches
c. Avoid alcohol abuse 4 weeks (<50ml of a 40% spirit)
d. Prehabilitation (from diagnosis to treatment) Includes
i. physical,
ii. nutritional &
iii. psychological assessment
e. Preoperative nutritional care
i. Subjective Global Assessment
ii. Albumin levels
Risk of complications increased when there is 5-10% of unintentional weight loss or more.
For malnourished patients -
· Oral nutrition for 7-10 days preop
· Additional parenteral nutrition when indicated.
f. Manage Anaemia
Factors causing Anaemia
1. Acute blood loss
2. Chronic blood loss
3. Vit B12, iron or Folate deficiency
4. Anaemia of chronic diseases
5. Combination of any of the above
The administration of blood products peri-operatively may also increase complications and have a long-term impact on survival in patients with colorectal cancer.
ASA guidelines recommend maintaining Hb atleast between 6 – 10.
For higher risk patients Hb >8
In anaemia of chronic disease, (eg inflammatory bowel disease) the iron regulatory protein hepcidin is activated in response to inflammation. It inhibits absorption of iron from the gastrointestinal tract and reduces bioavailability of iron stores for red cell production in the marrow, making oral iron therapy not very effective.
Intravenous iron infusions can overcome this problem in some instances
Oral iron
It is cheap and administered easily but may be tolerated poorly.
Absorption is better with low dose oral iron 40–60 mg per day or alternate day with 80–100 mg.
IV Iron
Use Ferric Carboxymaltose 1-1.5gm in single or divided doses.
Reticulocytosis starts in 3-5 days
Addition of Erythropoetin not recommended
Serum Ferretin <30mcg/l most sensitive and specific test used for the identification of absolute iron deficiency.
II. PRE-OPERATIVE WORKUP
1. Prevention of nausea & vomiting
2. Pre-anaesthetic medication
· Paracetamol, NSAID + Gabapentinoid – for opioid sparing
3. Antimicrobial prophylaxis & skin preparation
· IV antibiotic within 60 minutes of incision
· In patients receiving oral bowel preparation, oral antibiotics should be used
· Skin disinfection with Chlorhexidine + Alcohol
· Not enough evidence for antiseptic showering, shaving or adhesive incise sheets
4. Bowel preparation
· Mechanical bowel preparation alone with systemic antibiotic prophylaxis has no clinical advantage.
· Causes dehydration and discomfort and should not be used routinely in colonic surgery, but may be used for rectal surgery.
· There is some evidence from randomized controlled trials to support the use of a combination of MBP and oral antibiotics over MBP alone
5. Pre-operative fluid & electrolyte therapy
· Reach OT euvolemic. Electrolytes excess & deficits corrected
6. Pre-operative fasting & carbohydrate loading
7. Stoma counselling & marking
Principles of Carbohydrate-loading
· Attenuates the catabolic response induced by overnight fasting
· Reduces postoperative insulin resistance
· ↓ nitrogen and protein losses
· Preserves skeletal muscle mass
· ↓ preoperative thirst, hunger and anxiety
· Accelerated recovery through early return of bowel function and shorter hospital stay
· Improved peri-operative well-being
· Beneficial cardiac effects
Patients are allowed to take solids upto 6 hrs pre-operatively and clear fluids upto 2 hours before induction.
This is without an increase in the rate of complications, even in the obese & diabetics.
Preoperative Carbohydrate loading can be used in diabetics when accompanied by their morning dose of diabetic medications.
Box of 3sachets
2 the previous night – 800ml
1 in the morning 2-3 hrs prior to induction - 400ml
III. Intra-operative measures
1. Standard Anaesthetic protocol
i. Avoid benzodiazepines
ii. Use short acting anaesthetic agents
iii. Minimise opioid use
iv. Abdominal pressures 10-12mm Hg
v. Short acting muscle relaxation with adequate reversal with Neostigmine & Sugamadex
2. Intraoperative Fluid & Electrolyte therapy – (Goal directed fluid therapy)
Avoid Salt & water overload
3. Nasogastric tube to be avoided
Orogastric tube only to deflate the stomach.
Remove at extubation
4. Minimal Invasive Surgery (Laparoscopic / Robotic)
5. Prevent Hypothermia intraoperatively
Maintain Core temperatures >36 degrees C
Hypothermia due to dry cold CO2 insuffulation
6. Peritoneal Drainage – Not to be routinely used.
IV. Postoperative Care
A. Post op Analgesia
1. Multimodal anaesthesia
· Paracetamol, NSAIDs used in conjunction with local measures
· Helps reduce opioid usage
2. Epidural blockade
· Thoracic epidural
· LA + Opioid recommended for open surgery
· For Lap / Robotic Cannot be recommended
3. Spinal Analgesia
· Spinal with low dose opioids as adjunct to GA
4. Lignocaine infusion
· Reduces opioid use.
· Post op ileus – unclear
5. Abdominal wall blocks – TAP block
· T10 to L1 coverage only.
· Subcostal + Rectus blocks used in addition.
· LA can be mixed with Dexamethasone.
· Ultrasound guided or Laparoscopic approaches can be used.
B. Thromboprophylaxis
Without thromboprophylaxis there is an incidence of asymptomatic DVT in 30% patients
High risk patients
1. Ulcerative colitis
2. Advanced malignancy –Stages III & IV
3. Hypercoagulable states
4. Steroids
5. Old age
6. Obesity
Methods of thromboprophylaxis
A. Compression stockings
B. Intermittent pneumatic compression. (ICP)
C. Low Molecular weight Heparins / Heparin – Unfractionated
A combination of ICP together with pharmacological prophylaxis decreased the incidence of pulmonary embolism (PE) and DVT when compared with a single modalit at the expense of higher risk for bleeding complications when compayring to ICP alone.
After colorectal surgery extended thromboprophylaxis of 28 days is recommended. But has been recently questioned due to the data being old and for open surgery.
With reduced stress using ERAS & Minimal invasive techniques and near immediate mobilization, relevance of these older studies needs to be revisited.
C. Fluid & Electrolyte Therapy
· Oral diet to be started 4 hrs after surgery
· Only maintenance fluids to be given
· Correct ongoing losses
· In normo-volumic patients, hypotension due to epidural should be treated with vasopressors & not more volume
· Try to achieve a near zero fluid balance
· Balanced crystalloids preferred over normal saline
· Avoid Hyperchloremia as is associated with increased mortality and longer stays
· Low urine output & oliguria not reliable indicators of hypovolemia in first 48 hours of surgery
· Conservative fluid regimens do not appear to increase risk of oliguria or acute kidney injury but hypervolemia can
D. Urinary Drainage
· Used for prevention of urinary retention & monitoring urine output
· UTI risk markedly reduced with early removal of the catheter
· Lower retention rates when ERAS protocols followed - early catheter removal
· Pelvic surgeries & epidural anaesthesia at higher risk of urinary retention
· Delaying removal of Foley’s to 2nd or 3rd day justified in these patients
· If drainage for more than 5 days, Suprapubic or CISC preferred
E. Prevention of post-op ileus
Core elements of ERAS protocols limit duration of ileus
1. Limiting opioids
2. Multimodal anaesthesia
3. Minimal invasive techniques
4. Eliminate nasogastric tube placement
5. Maintaining fluid & electrolyte balance
· µ-opioid receptor antagonists – Alvimopan, Methylnaltrexone & Naloxone
· Chewing gum shows mild reduction in ileus
· Laxatives like bisacodyl may be used
· Magnesium oxide, Diakenchu & coffee(decaffinated) also can be tried
F. Post-op glycaemic control
· Insulin resistance is the hallmark of physiological response to surgical trauma
· ERAS protocols prevent insulin resistance
· Insulin to be used judiciously to maintain sugars as low as possible
G. Post-op nutritional care
· Delay in resumption of normal oral diet associated with increased infections and delayed recovery
· Oral feeds safe 4 hrs after surgery
· Low residue diet may be preferred over liquids only.
· Oral nutritional supplements proven useful
· Recent ESPEN guideline on perioperative nutrition concluded that peri-or at least postoperative immune-nutrition (arginine, omega 3 fatty acids and ribonucleotides) should be given to malnourished patients undergoing major cancer surgery.
H. Early Mobilisation
Prolonged bed rest associated with
· Pulmonary complications
· Decreased skeletal muscle strength
· Thrombo-embolic complications
· Insulin resistance
Goal directed mobilisation had shorter ICU stays & better mobility at discharge
Failure of early mobilisation due to
1. Inadequate pain control
2. Continued IV fluids
3. Prolonged urinary catheter
4. Abdominal drains
5. Patient motivation
6. Pre-existing morbidities
V. AUDIT ERAS OUTCOMES
· Continuous audits of the ERAS outcomes which includes adherence and deviation from the ERAS protocols
· Complete the audit cycle
· Audit & Feedback has its best effects when done repeatedly in writing and verbally with specific targets for change and multifaceted interventions.
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