Transcript Enhanced Recovery after Surgery - The Anesthetist point

Enhanced Recovery After Surgery
The ERAS protocol
Prof. Ioana Grigoraș
Anesthesia and Intensive Care Department
University of Medicine and Pharmacy, Gr.T.Popa
Regional Institute of Oncology
Iasi, Romania
Factors influencing patient recovery
Accelerated 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
Delayed recovery
Enhancing Recovery after GI
surgery
What is ERAS ?
Standardized protocol for perioperative care
 Multi-modal intervention
 Reduce operative stress
 Support organ function
 Reduced morbidity
 Accelerate convalescence
Functional capacity
Days
Weeks
Traditional Care
Enhanced Recovery
Henrik Kehlet, Br J Anaesth 1997; 78 : 606
What is ERAS ?
Standardized protocol for perioperative care
Multi-modal intervention
preop
information
nurses
stress
attenuation
surgeons
pain
relief
anesthesists
exercise
kinesitherapist
enteral
nutrition
dietician
Multi-disciplinary approach
Henrik Kehlet, Br J Anaesth 1997; 78 : 606
Peri-op fluid
management
Epidural
Anaesthesia
No premed
DVT prophylaxis
Pre-op
councelling
Early
mobilisation
No bowel prep
ERAS
Perioperative
nutrition
Bairhugger
Oral analgesics/
NSAID’s
Remifentanyl
CHO-loading/
no fasting
Incisions
Prevention
of ileus/
prokinetics
No NG tubes
Early removal of
catheters/drains
Lassen et al, Arch Surg, 2009
Outline
 Anesthetist approach
 Surgeon approach
 Protocolization
Outline
 Anesthetist approach
 Surgeon approach
 Protocolization
Enhanced Recovery in practice
Referral from
Primary Care
PreOperative
• Optimised
medical
conditions
• Nutrition
• Fasting time
• Carbohidrate
drinking
• Pre-anesthestic
medication
• Antithrombotic
prophylaxis
Admission
•
•
•
•
•
•
•
•
•
Fluid management
Postoperativ glycaemic control
Postoperative nutrition
Early mobilisation
Rapid hydration / nourishment
Appropriate iv therapy
Catheters removed early
Regular oral analgesia
Avoid opiates
Operative
• Antimicrobial
prophylaxis
• Multimodal analgesia
• PONV
• Optimal fluid
therapy
• Hypotermia
prophylaxis
PostOperative
Follow-up
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
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
Patient information
Preadmission education and counselling
Decrease fear and anxiety
 Improve
 wound healing
 perioperative feeding
 postoperative mobilisation
 pain control
Reduce the prevalence of complications
Enhance
Postoperative
Recovery
and Discharge
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
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
Prehab
Preoperative improvement of physiological function
Increasing exercise preoperatively
WALK
Training programs
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
Prehab
Preoperative improvement of physiological function
Increasing exercise preoperatively
Training programs
Prehab
 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
Hulzebos EH et al. JAMA. 2006;296(15):1851-1857
Prehab
postoperative pulmonary complication
time of postoperative hospitalization
Hulzebos EH, JAMA. 2006;296(15):1851-1857
Preoperative alcohol consumption
Increase (x 3) in postoperative morbidity
 Cardiopulmonary complications
 Bleeding
 Wound infections
Tønnesen et al. Br J Surg 1999;86:869-74
Preoperative alcohol consumption
Abstinence from alcohol
for 1 month before surgery
reduces postoperative morbidity
after colorectal surgery
Does it any difference???!!???
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
Preoperative alcohol consumption
Mean HR
Postoperative
ECG and pulse
oxymetry
SpO2
Ischemia %
Hypoxemic episodes
Arrhythmias
Tønnesen et al. BMJ 1999; 318:1311–6
Preoperative alcohol consumption
Mean BP
Responses to
surgical stress
Plasma noradrenaline
Mean HR
Plasma adrenaline
Serum cortisol
Plasma IL-6
Plasma glucose
Tønnesen et al. BMJ 1999; 318:1311–6
Preoperative alcohol consumption
Alcohol consumption should be stopped
4 weeks before surgery
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
Preoperative smoking
Increased postoperative morbidity
 Cardiopulmonary complications
 Wound infections
Lindström D. et al. Ann Surg 2008, 248:739-45. Anaesthesia, 2009
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
Preoperative smoking
 Meta – analysis, 11 RCTs, 1194 pts
T. Thomsen et al. Br J Surg 2009; 96: 451–461
Preoperative smoking
Any complication
T. Thomsen et al. Interventions for preoperative smoking cessation
Cochrane Database of Systematic, 2010, 7. CD002294
Preoperative smoking
Wound complications
T. Thomsen et al. Interventions for preoperative smoking cessation
Cochrane Database of Systematic, 2010, 7. CD002294
Preoperative smoking
Smoking should be stopped
4 weeks before surgery
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
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
Bozzetti, Nutrition, 2002, 18:953
Norman, Clinical Nutrition, 2008,27, 5/15
Questions regarding
perioperative nutrition:
• TNP vs EN ?
• Pre- vs post- vs pre- and postoperative ?
• Standard vs immunonutrition ?
ESPEN RECOMMENDATIONS
Preoperative
All malnourished patients
All cancer patients
Scheduled for upper gastro-intestinal surgery
No matter the nutritional status
Preoperative enteral (immuno)nutrition
for 10–14 days
RECOMMENDATION GRADE
A
ASPEN RECOMMENDATIONS
Perioperative
Only moderately/severely malnourished patients
scheduled for elective surgery
Imposibility of meeting nutritional needs > 7-14 days
Early postoperative enteral (delayed PN) nutrition
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
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
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 710days
• The enteral route is always prefered (when
possible)
• Combination with postoperative nutrition
• Immune-enhancing formulas
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
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
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
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
Preoperative fasting
Standard practice – fasting from midnight
 reduce the volume and acidity of stomach contents
 decrease the risk of pulmonary aspiration
But …
Thirst, headaches, hunger
 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.
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
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
Eur J Anaesthesiology 2011;28:556-569
What are
the effects
of the
preoperative fasting ?
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
Metabolic effects of overnight fasting
Day
Night
Hormones
Insulin +
Insulin –
Glucagon
Cortizol
Substrates
Storage
Breakdown
Utilization
CHO > Fat
Fat > CHO
Ljungqvist O.et al. Scand J Nutr 2004; 48 (2): 77-82
Surgical stress
Insulin resistance
Insulin sensitivity falls with the magnitude
of surgery
Percentage (%)
100
More
Insulin
Resistance
50
0
Thorell A et al, Curr Opin Clin Nutr Metab Care 1999; 2: 69
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
Can
we change
the metabolism ?
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
Carbohydrate treatment
 20% glucose iv
 12.5% carbohydrate drink
– 400 ml 2h before anesthesia
+ 800 ml evening before
 Induce insulin release
What is
the effect
of the
carbohydrate drink ?
Setting before surgery
Fasted
CHO fed
Hyperglycemia
-
+
Insulin sensitivity
-
+ 50%
Glucose production
+
---
Peripheral glucose uptake
-
+++
Ljungqvist et al, Clin Nutr 2001 , Svanfeldt et al Clin Nutr 2005
Carbohydrate treatment
 20% glucose iv
 12.5% carbohydrate drink
– 400 ml 2h before anesthesia
+ 800 ml evening before
 Safety ???
Carbohydrate treatment
Gastric emptying is complete in 90 min for CHO / water
Isotope activity in
the stomach (%)
120
*
100
CHO, n=6
Water, n=6
*
*
80
60
*
40
*
20
0
0
30
60
90
120
Minutes after intake
Nygren et al, Ann Surg, 1995
Oral intake of CHO does not
increase gastric volumes
Overnight fast
(n=89)
Placebo
(n=86)
CHO 12.5 %
(n=80)
Gastric volume
(ml)
6-41
Acidity
(pH)
1.6-4.0
12-35
1.6-2.5
7-41
1.6-2.7
Hausel et al, Anesth Analg 2001
Carbohydrate treatment
 20% glucose iv
 12.5% carbohydrate drink
– 400 ml 2h before anesthesia
+ 800 ml evening before
 Safe – fast gastric emptying
Preop CHO reduces
postoperative insulin resistance
CHO
Control
Per cent change from preop
20
10
*P < 0.05
0
-10
-20
-30
-40
-50
*
*
*
*
More
resistance
-60
Cholecystectomy
Colorectal
Arthroplasty
Arthroplasty
Nygren et al: Curr Opin Clin Nutr Metab Care 2001
Preop CHO activates
muscle insulin signalling pathways
PI3Kinase
(units)
1200
p=0.02
1000
800
600
400
200
0
Control
Placebo
Carbohydrate
Wang et al, BJS 2010
Preop CHO maintains
postoperative muscle anabolic
pathways
P<0.001
Protein Tyrosine Kinase Activity
0.06
0.05
0.04
0.03
0.02
0.01
0
Carbohydrates
Placebo
Control
Wang et al, BJS 2010
Preoperative CHO
retains lean body mass (MAC)
[cm]
P <0.05
Yuill et al, Clin Nutr 2005
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
Preoperative carbohydrates
Eur J Anaesthesiology. 2011;28:556-569
PCL
Study or Subgroup
Fasted / Placebo
Mean
SD
Total
Nygren
6.9
0.9
Soop 2001
5.5
0.5
Hausel 2001
1.2
Mean Difference
Weight
Mean Difference
Mean
SD
Total
IV, Random, 95% CI Year
7
9
0.8
7
8.1%
-2.10 [-2.99, -1.21]
1999
8
5.1
0.7
7
11.4%
0.40 [-0.22, 1.02]
2001
0.7
55
1.25
1.08
117
16.7%
-0.05 [-0.32, 0.22]
2001
7.3
17
14.1
8.7
31
0.5%
-0.60 [-5.23, 4.03]
2003
0.28
8
5
0.26
7
16.6%
0.50 [0.23, 0.77]
2004
0.7
49
11.2
0.8
53
16.4%
-0.60 [-0.89, -0.31]
2005
8.25
80
10.82
8.96
172
2.0%
0.84 [-1.41, 3.09]
2005
2.42
12
12.47
15.8
23
0.3%
-5.97 [-12.57, 0.63]
2006
0.1
105
1
0.1
103
18.6%
0.00 [-0.03, 0.03]
2009
1.99
74
10.25
3.37
75
8.2%
-1.18 [-2.07, -0.29]
2010
6.68
80
495
9.93
11.89
82
677
1.2%
100.0%
-1.25 [-4.21, 1.71]
-0.26 [-0.60, 0.08]
2010
IV, Random, 95% CI
1.2.1 All studies
Henriksen
Soop 2004
Yuill
Hausel 2005
Noblett
13.5
5.5
10.6
11.66
6.5
Lauwick
1
Kaska
9.07
Mathur
Subtotal (95% CI)
8.68
Preoperative carbohydrates
Meta analysis
Length of Stay
Heterogeneity: Tau² = 0.16; Chi² = 63.33, df = 10 (P < 0.00001); I² = 84%
Test for overall effect: Z = 1.52 (P = 0.13)
1.2.2 Major Abdominal Surgery
Nygren
6.9
0.9
7
9
0.8
7
24.0%
-2.10 [-2.99, -1.21]
1999
Henriksen
13.5
7.3
17
14.1
8.7
31
2.7%
-0.60 [-5.23, 4.03]
2003
Yuill
10.6
0.7
49
11.2
0.8
53
32.9%
-0.60 [-0.89, -0.31]
2005
11.66
8.25
80
10.82
8.96
172
9.1%
0.84 [-1.41, 3.09]
2005
Noblett
6.5
2.42
12
12.47
15.8
23
1.4%
-5.97 [-12.57, 0.63]
2006
Mathur
8.68
6.68
80
9.93
11.89
82
5.9%
-1.25 [-4.21, 1.71]
2010
Kaska
Subtotal (95% CI)
9.07
1.99
74
319
10.25
3.37
75
443
24.0%
100.0%
-1.18 [-2.07, -0.29]
-1.08 [-1.87, -0.29]
2010
Hausel 2005
Heterogeneity: Tau² = 0.47; Chi² = 15.13, df = 6 (P = 0.02); I² = 60%
Test for overall effect: Z = 2.68 (P = 0.007)
1.2.3 Operative procedures with expected LOS <3 days
Hausel 2005
1.2
0.7
55
1.25
1.08
117
1.0%
-0.05 [-0.32, 0.22]
2005
1
0.1
105
160
1
0.1
103
220
99.0%
100.0%
0.00 [-0.03, 0.03]
-0.00 [-0.03, 0.03]
2009
Lauwick
Subtotal (95% CI)
Heterogeneity: Tau² = 0.00; Chi² = 0.13, df = 1 (P = 0.72); I² = 0%
Test for overall effect: Z = 0.04 (P = 0.97)
1.2.4 Orthopaedic Surgery
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
Soop 2001
5.5
0.5
8
5.1
0.7
7
16.1%
0.40 [-0.22, 1.02]
2001
Soop 2004
Subtotal (95% CI)
5.5
0.28
8
16
5
0.26
7
14
83.9%
100.0%
0.50 [0.23, 0.77]
0.48 [0.23, 0.73]
2004
Heterogeneity: Tau² = 0.00; Chi² = 0.08, df = 1 (P = 0.77); I² = 0%
Test for overall effect: Z = 3.79 (P = 0.0002)
-10
-5
0
PCL
5
10
Fasted / Placebo
Awad et al, ClinNutr 2013; 32 : 34-44
All recent Guidelines recommend
oral carbohydrate loading
Germany
2003: 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
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
Pre-anesthetic medication
Education
Avoid starvation
CHO loading
No sedative medication
before surgery
Short-acting iv drugs
Prior epidural/spinal analgesia
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
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
Anti – thrombotic prophylaxis
Risk in colorectal surgical patients
DVT – 30% PE – 1%
Mechanical
Compression
stockings in
all patients
Pharmacological
Intermitent
pneumatic
compression
LMWH
for 28 days
in cancer patients
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
Intraoperative ERAS components
 Antimicrobial prophylaxis
 Anesthesia protocol
 PONV
 Fluid management
 Hypotermia prophylaxis
Intraoperative ERAS components
 Antimicrobial
prophylaxis
 Anesthesia protocol
 Multimodal analgesia
 PONV
 Fluid management
 Hypotermia prophylaxis
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)
Intraoperative ERAS components
 Antimicrobial prophylaxis
 Anesthesia
protocol
PONV
 Fluid management
 Hypotermia prophylaxis
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
Intraoperative Monitoring
BIS
Hypnosis
Algiscan
TOF
Analgesia
Muscle
relaxation
Glucometer
Glucose
ERAS
Oesophageal
doppler
Cardiac
output
Intraoperative ERAS components
 Antimicrobial prophylaxis
 Anesthesia protocol
 Multimodal analgesia
 PONV
 Fluid management
 Hypotermia prophylaxis
Multimodal analgesia
Epidural analgesia
iv analgesia
Wound catheters/infiltration
Peripheral blocks
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
Causes of ileus
•
•
•
•
•
Degree of surgical manipulation
Magnitude of inflammatory and stress response
Sympathetic reflexes
Opioids
Fluid overload/ bowel oedema
Epidural analgesia vs iv opiates
GI function
• EDA results in less GI paralysis
Jorgensen Cochr Database Syst Rev 2004
Intraoperative ERAS components
 Antimicrobial prophylaxis
 Anesthesia protocol
 Multimodal analgesia
 PONV
 Fluid management
 Hypotermia prophylaxis
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
Intraoperative ERAS components
 Antimicrobial prophylaxis
 Anesthesia protocol
 Multimodal analgesia
 PONV
 Fluid
management
 Hypotermia prophylaxis
Perioperative fluid management
Is fluid therapy vital for outcome ?
Are the fluid requirements the same ?
What about fluid shifts ?
 What amount ?
 What type of fluid ?
 Is there an indication for vasopressors ?
 When iv fluids should be discontinued ?
Post-op Weight Gain
Following Colorectal Resection
KCH Fearon 2004
3-6kg
Lobo et al, Lancet
359: 1812-18
Brandstrup et al, 2002;
Annals Surg 2003; 238: 641-8
Perioperative fluid management
DO2 = CO (SV x HR) x CaO2 x 10
Bundgaard-Nielsen,et al. Acta Anaesth Scand 2009, 53: 843–851
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
Fluid requirements are different
Open laparatomy
• Increase fluid shifts
• Bowel handling
• SIRS
Laparoscopy
• CO reduction
• Head-down position
• Pneumoperitoneum
Fluid shifts should be minimised
 Avoid bowel preparation
 Maintain hydration till 2 hours before surgery
 Minimise bowel handling
 Avoid blood loss
Goal Directed Therapy
The use of cardiac output / surrogate
to guide iv fluid
alone or in combination with inotropics
during the perioperative period.
Goal directed intra-operative fluid therapy
Noblett et al. BJS 2009
Meta analysis based on amount of fluid given
<1.75 liters/24h
>2.75 liters/24h
Varadhan K, Proc Nutr Soc, 2010
Fluids – recent meta‐analysis
Rahbari NN, BJS 2009: 96: 331
Types of fluids
cristaloids and coloids
Varadhan K, Proc Nutr Soc, 2010
59% reduced risk for complications
3.4 days reduction in hospital stay
Perioperative fluid management
Fluid therapy is vital for outcome
Fluid requirements are different
Fluid shifts should be minimised
Fluid administration must be goal directed
 The types of fluids – cristaloids and coloids
 Vasopressors are indicated in hypotensive normovolemic
patients
 Iv fluids should be discontinued as soon as practicable
Intraoperative ERAS components
 Antimicrobial prophylaxis
 Anesthesia protocol
 Multimodal analgesia
 PONV
 Fluid management
 Hypotermia
prophylaxis
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
Hypothermia prophylaxis
Hypothermia – central temperature < 36 C
Methods
warming devices
(forced air warming blankets)
warmed iv fluids
warm gases in laparoscopic surgery
Postoperative ERAS components
Postoperative analgesia
Fluid management
Postoperative glycaemic control
Postoperative nutrition
Early mobilisation
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
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
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
Postoperative analgesia
in open surgery

Thoracic epidural anesthesia (TEA)
– Low dose concentration
of local anesthetic
– Short acting opiate
– Maintained for 48 -72 h postoperative
Efficacy of Postoperative Epidural
Analgesia: A Meta-analysis
Block BM et al, JAMA. 2003;290(18):2455-2463
Epidural analgesia vs opiates GI function
• EDA results in less GI paralysis (vs iv opiates)
Jorgensen Cochr Database Syst Rev 2004
Postoperative analgesia
in laparoscopic surgery
• Spinal analgesia
– Low dose long acting opioid- morphine
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
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
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
Postoperative ERAS components
Postoperative analgesia
Fluid management
Postoperative glycaemic control
Postoperative nutrition
Early mobilisation
Varadhan K, Proc Nutr Soc, 2010
59% reduced risk for complications
3.4 days reduction in hospital stay
Postoperative ERAS components
Postoperative analgesia
Fluid management
Postoperative glycaemic control
Postoperative nutrition
Early mobilisation
Postoperative glycaemic control
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
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.
Postoperative ERAS components
Postoperative analgesia
Fluid management
Postoperative glycaemic control
Postoperative nutrition
Early mobilisation
Postoperative nutrition
Fluids immediately after recovery from anesthesia
Normal hospital food on day 1
Food intake
kcal / 24h
1600
1200
800
400
0
1
2
3
4
Postop days
 traditional care
 enhanced-recovery protocol
Nygren Clin Nutr 2003
Postoperative early enteral nutrition
Lewis et al BMJ 2001;323(7316):773-6
Postoperative ERAS components
Postoperative analgesia
Fluid management
Postoperative glycaemic control
Postoperative nutrition
Early mobilisation
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
Outline
 Anesthetist approach
 Surgeon approach
 Protocolization
”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
” 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
Surgeon:
Anesthetist:
No bowel prep
Carbohydrates
Food after surgery
No fasting
No drains or KAD
No premedication
No iv fluids, no lines
Epidural Anesthesia
Early discharge
Balanced fluids
Vasopressors
All evidence based!
No or short acting opioids
SURGEONS!!
TRADITION
EVIDENCE
BASED
MEDICINE
BOWEL PREPARATION
• PRO
– Avoids massive contamination !?!
– Minor inconvenience to the patient !?!
– Looks better inside !?!
• CON
– Preoperative dehydration !!!
– Modification of enteral flora !!!
– Delayed gut motility !!!
Arch Surg. 2004 Dec;139(12):1359-64; discussion 1365.
Mechanical bowel preparation for elective colorectal surgery: a
meta-analysis.
Bucher P, Mermillod B, Gervaz P, Morel 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.
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
Reduce surgical injury
Minimally invasive surgery
• FAST TRACK Surgery
• Early postoperative recovery
– Decreased stress response
– Decreased inflammatory response
– Decreased pain
– Early bowel movement
FAST TRACK
• Early rehabilitation
• Minimally invasive surgery
NOT MANDATORY for FAST TRACK surgery
but
shortens hospitalization
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.
No drains
• Rationale of drains:
“When in doubt, drain”
Lawson Tait, english surgeon
“The drain= the surgeon eye in the patients abdomen”
•
•
•
•
A surgical tradition
Difficult to be abandoned
For how long? 24h / 48h / 7days ???
In majority of cases – serous drained fluid
(physiological reabsorption)
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.
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
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
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
THE SURGEON
the cornerstone
of FAST TRACK and ERAS programs
Outline
 Anesthetist approach
 Surgeon approach
 Protocolization
Preoperative Preoperative
optimisation
Analgesia
nutrition
Preoperative
Fasting
Carbohydrates
Treatment
Fluid
management
Properative
prophylaxys
Preventing
PONV
hypotermia
Analgesia
Fluid
management
Postoperative
Early
nutrition
mobilisation
1. ERAS
Results?
Randomised trials
Meta analysis
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
ERAS - clinical outcome
 Review of 6 RCTs (n=452)
Complications
Reduce complications by 50%
K K. Varadhan et al. Clin Nutr, 2010: 29 ;434–440
ERAS - clinical outcome
 Review of 6 RCTs (n=452)
Mortality
K K. Varadhan et al. Clin Nutr, 2010: 29 ;434–440
ERAS - clinical outcome
 Review of 6 RCTs (n=452)
Length of stay
Shorter length of stay by 2.5 days
K K. Varadhan et al. Clin Nutr, 2010 : 29 ;434–440
Readmissions (days)
Experimental group= Enhanced
JAMA Surgery
2011
“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.
Ciaran O’Hare
Ciaran O’Hare
World J Surg. 2011 Sep 1.
Fast-Track Concepts in Major Open Upper Abdominal
and Thoracoabdominal Surgery: A Review.
Fagevik Olsén M, Wennberg E.
15 articles:
gastric (n = 2),
pancreatic (n = 5),
hepatic (n = 2),
esophageal (n = 3),
aortic surgery (n = 3)
.
Sipos P, HMJ, 2007 Vol.1, Number 2,165–174
Anesth Analg 2007;104:1380-1396
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000263034.96885.e1
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.
ORIGINAL ARTICLE
Current perioperative practice in rectal surgery in Austria and Germany
Till Hasenberg, Friedrich Längle, Bianca Reibenwein, Karin Schindler,
Stefan Post, Claudia Spies,Wolfgang Schwenk and Edward Shang
INTERNATIONAL JOURNAL OF COLORECTAL DISEASE 2010
Volume 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.
“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
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
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
“There is nothing new under the sun
but there are lots of old things
we don’t know.”
Ambrose Bierce.