ERAS: ENHANCED RECOVERY AFTER SURGERYMeredith C. Duffy, MDAssistant Professor, Gynecologic Oncology

MD Anderson Cancer Center at Cooper

Cooper Medical School of Rowan Univ.

LEARNING OBJECTIVES

Describe characteristics of ERAS pathway in gynecologic surgery

Described patient benefits of ERAS Review challenges of implementing ERAS

ERAS: ENHANCED RECOVER AFTER SURGERY

Fast Track, ERP (Enhanced Recovery Pathway) Collection of evidence-based practices bundled to

improve recovery for patients undergoing major surgery

Reduce surgical stress Maintain normal physiologic function Enhancing early mobilization after surgery

Presenter

Presentation Notes

Though intraoperatively, technique does not need to change, there is a trend toward MIS approach

PREOPERATIVE

COUNSELING Verbal education

Leaflets

Multimedia information

BENEFIT Sets expectations about surgery,

anesthesia and recovery

Explains procedure and planned interventions for ERAS

Reduce stress

PREOPERATIVE

PREOP OPTIMIZATION Smoking

Alcohol consumption

Glucose control

Anemia

BENEFIT Pulmonary improvement within 4

weeks of smoking cessation

Chronic EtOH use: cardiac function, blood clotting, immune function, response to surgical stress → excess morbidity

Risk of unrecognized hyperglycemia results in higher risk of adverse events than for those with known DM

Anemia should be identified preoperatively though there no evidence to support preoperative over intraoperative transfusion

PREOPERATIVE

OMIT PREOP BOWEL PREP Mechanical bowel prep and/or

enemas should not be used routinely, even if bowel resection is planned

BENEFIT Reduces patient stress/anxiety and

dehydration

Infection and anastomotic leak are similar with and without bowel prep (9.6% and 4.4% vs 8.5% and 4.5%)

May be benefit if patient undergoing low anterior resection

PREOPERATIVE

PREOP FASTING AND CARB LOADING

Clear fluids until 2 hours before surgery

Solid foods until 6 hours before surgery

Carb loading prior to surgery: ClearFast, Gatoraid,

G2 Poweraid Zero

BENEFIT Does not increase gastric content,

reduce gastric fluid pH, or increase complications

Reduces postop insulin resistance up to 50%

Improves preoperative wellbeing, reduces nausea/vomiting

PREOPERATIVE

PREOP MEDS DVT prophylaxis should be

administered preoperatively

BENEFITPreop vs Post op anticoagulation in Gyn Onc:

Heparin or LMWH plus mechanical methods

Reduce DVT risk:

1.9% vs 8% (p=0.04)

It is safe:

No increased risk of hemorrhage, thrombocytopenia

High Risk Benign Gyn surgery:

Heparin or LMWH or mechanical methods

Lasting less than 30 mins, older than 60

Lasting more than 60 mins, older than 40

INTRA-OPERATIVE

ANESTHESIA MANAGED Prevention of nausea/vomiting

Restrictive fluid management Normothermia during surgery

BENEFIT Administration of antiemetic

prophylaxis

PONV can be reduced with decreased or omission of opioids and emetogenic anesthetics (NO, neostigmine), use of propofol

Aim for normovolemia: shorter LOS, earlier return of GI function

Hypothermia diminishes drug metabolism, negatively impacts coagulation, cardiac morbidity and wound infection

INTRA-OPERATIVE

SURGEON MANAGED Minimally invasive surgery

Nasogastric tube

BENEFIT Decreased blood loss, LOS, return of

bowel function, less fluid requirements, less opioid requirements

ERAS is beneficial for open and MIS approaches

No improvement in nausea/vomiting with NG tube

Recommend NG tube during laparoscopy or robotics, but remove at extubation

POSTOPERATIVE

EARLY FEEDING Oral fluid and food intake on day of

surgery, when possible

Can add Protein drinks 3x daily

BENEFIT Accelerates return of bowel function Reduces length of stay Decreased complications:

Better nutrition assists with wound healing Maintain GI mucosal integrity: stress ulcers,

colonization, sepsis It is associated with increased rate of nausea,

but not vomiting, NG tube placement or distension

Improves patient satisfaction Decreases need for continued IV Fluids

Provides Protein, Vitamins and Minerals as well as Carbohydrates

POSTOPERATIVE

FLUID MANAGEMENT Discontinue IV Fluids 12-24 hours

postop

Minimize IV fluids when needed:

1.2 mL/kg crystalloid (about 90cc/hour for 75 kg female)

BENEFIT Provides normovolemia

Excess IV fluid is associated with a worse outcome:

Delays return of bowel function

Prolongs length of hospital stay

Impairs tissue oxygenation

Inhibits wound healing

Bundgaard-Nielsen. Acta Anaesthesiol Scand 2009;53: 843-851

POSTOPERATIVE

PREVENTION OF POSTOP ILEUS Laxatives

Perioperative chewing gum

BENEFIT Limited data, but low cost and side

effects Milk of Mag and Biscolic suppositories

Tolerated and decreased LOS compared to historic controls (20 nonrandomized gyn patient trial)

Promote gut motility via cephalic-vagal and cephalic-colic reflexes

Laxative-like effect of stereoisomer sugars in sugar-free gum

Less nausea and fewer with post-op ileus

POSTOPERATIVE

POST OP PAIN MANAGEMENTMultimodal approach:

NSAIDS and Acetaminophen (combo preferred)

Gabapentin

Dexamethasone (unless contraindicated)

Regional anesthesia (spinal, TAP block-transversus abdominus plane)

Wound infiltration with local anesthetic: catheter or liposomal bupivicaine

Minimally invasive surgery

BENEFITBetter pain control results in:

More patient satisfaction

Fewer postop complications

May lessen development of chronic pain

Regional anesthesia is a beneficial for open procedures

POSTOPERATIVE

POST OP PAIN MANAGEMENT Reduce opioid use

Opioids via oral or PCA route may be employed if needed

BENEFIT Reduces postop nausea, fatigue,

sedation, ileus

Can improve implementation of other ERAS objectives (ie early ambulation and feeding)

POSTOPERATIVE

URINARY DRAINAGE Removal of urinary catheter 6 hours

postop appears most advantageous

BENEFIT RCT of 221 women who underwent TAH

for benign reasons (in Egypt, 4/2010-12/2012)

Evaluated complications associated with immediate (0 hrs), intermediate (6 hrs) and delayed (24 hrs) removal

Immediate removal associated with urinary retention more often (16% vs 2.5 and 0%)

Delayed removal (24 hrs) associated with higher rates of: UTI (15 % vs early 1.4% and

intermediate 3.7%) p=0.008 Delayed ambulation (10.3 hrs vs 4.1

hrs and 6.8hrs)p=0.001 LOS (5.6 days vs 3.2 and 3.4 days)

p=0.001

POSTOPERATIVE

EARLY MOBILIZATION Start within 24 hours of surgery Eat all meals in chair

What limits patient mobilization? Symptoms: pain, dizziness

(hypotension, anemia), weakness Physical: Attachment to IV poles,

tubes, drains Psychological- need for continued

education throughout ERAS process

BENEFITHypothesized benefits: Reduced pulmonary complications Decreased insulin resistance Less muscle atrophy Reduced LOS Reduced venous thrombotic

complications

Compliance withother ERAS protocolshelp achieve earlymobilization

MAKING IT HAPPEN

CHALLENGES TO IMPLEMENTATION Manpower

Manpower

Manpower

Support staff to provide preoperative and ongoing education on ERAS

Educate all team members involved:

Staff in the office, PAT, Holding Area, PACU, Floor

Residents, Pas, NPs who are writing the orders

Communication: Designate cases as ERAS

Reassess how we are doing

THANK YOU!

erassociety.org

REFERENCES

1) ACOG Practice Bulletin. Clinical management guidelines for Ob-Gyn. Number 84: August 2007

2) Ahmed, et al. Timing of urinary catheter removal after uncomplicated total abdominal hysterectomy: a prospective randomized trial. Euro J Obstet Gyn RB. 2014; 176: 60-63.

3) Awad S, Lobo D. Metabolic conditioning to attenuate the adverse effects of perioperative fasting and improve patient outcomes. CurrOpin Clin Nutr Metab Care 2012; 15:194-200.

4) Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative compolications. Cochrane Database Syst Rev 2009; 7(4):CD005285

5) Bundgaard-Nielsen M, Secher N. ‘Liberal ‘ vs ‘restrictive’ perioperative fluid therapy- a critical assessment of the evidence. Acta AnaesthesiolScan. 2009; 53: 843-851.

6) Collins R. No more overnight fasting? Lecture ERAS Society Congress Lecture Series. 2nd World ERAS Congress. April 2014. Valencia, Spain.

REFERENCES

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10) Kalogeria, et al. Enhanced recovery in gynecologic surgery. Obstet. Gynecol. 2013; 122 (2 Pt1), 319-328.

REFERENCES

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13) Lobo D, Bostock K, Neal K, et al. Effects of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet 2002; 359(9230): 1812-1818.

14) Minig, et al. Reduction of postoperative complication rate with the use of early oral feeding in gynecologic oncology patients undergoing a major surgery: a randomized control trial. Ann. Surg. Onc 2009; (16) 3101-3110.

15) Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2005; 1: CD004929.

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