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ERAS IN CHIRURGIA ONCOLOGICA PROGETTO EUROPEO
Prof. Marco Braga Università Vita-Salute San Raffaele Milano
X-Files in Nutrizione Clinica e Artificiale Genova, 7-8 Giugno 2012
COST-BENEFIT ANALYSIS ( 100 pts, case-matched )
ERAS IN COLORECTAL SURGERY
ERAS reduced intravenous fluids, epidural analgesia, morbidity, and LOS ERAS significantly reduced costs ( NZ$ 6,900 per patient ).
Simmons, NZMJ 2010
DISTAL PANCREATECTOMY
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Pain
Mobile
U Cath
Drink
Food
No IV
GasSto
ol
Length
of S
tay
Pos
tope
rati
ve d
ays,
med
ian
ERASBefore Eras
HSR series
The main purpose of ERAS is to improve patient quality of life
updating perioperative care pathway
Nursing + Surgery + Anaesthesiology
Evidence-based Surgery vs.
Eminence-based Surgery
ERAS
Epidural Anaesthesia
Prevention of ileus/
prokinetics
CHO - loading/ no fasting
Early mobilisation
Fluid restriction
DVT prophylaxis
Pre-op councelling
Short acting drugs
No - premed
No bowel prep
Perioperative Nutrition
Warming
Oral analgesics/ NSAID’s
Incisions
Early removal of catheters/drains
Lassen , Arch Surg 2009
No NG tubes
ERAS Making radical changes
SURGEON No bowel prep Food after surgery No drains or NGT No iv fluids, no lines Early discharge All evidence based!
ANESTHETIST CHO not fasting No premedication EDA Balanced fluids Vasopressors No or short acting opioids
*Lassen , Arch Surg 2009
N: Univ Tromsö / A Revhaug, K Lassen F: Clermont Ferrand/ K Slim SCO: Univ Edinburgh/ K Fearon Paris/ P Friloux Ge: Charité, Berlin / C Spies CH: Lausanne/ P Dimartines NL: Maastricht/ M v Meyenfeldt, C deJong It: Milan / M Braga ENG: Nottingham/ D Lobo SP: Zaragosa/ J Ramirez St Marks/ R Kennedy S: Örebro/ O Ljungqvist NZ: Northshore Auckland/ M Soop Ersta / J Nygren, J Hausel, More are waiting in line: Israel, Austria, Brazil, Japan, Australia, USA....
ERAS® Society
ERAS Implementation Program
To develop protocols for all major surgery (tailored approach)
ERAS Hospitals Network
ERAS is an integrated perioperative care program
Evidence in medical literature Multi-professional team
Head(s) fully backing working group
July – November 2011
Current Practice Audit 16 December 2011 : I Meeting Presentation Audit ERAS Network
Specialty Sessions (protocols)
Network ERAS Italy
28 strutture aderenti Survey (ottobre- novembre) 700 pazienti 9 specialita’ chirurgiche
DIGIUNO Preoperatorio
Liquidi 8 ± 2
Solidi 13 ±3
Oppiacei Postoperatori
~ 44%
Chirurgia Colica
ERAS ITALY NETWORK
31 HOSPITALS JOINED THE NETWORK SINCE JUNE 2011
−Ospedale Civile - Legnano (MI) −Ospedale Civile - Abbiategrasso (MI) −Ospedale Civile - Magenta (MI) −Ospedale San Matteo - Pavia −A. Osp. Desenzano - Manerbio (BS) −Ospedale S. Anna - Como −S. Antonio Abate – Cantù (CO) - Ospedale Lugano - Svizzera −Ospedale di Lodi −Humanitas, Rozzano (MI) −Clinica S. Carlo - Paderno Dugnano (MI) −IEO - Milano −Ospedale San Paolo – Milano −Ospedale Sacco – Milano - Ospedale Peschiera del Garda (VR)
−Ospedale San Raffaele - Milano −Ospedale S.G. Bosco – Torino −Ospedale Valdese – Torino −Ospedale Misericordia e Dolce – Prato −Centro Oncologico Fiorentino – Firenze - Ospedale Careggi - Firenze −Ospedale S. Martino – Genova −IST – Genova −Ospedale Belcolle – Viterbo −Ospedale Città di Udine - Udine −S. Croce e Carle – Cuneo −Policlinico S. Donato – Milano −Ospedale Parini – Aosta
ERAS ITALY NETWORK
COLORECTAL UROLOGY THORACIC
GYNECOLOGICAL HEAD & NECK UPPER GI
BILIO-PANCREATIC
30 4
2
5
4 2
4
May 2012 Database availability (all patients recording) 14 September 2012 : II Meeting Clinical Report
Deviation Single Items
Italian Project: Next Steps
From October 2012 Problem Correction March 2013 : III Meeting Full Activity Clinical Report
Outcome Data
Manager Circle
Italian Project: Next Steps