Transcript Enhanced Recovery after Surgery, what is it and is it worth the trouble

Enhanced Recovery After Surgery:
What is it and is it worth the trouble?
Andrew Hill
Colorectal Surgeon
Middlemore Hospital, University of Auckland
Auckland Enhanced Recovery After Surgery Group
What is ERAS?
•
•
•
•
AKA Fast-track or ERP
Developed by Kehlet in Denmark in colonic
surgery
Gradually has gained world-wide acceptance
Originally described in Open Surgery but same
advantages seem to apply for Laparoscopy
ERAS Results
Type of Operation
Duration of stay
Carotid endarterectomy
1-2 days
Lung lobectomy
1-2 days
Prostatectomy
1-2 days
Colectomy
1-3 days
Aortic Aneurysm
3-4 days
What is ERAS?
Pre-op
Patient Information
•
•
At the clinic
Ward visit
Carbohydrate drinks
•
•
4 night before surgery if having bowel prep
2 morning of the surgery
No mechanical bowel preparation
•
Enema morning of surgery for L) sided cases
Patients admitted on the morning of surgery
Surgery
Thoracic Epidural Analgesia
Incision choice
•
•
Transverse for R) sided
Mid-line or Laparoscopic for L) sided
Avoidance of Drains and NGT post-operatively
Limited Intra-Operative fluid therapy
•
•
Aiming to max of 1.5-2 L
Goal Directed
After surgery
Cessation of IVF
•
•
unless clinically indicated
Pressors for epidural hypotension
Regular pre-emptive antiemetics
•
ondansetron as first line
On arrival to the ward
•
•
Patient sits up
Starts drinking protein drinks (Resource/Fortisip etc)
Day 1
•
•
•
•
IDC 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 1400 if pain
controlled, and timed with Clexane dose
Day 3/4 - discharge criteria:
•
•
•
•
•
Return of GI function
Able to eat and drink without discomfort
Passing flatus, or moved a B/M
Pain controlled with oral analgesia
Adequate home support
Discharge date is an important target for
patients and staff but flexibility is vital
ERAS Group
(n = 50)
Control Group
(n = 50)
P Value
Intravenous fluids
Intra-operative
First 3 days
2 (1 – 8)
2 (1 – 10)
3 (1 – 7.5)
6.5 (1 – 12)
<0.0001†
<0.0001†
Epidural analgesia
No. of patients
Duration of use (days)
44 (89%)
2 (0 – 3)
38 (76%)
3 (0 – 4)
0.223‡
<0.0001†
1 (1 – 3)
2 (0 – 8)
1 (1 – 3)
2 (1 – 15)
3 (0 – 18)
3 (1 – 7)
<0.0001†
<0.0001†
<0.0001†
12 (24%)
4 (3 – 34)
4 (3 – 34)
29 (58%)
6.5 (3 – 18)
8 (4 – 29)
<0.0001‡
<0.0001†
<0.0001†
6
7
0.766‡
Recovery
Days to 1st full meal
Days to passage of flatus
Days to independent mobilisation
Day stay
No. admitted > 1 day before surgery
Postoperative stay (days)
Total hospital stay (days)
Readmissions
No. patients readmitted
ERAS Group Control Group
(n = 50)
(n = 50)
P Value
Complications
Patients with > 1 complication
27
33
0.221
Death
Reoperation
Anastomotic leak
Intra-abdominal collection
Ileus
Wound complication
Urinary tract infection
Urinary retention
Cardiopulmonary
0
4
4
1
5
6
2
5
11
2
4
3
1
18
10
12
3
21
0.495
1.000
1.000
1.000
0.005
0.275
0.008
0.715
0.032
Postoperative Fatigue
Differential cost analysis of
st
1
50 patients
(Savings on day stay and complications)
minus
(Full implementation + maintenance cost)
Final tally
= $446,000 – $102,000
= $344,000
= $6880 per patient
Length of hospital stay (days)
Experimental group= Enhanced Recovery After Surgery (ERAS)
Control = Traditional Care (TC)
Complications
Experimental group= Enhanced Recovery After
Surgery (ERAS)
Readmissions (days)
Experimental group= Enhanced Recovery After
Surgery (ERAS)
Mortality
Experimental group= Enhanced Recovery After
Surgery (ERAS)
A Personal Series-100 Colectomies
Age (median) and range
70 (16-92)
Male
48%
Malignancy
83%
Laparoscopic
17%
ASA 2+
84%
Median Day Stay (range)
3 (2-60)
Readmission Rate
21%
Major Complications
8%
ERAS in Bariatrics
• Randomised Controlled Trial
• 2 Arms
• ERAS vs. Standard Perioperative
Care
Population
•
•
•
Patients undergoing laparoscopic sleeve
gastrectomy (LSG) for weight loss
Eligibility Criteria
•
•
Procedure at Manukau Surgery Centre (MSC)
Consenting surgeon
Exclusion Criteria
•
•
Not at MSC
Redo procedure
Intervention and
Control
• Perioperative care as per Bariatric
Specific ERAS protocol
VS.
• Standard perioperative care
Outcomes
• Primary outcome was initial
median length of hospital stay
(LOS)
• Powered to detect a reduction in
median LOS from 3 (current
figure) to 1 (target from the
literature)
•  :0.05; β:0.8; Sample Size = 56
(28 in each arm)
Follow up time
• 30 day follow up
• Further analysis planned for longer
term follow up on weight loss data
Results
• 71 randomised
• 11 post randomization exclusions
• 60 patients included in analysis
• 31 ERAS group
• 29 Non ERAS group
Baseline
Characteristics
ERAS (31)
Non ERAS (29)
p value
Mean Age
44.3
43.6
0.66
Female
Gender (%)
23 (74)
24 (83)
0.54
Planned Admit
to PCU (%)
8 (26)
1 (3)
0.027
Baseline
Characteristics
ERAS (31)
Non ERAS (29)
p value
Mean Weight
(kg)
132
133.6
0.78
Mean BMI
(kg/m2)
46.2
46.7
0.80
Mean Excess
Weight (kg)
66.9
67.8
0.85
Baseline
Characteristics
ASA
ERAS (31)
Non ERAS (29)
p value
ASA 1
1
0
1.00
ASA 2
18
18
0.80
ASA 3
12
11
1.00
Complications (Cx)
ERAS (31)
Non-ERAS (29) p value
9 (30)
7 (24)
0.77
Major Cx (%) 5 (16.1)
4 (13.7)
1.00
Leak (%)
2 (6.4)
2 (6.8)
1.00
Bleed (%)
3 (9.7)
2 (6.8)
1.00
Total Cx (%)
Length of Stay
(LOS)
ERAS (31)
Non ERAS (29)
p value
Initial LOS
(median)
1
2
<0.001
Readmissions
(%)
5 (18)
5 (18)
1.00
Conclusion
ERAS is possible in a New Zealand public hospital.
ERAS is safe in a New Zealand Hospital
ERAS enhances recovery in a New Zealand Hospital
ERAS is cost-effective in a New Zealand Hospital
ERAS is more than just Colorectal Surgery