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,
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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 F o o d in ta k e 1600 kcal / 24h 1200 800 400 0 1 2 3 4 P o sto p d a y s 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.