Enhanced Recovery After SurgeryKaya YORGANCI MD, Professor of Surgery &

Critical CareHacettepe University Faculty of Medicine

Department of General Surgery Ankara - Turkey

Background

• Average length of hospital stay after colorectal abdominal surgery was still 10–15 days

• OR and hospital beds shortage• Looooong waiting lists• ERAS originated in colorectal surgery in

Denmark

Background

• Key actors that keep a patient in hospital after uncomplicated major abdominal surgery – the need for parenteral analgesia (persistent pain), – intravenous fluids (persistent gut dysfunction), – bed rest (persistent lack of mobility).

What is Enhanced Recovery After Surgery ?

• Transformed perioperative care• Patients’ optimal return to normal function after major

surgery. • The term ERAS was coined in 2001 by a group of academic

clinicians (the ERAS Group) to replace the expression of ‘Fast Track’ surgery, and to emphasise the quality of the patients’ recovery, rather than the speed of discharge.

• This group formed the ERAS Society for perioperative care ( www.erassociety.org )

• Enhanced recovery is now becoming firmly established across a range of disciplines– Within the UK, including colorectal, musculoskeletal,

gynaecological and urological surgery.• Quicker recovery• Efficient use of resources• Successful implementation requires close

collaboration between surgeons, anaesthetists, nurses, dietitians and experts in rehabilitation

Elements of enhanced recovery protocol

Members ofthe multidisciplinary team

• Nurses• Dietitians• Physiotherapists• Pain team• Theatre staff• Anaesthetists• Surgeons• Hospital management• Audit team

Preadmission Information and Counselling

• Explicit preoperative patient information can facilitate postoperative recovery

• Pain control, particularly in patients who exhibit the most denial and highest levels of anxiety

• A clear explanation of what is to happen during hospitalisation

• Patient should also be given a clear role with specific tasks to perform, including targets for food intake and mobilisation

Preoperative Fasting and Metabolic Conditioning

• Fasting after midnight has been standard practice to avoid pulmonary aspiration in elective surgery– clear fluids up until 2 h before surgery– 6 h fast for solid food

• Patients should be in a metabolically fed state rather than fasted when they go to OR– Clear carbohydrate-rich beverage before midnight and 2–3 h before

surgery. • reduces preoperative thirst, hunger and anxiety• Significantly reduces postoperative insulin resistance• This also results in patients being in a more anabolic state with less

postoperative nitrogen and protein losses, • better maintained lean body mass and muscle strength

Anaesthetic Protocols• The evidence to direct the choice of the optimal anaesthetic

method for ER procedures is complex and controversial. – However, it is rational to use short-acting agents (propofol,

remifentanil)– Long-acting i.v. opioids (morphine, fentanyl) should be avoided.– Shortacting inhalational anaesthesia is a reasonable alternative to

total intravenous anaesthesia.• Mid-thoracic epidural catheter

– blocks stress hormone release and attenuates postoperative insulin resistance

– Analgesia– Prevents gut paralysis

Surgical Technique

• Minimal invasive surgery, if possible

• Fine surgical technique– Less bleeding– Less trauma– Respect to tissues and organs– Avoid hypothermia

Surgical Incisions

• Transverse or curved incisions cause less pain and pulmonary dysfunction than vertical incisions following abdominal procedures

• incision length affects patient recovery

Multimodal Pain Relief

• Continuous epidural local anaesthetic • NSAID’s• Avoid opioids

Promoting Early Oral Intake

• Postoperative ileus is a major cause of delayed discharge from hospital – Epidural analgesia– Avoiding fluid overloading during ,and following

surgery – Laparoscopic surgery– Avoidance of routine nasogastric intubation– Control of post-op nausea and vomiting– Access to adequate normal food, access to oral

nutritional supplements

Early Mobilisation

• Bed rest increases insulin resistance and muscle loss,

• Decreases muscle strength, pulmonary function and tissue oxygenation

• The aim is for patients to be out of bed for 2 h on the day of surgery, and for 6 h a day until discharge.

Discharge Criteria

• Patients can be discharged when they meet the following criteria:– Good pain control with oral analgesia– Taking solid food, no intravenous fluids– Independently mobile or same level as prior to

admission– All of the above and willing to go home.

• The discharge process starts at the preadmission counselling session

Enhanced Recovery After Surgery

• Saves money• Saves resources• Saves time• With no inreased complication rate