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Enhanced Recovery After Surgery

Kaya YORGANCI MD, Professor of Surgery & Critical CareHacettepe University Faculty of MedicineDepartment of General Surgery Ankara - Turkey

BackgroundAverage length of hospital stay after colorectal abdominal surgery was still 1015 daysOR and hospital beds shortageLooooong waiting listsERAS originated in colorectal surgery in Denmark

BackgroundKey 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 carePatients 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 disciplinesWithin the UK, including colorectal, musculoskeletal, gynaecological and urological surgery.Quicker recoveryEfficient use of resourcesSuccessful implementation requires close collaboration between surgeons, anaesthetists, nurses, dietitians and experts in rehabilitation

Elements of enhanced recovery protocol

Members ofthe multidisciplinary teamNursesDietitiansPhysiotherapistsPain teamTheatre staffAnaesthetistsSurgeonsHospital managementAudit team

Preadmission Information and CounsellingExplicit preoperative patient information can facilitate postoperative recoveryPain control, particularly in patients who exhibit the most denial and highest levels of anxiety A clear explanation of what is to happen during hospitalisationPatient should also be given a clear role with specific tasks to perform, including targets for food intake and mobilisation

Preoperative Fasting and Metabolic ConditioningFasting after midnight has been standard practice to avoid pulmonary aspiration in elective surgeryclear fluids up until 2 h before surgery6 h fast for solid foodPatients should be in a metabolically fed state rather than fasted when they go to ORClear carbohydrate-rich beverage before midnight and 23 h before surgery. reduces preoperative thirst, hunger and anxietySignificantly reduces postoperative insulin resistanceThis 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 ProtocolsThe 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 catheterblocks stress hormone release and attenuates postoperative insulin resistanceAnalgesiaPrevents gut paralysis

Surgical TechniqueMinimal invasive surgery, if possible

Fine surgical techniqueLess bleedingLess traumaRespect to tissues and organsAvoid hypothermia

Surgical IncisionsTransverse or curved incisions cause less pain and pulmonary dysfunction than vertical incisions following abdominal proceduresincision length affects patient recovery

Multimodal Pain ReliefContinuous epidural local anaesthetic NSAIDsAvoid opioids

Promoting Early Oral IntakePostoperative ileus is a major cause of delayed discharge from hospital Epidural analgesiaAvoiding fluid overloading during ,and following surgery Laparoscopic surgeryAvoidance of routine nasogastric intubationControl of post-op nausea and vomitingAccess to adequate normal food, access to oral nutritional supplements

Early MobilisationBed 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 CriteriaPatients can be discharged when they meet the following criteria:Good pain control with oral analgesiaTaking solid food, no intravenous fluidsIndependently mobile or same level as prior to admissionAll of the above and willing to go home.The discharge process starts at the preadmission counselling session

Enhanced Recovery After SurgerySaves moneySaves resourcesSaves timeWith no inreased complication rate