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Enhanced Recovery After Surgery (ERAS) Program: Update Course 2016
Chapter 5 of 5 · Case-Based Learning
Q&A session
Interactive Discussion and Practical Questions
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What the experts said
National anesthesia guidelines permit drinking carbohydrate clear liquids until 2 hours before operation, though this is not widely practiced
The sooner an IV is out of the patient's hand and the patient is out of the hospital, the patient becomes safer, because as long as humans are in the hospital there is risk for medication errors involving the five rights
Preoperative pain medicine cocktail includes gabapentin and acetaminophen in large quantities; adult colleagues add celecoxib
Patients receive complex carbohydrate drinks 2 hours preoperatively to drive insulin levels up protectively during the case
Some adult programs use IV lidocaine intraoperatively to attenuate inflammatory response from surgical wounding, helping patients recover more quickly
A 17-year-old outpatient ulcerative colitis patient had colectomy and was ready to go home on postoperative day 1 (kept until day 2 for ileostomy teaching), same pattern for J-pouch and ileostomy closure
Inpatient IBD patients on TPN and steroids don't go home in 2 days but will go home in 3-4 days with ERAS protocol, compared to longer traditional stays
Individual ERAS components may not have significant evidence base by themselves, but when bundled together like other care bundles, they create a second-order change
In first 3 years of ERAS implementation, speaker achieved 5-8 protocol components individually; after formally creating multidisciplinary team with nurse clinician and engaged anesthesiologists, compliance dramatically improved
Anesthesiologists see ERAS as part of their future through the surgical home concept, making them natural partners in implementation
Monthly ERAS team meetings discuss compliance, review each individual patient from the past month, identify upcoming cases, and address areas needing improvement
Nursing staff, anesthesiologists, and surgeons each see different aspects of ERAS; training the team about all components is very important for successful implementation
Society of Pediatric Anesthesia annual meeting last year focused entirely on enhanced recovery, generating significant excitement among anesthesiologists
Providing data and improved outcomes to surgical colleagues is more effective for gaining adoption than simply advocating for protocol changes
Residents from general surgery rotating through adult colorectal programs understand ERAS and create a halo effect, with fellows surreptitiously applying ERAS principles to other surgeons' patients
Better to underpromise and overdeliver with ERAS implementation; establish solid foundation in your own division before spreading to other services like urology or head and neck surgery
Gabapentin is an anti-seizure medication that influences neurologic pain and works well without narcotic side effects; in-house dosing is 10 mg per kilogram
Chewing gum in school-aged patients generates saliva that goes down GI tract, stimulating bowel function and gas passage; it is a cheap addition to ERAS protocol
Henrik Kehlet published results 20 years ago showing sigmoidectomy patients discharged within a couple of days after open operation with multimodal care, achieving return to work without high return-to-system rate and very low complication rate
Traditional patients receive 3 times the IV volume intraoperatively compared to enhanced recovery patients, based on studies monitoring intraoperative fluid administration
Adult colorectal surgeons have a large number of randomized controlled trials demonstrating ERAS reduces complications and length of stay without causing return to the system
Meta-analysis from adult colorectal surgery demonstrates ERAS significantly decreases length of stay and types of non-surgical complications including VTEs, urinary tract infections, and surgical site infections without increase in readmissions
Pediatric ERAS literature consists of only 5-6 articles, most written by Ben-Oni Mathai, showing decreased length of stay with same complication rate and no increase in return-to-system rate
Pediatric ERAS studies only used about 25% of available protocol components (approximately 5 of 20 steps), whereas adult programs implement 17-20 steps
Goal-directed fluid therapy using pressors and albumin helps limit fluid administration; the most important inflection point at MD Anderson was preventing residents from bolusing patients postoperatively
Emory adult colorectal program uses checklists for pre-op clinic, day surgery, day of surgery/post-op day 0, and post-op day 1, plus patient goal sheets
Recent Journal of Pediatric Surgery study showed 70% of patients are NPO longer than necessary and come to operating room dehydrated
Most recent literature on mechanical bowel prep suggests combining mechanical prep with oral antibiotics provides the best outcomes, though this changes yearly
When Atul Gawande's checklist protocol had only 30% compliance rate, it still dropped mortality in half, demonstrating that partial protocol compliance can still produce significant benefits