Enhanced Recovery after Surgery a paradigm shift in preoperative care

objectives Define Enhanced Recovery After Surgery (ERAS) Benefits of ERAS Results of initiating an ERAS program AHRQ Safety Program for Improving Surgical Care and Recovery (ISCR)

What is ERAS? Fast Track Surgery Multimodal optimization Enhanced recovery after surgery What is ERAS? Fast Track Surgery Multimodal optimization Combination of evidence based peri-operative strategies which work synergistically to expedite recovery after surgery

Why is ERAS different from what we have been doing? Enhanced recovery after surgery Why is ERAS different from what we have been doing? Traditional practices are examined and when necessary replaced with evidence based practice Comprehensive in scope covering all areas of the patient’s journey through the surgical practice

Why is ERAS important? University of Virginia ERAS protocol Enhanced recovery after surgery Why is ERAS important? University of Virginia ERAS protocol 109 patient placed on protocol and compared to 98 historical controls Substantial reductions in length of stay, morphine use, time to return bowel function

Why is ERAS important? length of stay reduced by 2.3 days Enhanced recovery after surgery Why is ERAS important? length of stay reduced by 2.3 days no increase in readmission rate Decrease in Complications (SSI decreased from 20.4 to 7.3)

Why is ERAS important? Decreased total cost of $6,567 per patient Enhanced recovery after surgery Why is ERAS important? Decreased total cost of $6,567 per patient Patient satisfaction (Press Ganey Survey) increased from 36th to 59th percentile

What type of Surgery? Colorectal Gastric Surgery Enhanced recovery after surgery What type of Surgery? Colorectal Gastric Surgery Pancreaticoduodenectomy (Whipple) Gyn-oncology Urology Orthopedics Bariatrics

ERAS for colorectal surgery at QMC Enhanced recovery after surgery ERAS for colorectal surgery at QMC Lilian Kanai, MD Duncan Macdonald, MD Irminne Van Dyken, MD Jun Luo, MD Steven Nishida, MD

Preoperative Referral to Pre Surgery Center (PSC) Enhanced recovery after surgery Preoperative Referral to Pre Surgery Center (PSC) Nutritional optimization Smoking cessation Diabetic control Patient education

Preoperative Regular diet until 2 pm the day prior to surgery Enhanced recovery after surgery Preoperative Regular diet until 2 pm the day prior to surgery Clear liquids after that until 3 hours prior to surgery Mechanical bowel prep (golytely) with Reglan and antibiotic bowel prep (neomycin and erythromycin or metronidazole) Chlorohexidine shower 20 oz Gatorade Thirst Quencher G series 3 hours preop

Preop Hold Area Alvimopan (Entereg) 12 mg PO Gabapentin 600 mg PO Enhanced recovery after surgery Preop Hold Area Alvimopan (Entereg) 12 mg PO Gabapentin 600 mg PO Acetaminophen 1000, mg PO Celecoxib?

Nonsteroidal Anti-inflammatory Drugs and the Risk for Anastomotic Failure A Report From Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP) JAMA Surg. 2015;150(3):223-228. doi:10.1001/jamasurg.2014.2239. Of the 13 082 patients (mean [SD] age, 58.1 [15.8] years; 60.7% women), 3158 (24.1%) received NSAIDs. The overall 90-day rate of anastomotic leaks was 4.3% for all patients (151 patients [4.8%] in the NSAID group and 417 patients [4.2%] in the non- NSAID group; P = .16). After risk adjustment, NSAIDs were associated with a 24% increased risk for anastomotic leak (odds ratio, 1.24 [95% CI, 1.01-1.56]; P = .04). This association was isolated to nonelective colorectal surgery, for which the leak rate was 12.3% in the NSAID group and 8.3% in the non-NSAID group

Nonsteroidal Anti-inflammatory Drugs and the Risk for Anastomotic Failure A Report From Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP) JAMA Surg. 2015;150(3):223-228. doi:10.1001/jamasurg.2014.2239. Of the 13 082 patients (mean [SD] age, 58.1 [15.8] years; 60.7% women), 3158 (24.1%) received NSAIDs. The overall 90-day rate of anastomotic leaks was 4.3% for all patients (151 patients [4.8%] in the NSAID group and 417 patients [4.2%] in the non- NSAID group; P = .16). After risk adjustment, NSAIDs were associated with a 24% increased risk for anastomotic leak (odds ratio, 1.24 [95% CI, 1.01-1.56]; P = .04). This association was isolated to nonelective colorectal surgery, for which the leak rate was 12.3% in the NSAID group and 8.3% in the non-NSAID group

Preop Hold Area Alvimopan (Entereg) 12 mg PO Gabapentin 600 mg PO Enhanced recovery after surgery Preop Hold Area Alvimopan (Entereg) 12 mg PO Gabapentin 600 mg PO Acetaminophen 1000, mg PO Celecoxib?

Preop Hold Area Alvimopan (Entereg) 12 mg PO Gabapentin 600 mg PO Enhanced recovery after surgery Preop Hold Area Alvimopan (Entereg) 12 mg PO Gabapentin 600 mg PO Acetaminophen 1000, mg PO Celecoxib? No NSAID if anastomosis is planned

Preop Hold Area Aprepitant 40 to 80 mg po for high risk PONV patients Enhanced recovery after surgery Preop Hold Area Aprepitant 40 to 80 mg po for high risk PONV patients Scopolamine transdermal patch if patient less than 65 years old (24 hours duration total) Lovenox 40 mg SubQ if no neuraxial block was to be given Preoperative Antibiotics Cefazolin/Metronidazole or Cipro/Metronidazole

Preop Hold Area Aprepitant 40 to 80 mg po for high risk PONV patients Enhanced recovery after surgery Preop Hold Area Aprepitant 40 to 80 mg po for high risk PONV patients Scopolamine transdermal patch if patient less than 65 years old (24 hours duration total) Lovenox 40 mg SubQ if no neuraxial block was to be given Preoperative Antibiotics Cefazolin Ceftriaxone/Metronidazole or Cipro/Metronidazole Ertapenem

Enhanced recovery after surgery Intraoperative Thoracic epidural if open surgery (avoid lovenox if spinal or epidural) Spinal Duramorph Heparin 5,000 SubQ given immediately after neuraxial block Transversus Abdominis Plane Block if Laparoscopic Avoidance of narcotics

Enhanced recovery after surgery Intraoperative Lidocaine Drip 1.5 mg/kg/hr to be stopped at end of surgery if epidural or spinal unsuccessful or contraindicated Ketamine 0.5 mg/kg/hr to be stopped before end of surgery magnesium 30 mg/kg with induction

Intraoperative Dexamethasone 4 mg IV after induction of anesthesia Enhanced recovery after surgery Intraoperative Dexamethasone 4 mg IV after induction of anesthesia Prevention of hypothermia Avoidance of N2O Ondansetron 4 mg IV at the end of surgery

Intraoperative Fluid management guided by Goal Directed Therapy Enhanced recovery after surgery Intraoperative Fluid management guided by Goal Directed Therapy Maximo Pleth Variability Index Esophageal Doppler LiDCO Rapid Edwards ClearSight or FloTrac

Intraoperative Enhanced recovery after surgery Figure 1. Intraoperative fluid management algorithm. EBL, estimated blood loss; gtt, drip; MAP, mean arterial pressure; PHE, phenylephrine; PVI, Pleth Variability Index; UOP, urine output.

Enhanced recovery after surgery Goal Directed Therapy

Intraoperative Preference for use of laparoscopy Enhanced recovery after surgery Intraoperative Preference for use of laparoscopy Short low transverse incisions for open surgery Avoidance of drains and NG tube Separate clean fascial closure tray

PACU Clear Liquids unless aspiration risk 80% FiO2 for 6 hours postop Enhanced recovery after surgery PACU Clear Liquids unless aspiration risk 80% FiO2 for 6 hours postop Avoidance of narcotics

Morphine paradoxically prolongs neuropathic pain in rats by amplifying spinal NLRP3 inflammasome activation Peter M. Gracea,, Keith A. Stranda,, Erika L. Galera,, et.al. Proc Natl Acad Sci U S A. 2016 Jun 14;113(24) a short course of morphine after nerve injury doubles the duration of neuropathic pain.

Postop Acetaminophen 1 gm oral or intravenous q 6 hours Enhanced recovery after surgery Postop Acetaminophen 1 gm oral or intravenous q 6 hours Oxycodone 5-10-15 mg q 4 hr prn pain or Tramadol 50 mg q 4 hours after surgery Celecoxib 100mg PO BID if no anastomosis Alvimopan 12 mg BID for 7 days Magnesium oxide 400 mg PO daily

Postop Ondansetron 4 mg IV q6 or 8 mg PO q6 prn Enhanced recovery after surgery Postop Ondansetron 4 mg IV q6 or 8 mg PO q6 prn Promethazine 6.25 to 12. 5 mg IVPB or 12.5 to 25 mg PO q4 to q6 h prn Gabapentin 300 mg PO QHS If not regional block consider IV parenteral opioid rescue

Postop IV fluids are run at 40 ml/hr Enhanced recovery after surgery Postop IV fluids are run at 40 ml/hr IV fluids are discontinued within 24 hours after surgery No IV boluses for low urine output Decision to bolus fluid should based on hypotension and tachycardia

Postop Continuation of 80% FiO2 for 6 hours postop Enhanced recovery after surgery Postop Continuation of 80% FiO2 for 6 hours postop Ambulation within 3 hours of surgery Elevation of head of bed at 30 degrees at all times Regular diet on Postop day 1 Removal of foley on Postop day 1

Discharge When tolerating a regular diet and having brown BM Enhanced recovery after surgery Discharge When tolerating a regular diet and having brown BM Acetaminophen 1 gm q 8 hours for one week Oxycodone 5 mg q 4 hours prn

ERAS Our results

ERAS at Queen’s Health Systems

ERAS Demographics Risk Level 1: 10 year survival rate of > 90%

ERAS group has less outliers and a shorter LOS

This even applies to laparoscopic procedures – ERAS patients has a shorter LOS

No aspiration cases in ERAS group. Lower rates of ileus in ERAS group.

Enhanced recovery After surgery Where do we go from Here?

Using this dashboard to monitor our process and balance metrics – also as a marketing tool to get buy in from other surgeons, administration etc.

AHRQ Safety program for improving surgical care and recovery (ISCR) Enhanced recovery after surgery AHRQ Safety program for improving surgical care and recovery (ISCR) Comprehensive program for improving perioperative care Included principles or ERAS but also incorporates all of the most recent evidence for SSI, DVT and UTI prevention Joint endeavor of American College of Surgeons, John Hopkins Armstrong Institute for Patient Safety and Quality, and is sponsored by the Agency for Healthcare Research and Quality (AHRQ)

Triple Aim!! Summary ERAS protocols are an effective way to: Enhanced recovery after surgery Summary ERAS protocols are an effective way to: Decrease costs by decreasing hospital stay Decrease patient complications Improve patient satisfaction Triple Aim!!

Questions?