Enhanced Recovery After Surgery (ERAS) clinical pathway for patients undergoing pancreatic surgery decreases hospital length of stay   Hayden P. Kirby, M.D.1, Timothy P. Rohman, M.D.1, Ryan Bialas M.D.1, Robert S. Isaak, D.O.1, Lyla Hance, M.P.H.1, Hong J. Kim, M.D.2, Lavinia M. Kolarczyk, M.D.1 1Department of Anesthesiology, 2Department of Surgery, University of North Carolina-Chapel Hill, North Carolina 27599 Anesthesiology INTRODUCTION ERAS includes evidence-based recommendations for preoperative, intraoperative, and postoperative care of patients undergoing a variety of major surgeries. The goals of the ERAS pathways are to maintain normal physiologic function and to facilitate early postoperative recovery1. Studies have shown that ERAS clinical pathways for pancreatic surgery can decrease hospital stay to an average of 8 days2. Historically, the average length of stay (LOS) at our institution for pancreatic surgery patients was 10.5 days. RESULTS RESULTS Forty patients undergoing pancreatic surgery have completed the ERAS pathway. LOS was analyzed by specific surgical procedure for both historical controls and ERAS pathway patients. The mean LOS for Whipple and distal pancreatectomy patients in the control group was 10.9 days and 9.1 days respectively. The mean LOS for Whipple and distal pancreatectomy patients in the ERAS group was 8.0 days and 6.5 days respectively. There was a decrease in hospital LOS of 2.9 days for Whipple patients (p=0.00125, n=21) and 2.5 days for distal pancreatectomy patients (p=0.0337, n=19) after implementing the ERAS clinical pathway3 (table 2 and figures 1 & 2). Table 2: LOS for Whipple procedures and distal pancreatectomy Whipple Procedures   Total LOS (days) Controls ERAS Difference N= 42 21 Mean LOS (days) 10.9 8.0 -2.9 Median LOS (days) 9.0 7.0 -2.0 Standard deviation (days) 4.64 2.56 -2.08 p-value 0.00125 Distal Pancreatectomies   Total LOS (days) Controls ERAS Difference N= 17 19 Mean LOS (days) 9.1 6.5 -2.5 Median LOS (days) 7.0 6.0 -1.0 Standard deviation (days) 4.41 1.81 -2.60 p-value 0.0337 MATERIALS AND METHODS All patients having major open or laparoscopic pancreatic surgery were included in the ERAS clinical pathway. Patients undergoing pancreatic surgery from the year prior were used as historical controls. Preoperative, intraoperative and postoperative components of the pathway are summarized below in table 1. Figure 1: LOS for control vs. ERAS Whipple Figure 2: LOS for control vs. ERAS distal pancreatectomy Table 1: ERAS clinical pathway components CONCLUSION Implementation of ERAS pathway for pancreatic surgery decreases hospital LOS by standardization of perioperative care. This ultimately improves the quality of care delivered, accelerates recovery, improves patient outcomes, and optimizes utilization of health care resources. PREOPERATIVE INTRAOPERATIVE POSTOPERATIVE Patient education Defined blood pressure goals Extubation in operating room Identification of baseline blood pressure and ideal body weight Antibiotic prophylaxis (per SCIP guidelines) Thoracic epidural analgesia, avoidance of systemic opiates Consumption of 240 ml (8.1 oz) carbohydrate drink Standardized anesthetic approach Multimodal analgesia Low thoracic epidural Thoracic epidural management strategy, avoidance of systemic opiates Daily ambulation goals Preoperative crystalloid bolus Goal-directed fluid therapy algorithm Early removal of nasogastric tube Mechanical Ventilation Strategy Early removal of urinary (Foley) catheter VTE Prophylaxis Transfusion Guidelines REFERENCES Surgery 2011 Jun;149(6):830-40 HPB (Oxford). 2014 April 18 World J Surg (2013) 37: 240-258