1. Enhanced Recovery after Surgery
a paradigm shift in preoperative care

3. 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)

4. 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

5. 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

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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?

15. 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): doi: /jamasurg
Of the 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, ]; 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

16. 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): doi: /jamasurg
Of the 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, ]; 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

17. 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?

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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.

26. Enhanced recovery after surgery
Goal Directed Therapy

27. 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

28. 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

29. 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.

31. 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 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

32. 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 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

33. 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

34. 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

35. 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

42. ERAS
Our results

46. ERAS at Queen’s Health Systems

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

48. ERAS group has less outliers and a shorter LOS

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

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

53. Enhanced recovery After surgery
Where do we go from Here?

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

58. 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)

60. 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!!

61. Questions?