1. DEBATE?

2. THERE IS NO DEBATE

3. Traditional Perioperative Care StarveStarve StressStress DrownDrown

4. Enhanced recovery after surgery Functional capacity Surgery Multi-modal intervention Traditional care DaysWeeks

5. Preop Audit of compliance & outcomes Home Surgery ↨ Anesthesia Ward HDUHDU CLINICCLINIC PATIENT’S JOURNEY KCH Fearon 2004

6. Preadmission counselling Selective bowel-prep CHO- loading/no fasting No - premed No NG tubes Thoracic epidural Anaesthesia Short-acting Anaesthetic agent Avoidance of Sodium/fluid overload Short incisions Warm air body heating in theatre Standard mobilisation Non-opial oral Analgetics/NSA ID`s Prevention of nausea and vomiting Stimulation of gut mobility Early removal of catheters/drains Perioperative oral nutrition Audit of compliance/ outcomes ERAS Core Protocol

7. FLUIDS FOOD

8. BALANCED IS BETTER ELECTIVE SURGERY RESUSCITATION WET IS BEST

9. Post-op Weight Gain Following Colorectal Resection Lobo et al, Lancet Brandstrup et al, 2002; 359: 1812-18 Annals Surg 2003; 238: 641-8 3-6kg KCH Fearon 2004

10. HypothesisFluid/SalineOverloadHypoalbuminaemia/Acidosis/Hyperchloraemia Gut oedema/Malfunction Delayed recovery

11. Effect of salt and water balance in recovery of gastrointestinal function after elective colonic resection 20 colonic resection patients 10 10 10 10 Standard IV Restricted IV* fluids fluids fluids fluids (* 2l H 2 0 and 77mmol NaCl) Lobo et al, 2002 Lancet; 359: 1812-8

12. Effect of fluid and salt restriction in post-op recovery -2 0 1 2 3 4 5 Standard Group Restricted Group p<0.0001 Change in weight (kg)       0 1 2 3 4 5 Postoperative days Standard Group Restricted Group 25 30 35 40 Serum albumin (g/L) p=0.01 Preop    1 2 3 4 5 6  Postoperative days

13. Effect of fluid and salt restriction in post-op recovery Solid phase gastric emptying time T 50 (mm) 250200150100500 n=10 n=10 p=0.028 Standard Restricted Group Group Group Group Liquid phase gsric emptying time T 50 (min) 200150100500n=10 n=10 p=0.017 Standard Restricted Group Group Group Group

14. Post-op Fluid Management TRADITIONAL BALANCED 4-6L 2-3L 2-3L 1-2L OPERATION POST-OP 2-4d 1-2d

15. What is the evidence base to suggest that BALANCED fluid management can improve outcomes?

16. Effects of IV fluid restriction on post-op complications 172 Colorectal resection patients 8686 Standard IV Restricted IV Standard IV Restricted IV fluids fluids fluids fluids 7269 competed completed competed completed Brandstrup et al, 2003; 238: 641-8

17. Number of Patients with Complications (Per-Protocol Analysis) Restricted Group Standard Group p value Overall complications 21400.003 Major complications † 8180.040 Minor complications † 15360.000 Tissue-healing complications † 11220.040 Cardiopulmonary complications † 5170.007 Blinded Assessment

18. Effect of Intra-operative Fluid Management on Outcome after Intra-abdominal Surgery Nisanerich et al 2005, Anaesthesiology; 103: 25-32 n=152 n=75n=77 Randomised Liberal regimen (Bolus 10ml/kg followed By 12ml/kg/hr) Restricted regimen (4ml/kg/hr) 3.8 ± 1.2 L 2.0 ± 0.5 L 1.9 ± 0.5 L 1.4 ± 1.0 L 2.2 ± 0.5 L 2.1 ± 0.5 L 2.0 ± 0.5 L Intra-op Day 1 Day 2 Day 3 <0.001 N.S. N.S. N.S. P

19. Effect of Intra-operative Fluid Management on Outcome after Intra- abdominal Surgery Nisanevich et al 2005, Anaesthesiology; 103: 25-32 OutcomeRestrictedLiberalP No. of pts with complications 1323<0.05 Length of stay (d) 89<0.01 Moved bowels (d) 46<0.001

20. If you Limit Intra-operative Fluids (10ml/kg/hr), does Early Discontinuation of IV Fluids Influence Outcome? Makay et al (sumbitted) n=80 Colorectal n=41n=39 STANDARDLIMITED 3L H 2 0/d 154mmol Na/d 3d 2L H 2 0/d 60mmol Na/d 1d

21. Effect of Restricted Intra-op Fluids Plus Discontinuation of IV Fluids on Day 1 Makay et al (submitted) Restricted‘Liberal’P No of complications 1410NS Length of stay (day) 66NS Moved bowels (day) 44NS

22. BALANCED IS BEST

24. Postoperative early enteral nutrition Lewis BMJ 2001

25. Traditional Care Day1 ERAS Day1

26. Nygren Clin Nutr 2003 Effect of ERAS on spontaneous oral diet  traditional care  enhanced-recovery protocol

27. Complications, length of stay and readmissions within 30 days of colorectal resection ERAS n = 425 Traditional* n = 451 P Anastomotic leak % 4.23.9 Mortality % 1.21.5 Actual length of stay (days) (median) 58<0.01 * Nygren et al Clin Nut 2005;24:455-461 ERAS GROUP

29. THE END