Professional Documents
Culture Documents
IMPLEMENTATION OF
ENHANCED RECOVERY
PROTOCOLS
December 2009
www.asgbi.org.uk
GUIDELINES FOR
IMPLEMENTATION OF
ENHANCED RECOVERY
PROTOCOLS
AUTHORS
Mr Shakeeb Khan, MBBS, MRCS
Mr Marcel Gatt, MD, FRCS
Mr Alan Horgan, MD, FRCS
Consultant Colorectal Surgeon and National Lead for
Enhanced Recovery Programmes, National Cancer Action Team.
PUBLICATION DATE
December 2009
PUBLISHED BY
Association of Surgeons of Great Britain and Ireland
35-43 Lincolns Inn Fields, London, WC2A 3PE
1
FOREWORD
Issues in Professional Practice is an occasional series of booklets
published by the Association of Surgeons of Great Britain and
Ireland to offer guidance on a wide range of areas which impact on
the daily professional lives of surgeons. Some topics will focus on
clinical issues, some will cover management and service delivery,
whist others will feature broader aspects of surgical working life
such as education, leadership and the law.
Peri-operative surgical care is undergoing a paradigm shift.
Traditional practices such as prolonged pre-operative fasting (nil
by mouth from midnight), bowel cleansing and the use of
nasogastric decompression are being shunned. These, and other
similar changes, have been formulated into protocols called
Enhanced Recovery after Surgery (ERAS) pathways, and this
booklet offers Guidelines for Implementation of Enhanced
Recovery Protocols.
The Association hopes that this publication, and the others in the
series to follow, will provide concise advice and guidance on major
current issues, and grow into a helpful and accessible resource to
support your professional practice.
Suggestions for any potential topics for future booklets in the
Issues in Professional Practice series would be gratefully received.
CONTENTS
Page No.
Summary of Recommendations
Introduction
Special circumstances
16
17
Future research
19
Quality of life
Laparoscopic surgery
Gut specific nutrients
Index
20
References
21
ABBREVIATIONS
ERAS
FTc
QoL
Quality of life
SV
Stroke volume
TEDs
PCA
PONV
SUMMARY OF RECOMMENDATIONS
Peri-operative surgical care is undergoing a paradigm shift.
Traditional practices such as prolonged pre-operative fasting (nil
by mouth from midnight), bowel cleansing and the use of
nasogastric decompression are being shunned. These, and other
similar changes, have been formulated into protocols called
Enhanced Recovery after Surgery (ERAS) pathways. The
Association of Surgeons of Great Britain and Irelands current
recommendations on ERAS are summarised below and will be
presented in more detail in this document:
Pre-operative recommendations
1) Pre-operative counselling and training.
2) A curtailed fast (6 hours to solids and 2 hours to clear liquids)
and pre-operative carbohydrate loading.
3) Avoidance of mechanical bowel preparation.
4) Deep vein thrombosis prophylaxis using low molecular weight
heparin.
5) A single dose of prophylactic antibiotics covering both aerobic
and anaerobic pathogens.
Peri-operative recommendations
1) High (80%) inspired oxygen concentration in the peri-operative
period.
2) Prevention of hypothermia.
3) Goal directed intra-operative fluid therapy.
4) Preferable use of short and transverse incisions for open
surgery.
5) Avoidance of post-operative drains and nasogastric tubes.
6) Short duration of epidural analgesia and local blocks.
Post-operative recommendations
1) Avoidance of opiates and the use of Paracetamol and non
steroidal anti-inflammatory drugs (NSAIDS).
2) Early commencement of post-operative diet.
3) Early and structured post-operative mobilisation.
4) Administration of restricted amounts of intravenous fluid.
5) Regular audit.
4
INTRODUCTION
Enhanced recovery after surgery (ERAS) protocols, also known as
fast-track surgery or multimodal optimisation, are a combination
of evidence based peri-operative strategies which work
synergistically to expedite recovery after surgery [1, 2]. These
strategies include, for example, a curtailed pre-operative fast, preoperative carbohydrate loading, pre-emptive analgesia and early
post-operative mobilisation together with expedited re-introduction
of diet and fluids. Although each of these individual strategies is
beneficial, to some extent, on its own, to achieve maximum benefit
they have to be used together in the form of a package. Using
ERAS protocols, post-operative stays following colorectal resection
can be safely reduced to around two to four days. This expedited
discharge is not achieved by lowering the prerequisites for release
from hospital, but rather by fulfilling standard discharge criteria
earlier due to an accelerated post-operative phase. The advantages
of ERAS have been repeatedly borne out in a number of
randomised clinical trials and meta-analyses. The underlying
mechanism of ERAS protocols is thought to be an attenuation of
the peri-operative stress response [3-5], although there is increasing
evidence to suggest that benefits of ERAS are actually mediated by
return of organ, particularly gut function [6].
The purpose of this document is threefold: To present the various
components of enhanced recovery along with the rationale behind
their inclusion; to suggest strategies to facilitate their
implementation and compliance in day-to-day clinical practice,
and; to propose directions for future research. Specific emphasis
shall be given to ERAS in colorectal surgery as a reflection of the
majority of research having been performed in this field. Many of
the strategies are, however, transferrable to other branches of
surgery. It is also noteworthy that different ERAS protocols have
been trialled and validated in the literature. They have all been
shown to produce similar results, suggesting that protocols can be
tailored to take into account local requirements and available
resources. Nonetheless, it must be emphasised that the principles of
ERAS presented in this document are guidelines only and may not
be applicable, particularly in the care of patients undergoing
complex procedures.
ii.) What the patient should expect during the course of the
hospital stay. This should include specifics of how ERAS
is implemented locally and which modalities are employed.
iii.) Specific issues which may delay discharge (such as lack of
social support).
iv.) Clear and specific instructions should be given about
mobilisation, early introduction of diet and breathing
exercises. Active participation of the patients themselves in
their recovery should be sought, and daily targets for the
patient to achieve should be set up.
v.)
No
Yes
Colloid Challenge
7 ml/kg first bolus (if low FTc)
3 ml/kg subsequent bolus (or initial SV)
Yes
FTc <350ms or
SV decrease >10%
FTc <350ms
No
FTc >400ms
Yes
No
SV increased >10%
since previous
bolus or measurement
No
15
SPECIAL CIRCUMSTANCES
1) Elderly patients and those with high co-morbidity
Such patients have been shown to benefit from enhanced recovery
and should be included in these programmes. There is no evidence
for concern in including ASA 3 and 4 patients into ERAS
programmes, although the literature in this area is limited [67].
Elderly patients may not be able to cope at home after discharge if
there is no one to assist them. This may delay patient discharge,
cognisant of the fact that the overarching aim of ERAS is to
enhance post-operative recovery, not to discharge patients home
earlier. The elderly may require a degree of input after discharge
and this may be in the form of regular telephone calls, a home-visit
by a healthcare professional or even by a relative. Therefore,
discharge planning should be initiated at a very early stage for
these patients.
Certain components of ERAS protocols may be even more relevant
in this cohort of patients. For example, Doppler guided fluid
therapy may be particularly useful in the elderly and high risk
patients in whom accurate fluid administration is possibly more
important due to the increased risk of fluid overload.
2) Emergency surgery
Although ERAS pathways have been primarily studied in the
elective setting, they should still be applied to the emergency
situation. Although in emergencies implementation of the preoperative components may not be possible, every effort should be
made to implement as many components as possible [68].
16
18
FUTURE RESEARCH
The safety and applicability of ERAS, in terms of reducing the
post-operative length of stay and morbidity, is well established from
well designed randomised clinical trials and meta-analyses.
However, certain issues related to ERAS require further research:
1) Influence on quality of life (QoL) and patient satisfaction
Although ERAS pathways have not been shown to adversely
influence patient satisfaction or quality of life, the full impact of
the various strategies employed, as well as earlier discharge from
hospital after major surgery, requires further research for a better
understanding [69].
2) Role of laparoscopic surgery within an ERAS programme
Both laparoscopic surgery and ERAS significantly shorten postoperative lengths of stay. However, whether or not the inclusion of
laparoscopic surgery within a successful ERAS protocol offers any
further advantage to that of ERAS alone is not clear. There is
currently no adequately powered study in the literature to answer
this question, but the results of on-going appropriately designed
studies are awaited [43, 44]. Current evidence seems to suggest that, in
the presence of a well implemented ERAS pathway, similar results
can be obtained with or without the laparoscope. Future research
should also compare the costs and quality of life after inclusion of
the laparoscopic approach within an ERAS pathway.
3) Inclusion of gut specific nutrients in ERAS pathways
ERAS pathways are thought to work by preserving organ function
and particularly gut function. Glutamine is a conditionally
essentially amino acid which is used as a preferential nutrient
source by the gut enterocytes and cells of the immune system.
Glutamine levels are known to be sub-normal in catabolic states
such as after surgery, trauma or burns. Preliminary research has
shown that pre-operative oral Glutamine supplementation reduces
septic complications and length of stay after surgery. However,
further research in the form of well designed and appropriately
powered randomised trials is required [70-73].
4) Cost-benefit analysis
Whilst it is self-evident to some that ERAS should be cost effective,
targeted studies investigating the cost-benefit interplay of ERAS
protocols are conspicuous by their scarcity [74-77]. A sound economic
basis for implementing ERAS protocols in various surgical
specialties would greatly enhance the argument in favour of ERAS.
In many branches of surgery, such studies are eagerly awaited.
19
INDEX
20
Antibiotic prophylaxis
Audit
15, 18
Diabetics
Education
Elderly patients
16
Emergency surgery
16
17
Epidural analgesia
12
Glutamine
19
10
19
Hypothermia
Incisions
11
Intravenous fluids
11
Laparoscopic surgery
11, 19
Local blocks
12
Nasogastric tubes
12
13
Oesophageal Doppler
10
Opiates
13
Postoperative diet
14
Postoperative mobilisation
14
Preoperative fasting
Quality of life
19
Research
19
Staff education
19
Surgical drains
12
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