Enhanced Recovery After Surgery Elective Colorectal Surgery

Enhanced Recovery
After Surgery

(Elective Colorectal
Surgery)

Nunoo-Mensah/Mbale

8 October 2010

Background

‘Multimodal FT recovery programme for
elective large bowel surgery’

Pioneered by Kehlet in Denmark 01/02
Modification ERAS study group

Objectives:
• 10 Enhance postoperative recovery
• 10 Avoid common hindrance to early hospital

discharge
• 20 Reduced hospital stay & healthcare costs

Main Elements of ERAS

Preoperative No Pre-med
counselling No fasting - Fluid/CHO Loading

Early removal Avoiding bowel preparation
of catheters

Stimulation of ERAS No NG tubes
gut motility
Synbiotics Thoracic epidural
Short-acting
Mobilisation anaesthetic agents

Non-opiate oral Avoidance of fluid/Na
analgesic/NSAID overload

No drains Short incisions High PO2

Temperature regulation (Transverse/Laparoscopy)

What's the Evidence ERAS

‫ ‏‬Systematic review of enhanced recovery
programmes in colonic surgery

‫ ‏‬Wind et al, BJS 2006;93:800-809

Objectives:
• Assess FT vs. TC
• Used RCT & Non RCT with prospective collected data

44 (6 papers included – with Av 9 elements)
• Outcomes - M&M, Hospital stay (PHS/OHS),

Readmission rates

Accepting for heterogeneous data, bias …

Mortality & Morbidity Rates (RR)

No difference in mortality

Hospital Stay (PHS)

WMD : Weighted mean difference

Relative Risk For Readmissions Rates

KCH ERAS (Colorectal Surgery)

Introduced ERAS at KCH - Aug 2009
Appointed ERAS Colorectal nurse

Role:
• Education (Training and education of all MDT)
• Peri-operative management of ERAS patients

ERAS Colorectal Nurse

Patient Management

• Pre-Operative Phase
• Intra-Operative Phase
• Post-Operative Phase

Pre-Operative Phase

• Pre-Op counselling
‘Patient education of ERAS – leaflets, diary etc’

• Identify co-morbidities & Optimisation

Anaemia

Hypertension GP

Diabetes Other MDT specialties

Malnutrition etc…

• Social Assessment

Post -Operative Phase

In Hospital

• Support and facilitation of pathway by participate on
daily ward rounds

• Re-enforcing patient goals - motivation, mobilization,
supplementary drinks, incentive spirometry,
catheters, stoma care (Early rehabilitation)

• Documentation (audit)

Discharge Criteria

No change in discharge criteria!!

• Tolerating diet with no N&V
• Good pain control on oral analgesia
• Independently mobile
• Passing flatus +/- bowel movement
• All of the above + ‘confident to go home’

Post-Operative Phase

At Home

• Telephone FU (≥1 week)
• Patient direct access to ERAS Nurse via phone

for 2/52
• Liase with GP’s and district nurses
• ERAS Nurse led follow up OPA in 2/52 & Normal

4-6 week follow up with consultant

Post ERAS

> 12 months ERAS program
114 patients

Median Length Of Stay

All colorectal elective patients

Pre-era ERAS ERAS era ERAS era ERAS era (All
< Aug 2009 patients)
(non-ERAS (ERAS
9 patients) patients) 8

13 7

Data analysis June 2010

Re-admission rate 17.3% (ERAS period), 15% (Pre-
ERAS period)

Feedback

Patient diaries

• “Short is good – it was great to go home after
2 days and keep recuperating fast”

• “I was a partner in the treatment,… I felt
engaged”

• “Continued recovery at home – surprised at
rapidity recovery is taking place”

Feedback

• “Went home 4 days after sigmoid colectomy,
visitors child at home asked if they could take
flowers back home as I did not look unwell”

• “Phone call from ERAS nurse – nice to know
not forgotten and personal care is continuing”