Enhanced Recovery Programmes

1. ENHANCED RECOVERY
PROGRAMMES
DR.MASUMAHAQUE SHARMIN
MS RESIDENT- GENERALSURGERY
SU - III

2. Dogma: Back to the Past….
Senior surgeons had strong principles and they were assumed
as a dogma.
• Preoperative prolonged fasting, Mechanical bowel
preparation and nasogastric tubes were thought to be
necessary to
 empty the bowel
 to prevent intraoperative contamination
 and to prevent early passage of bowel content through
an anastomotic suture line while it is healing.
• Drain tube was believed essential in any GIT surgery
• Prolonged bed rest were recommended to facilitate
abdominal wall healing.

3. …but Evidence always trumps Dogma

4. Evolution of surgical
principles brought about the
concept of
E R A S
This concept was first described in 1990s by Henrik
Kehlet, MD, PhD, Surgical Gastroenterologist.

5. What is ERAS and ERPs?
ERAS stands for Enhanced Recovery After
Surgery
also Known as
Fast Track Surgery
ERAS consists of Enhanced Recovery Programs
which is a multimodal perioperative care
pathway that aims at reducing stress response to
surgery and acceleration of recovery.

6. ERAS - Goals
• Reduction of stress response to
surgery
• Acceleration of recovery.
Usual hospital stay following major colorectal
surgery: 7-14 days.
Strict adherence to ER Programme reduces
hospital stay to 2-3 days

8. Team Members for Successful ERP
Nurses
Dietitians
Physiotherapists
Occupational therapists
Pain team
Theatre staff
Anesthetists
Surgeons
Hospital management
Audit team

9. Pre-Admission
Optimization
Counseling
Oral Supplements
Pre-Operative
Admission on the day of surgery
Preoperative fasting and Carbohydrate Loading
No Mechanical Bowel Preparation
Prophylaxis: DVT, Antibiotic
Perioperative opioid sparing analgesia
Anesthesia
Normothermia
Mid Thoracic Epidural Analgesia
Avoidance of fluid overload
Surgical
Approach: Laparoscopy/ Short Incision/ Transverse Incision
Avoid Surgical Drains or Nasogastric tubes
Post-Operative
Hydration
Active, Multimodal and preventive pain control
Aggressive management of nausea and vomiting
Early oral feeding and mobilization
Nutritional support
Remove urinary catheters and drains
Discharge criteria
ERP Components

10. 1. Pre admission counseling:
• A clear explanation of what is to happen
during hospitalization
• Explanation of role of the patient about
food intake, oral nutritional supplements
and mobilization after surgery
ERP - Key Elements

11. ERP - Key Elements
2. Selective Bowel Preparation:
• Avoid mechanical bowel preparation
• 6 hour fast for solid food and liquids
containing fat or particulate material
• Clear fluids can be taken until 2 hour
before induction of anesthesia.

13. ERP - Key Elements
3. Pre operative carbohydrate loading
and metabolic conditioning:
• Clear carbohydrate-rich beverage i.e.
Nutricia Preop™ before midnight and 2–
3 hour before surgery .
“This reduces preoperative thirst,
hunger and anxiety, and significantly
reduce postoperative insulin resistance.”

14. ERP - Key Elements
4. Avoid pre anesthetic sedatives or anxiolytics
if possible
5. Nasogastric Tubes in GI Surgery- (Avoid)
• Can impair return of gut function.
• Are disliked by patients.
• Increase the incidence of postoperative fever,
atelectasis and pneumonia.
• Lower GI surgery: Only insert if gastric
distension or requested by surgeon.
• Upper GI Surgery: May be necessary.

15. ERP - Key Elements
6. Thoracic Epidural Anesthesia:
• Reduces pain and the dosage of general
anesthetic agents.
• Blocks stress hormone release and decrease
postoperative insulin resistance.
• In colonic surgery the epidural catheter in mid-
thoracic level (T7/8) blocks sympathetic
nerves and prevents gut paralysis

16. ERP - Key Elements
7. Short acting anesthetic agents:
Use Propofol, Remifentanil instead of
Fentanil or Morphine.
Short acting Inhalational anesthesia is
an alternative to Total intravenous
anesthesia (TIVA)

17. ERP - Key Elements
8. Individualized perioperative fluid
administration:
Avoid Na and Fluid overload
Goal directed fluid therapy via
Oesophageal Doppler(OD) monitoring
Fluid overload is associated with delayed
gut function and increased complication
rates.

18. ERP - Key Elements
9. Avoid Perioperative Hypothermia
• Warm air blowers on the patients during
surgery and warm IV fluids administered.
• Continue warming into the postoperative
period. Keep Temp. > 96.7˚F
• Monitor temperature, avoid hyperthermia.
• Hypothermia increases the risk of wound
infection, bleeding and transfusion requirements

19. ERP - Key Elements
10. Short, Transverse Incision/ Laparoscopic
Colon surgery:
• reduce in-patient stays,
• lessen morbidity
• and lower postoperative pain
11. Avoid Drain Tubes in routine colonic
resections above peritoneal reflections and
consider short-term (<24 h) drainage for low
anterior resections.

20. ERP - Key Elements
12. Prevention of Postoperative Nausea and
Vomiting (PONV)
• PONV is unpleasant, delays gut function,
affects mobility and has metabolic
consequences.
• Give prophylactic anti-emetics i.e.
Ondansetron during anesthesia around 30 min
before the end of surgery.

21. ERP - Key Elements
13. Encourage Early Postoperative Oral Intake
• Facilitates early return of bowel function,
• Allows stopping of intravenous drips,
• Aids mobilization,
• Leads to faster recovery.
• Reduces postoperative morbidity and is not
associated with an increased risk of anastomotic
dehiscence

22. ERP - Key Elements
14. Early mobilization
Bed rest
• ↑ insulin resistance , muscle loss and risk of
thromboembolism.
• ↓ muscle strength, pulmonary function and
tissue oxygenation .
• The aim is for patients to be out of bed for 2 h
on the day of surgery, and for 6 h a day until
discharge.

23. ERP - Key Elements
15. Non-opiate Analgesics/NSAIDs
Opiates are associated with decreased gut
motility.
Short term NSAIDs use can avoid Gastric
irritation.

24. Day of
Surgery

25. 1st POD
TWOC- Trial Without
Catheter
NMBM- No Meal by
Mouth

26. 2nd POD

27. 3rd POD

28. ERP – Discharge Criteria
Patients can be discharged when they meet
the following criteria:
• Good pain control with oral analgesia
• Taking solid food, no intravenous fluids
• Independently mobile or same level as prior to
admission
• All of the above and willing to go home.

30. Reference
• 1. Manual of Fast Track Recovery for Colorectal Surgery- Nader
Francis, Robin H. Kennedy, Olle Ljungqvist, Monty G. Mythen
• 2. Enhanced recovery programme in colorectal surgery: Does
one size fit all?- Alison Lyon, Christopher J Payne, Graham J
MacKay World J Gastroenterol 2012 October 28; 18(40): 5661-
5663
• 3. Multimodal Approach to control postoperative
Pathophysiology and rehabilitation- Henrik Kehlet. Brit. J A
1997; 78: 606-617
• 4. ERAS (Enhanced Recovery after Surgery) in Colorectal
Surgery- Raúl Sánchez-Jiménez, Alberto Blanco Álvarez, Jacobo
Trebol López, Antonio Sánchez Jiménez, Fernando Gutiérrez Conde
and José Antonio Carmona Sáez