ERAS (Enhanced Recovery After Surgery)

Min Kyu Kim

Introduction

ERAS=?

ERAS in SGO

ERAS in ESGO

ERAS In Korea

Contents• Introduction

• What is ERAS ?

• Why Now ERAS ?

• ERAS in Korea ?

References1. Nelson G et al,Guidelines for pre- and intra-operative care in gynecologic/oncologic surgery:Enhanced Recovery After Surgery(ERAS),Society Recommendations- Part I.Gyn Oncol 140 (2016) 313-322

2.G nelson et al,Guidelines for postoperative care in gynecologic/oncologic surgery:Enhanced Recovery After Surgery(ERAS),Society Recommendations- Part II.Gyn Oncol 140 (2016) 323-332

3. www.erassociety.org

4.//sgo.peachnewmedia.com,Enhanced Recovery:The New Standard for Perioperative Care in Gynecologic Oncology Session 1:What is ERAS and how can it help us?

//sgo.peachnewmedia.com

Verbal Disclosure

erassociety.orgWhat is ERAS?

Guideline & ERAS

What are we trying to achieve after Surgery?

• Normal gastrointestinal function• Pain control• Mobility• No complications!

전통적 방법?

오래되고 안전한 방법?

검증된 방법?

많은 사람들이 하는 방법?

Reference?

Mechanical bowel preparationNo regional anesthesia

Liberal narcoticsProlonged NG tube

Prolonged urinary drainagePatient controlled anesthesia

NPO at midnightDrains

Liberal fluidsBowel restBed rest

“Traditional Peri-operative care• Starvation• Fluid overload• Catabolism• Pain• Insomnia• Dehydration• N/V• Venous stasis• Infection• Adynamic ileus• Patient

dissatisfaction

Pre-op Interventions and Rationale

• Preop counseling and dismissal planning-Education and expectation management

• No oral bowel prep-Euvolemia

• No solids after midnight-Aspiration safety

• Clear oral liquids until 4 hours before surgery-Aspiration safety+euvolemia

Pre-op Interventions• Pre-op carbohydrate

- Mitigate catabolism- Good nutrition=good healing

• VTE prophylaxis-Gyn cancer surgery often high risk for VTE

• Antibiotics prophylaxis• Pre-warming

Side effects of Mechanical Bowel Preparation

• Dehydration• Decreased exercise capacity(9%),decreased weight(>1kg)• Hyperphosphatemia,hypocalcemia• Hypokalemia• Systemic review(GYN)-5 RCTs:no improvement in operative time,surgical field view-More unpleasant patient experience

• SSI reduction achievable to 1% in ovarian cancer debulking s without bowel prep

Reumkens,et al.Gastrointest Endosc 2017Johnson et al.Onstet Gynecol 2016Arnold et al JMIG 2015Holte et al Dis Colon 2004

Preoperative Carbohydrates• Rationale:Mitigate deleterious effects of

fasting(catabolism,insulin resistance)• Systemic review

-17 RCTs,1445 patients-Improved insulin resistance-Improved patient comfort indices-

hunger.thirst.malaise,anxiety,nausea-No increase in aspiration

Bliku et al.Ann R Coll Surg Eng 2014

Preoperative Carbohydrates• Cochrane review

->45g carbohydrates within 4 hours of surgery-27 RCTs,1976 patients-Abdominal surgery,ortho,cardiac,thyroid-Decreased length of stay-Increased postop peripheral insulin sensitivity-No difference in postop complications-No patients dx with aspiration pneumonitis

Smith et al Cochrane Data Syst Rev 2014

ASA Practice Guidelines for Preoperative Fasting

Apfelbaum et al.Anesthesiology.2017

Enhanced Recovery After Surgery Pathways Gynecologic Oncology MD Anderson Updates.Pedro T.Ramirez.SGO Education

Enhanced Recovery After Surgery Pathways Gynecologic Oncology MD Anderson Updates.Pedro T.Ramirez.SGO Education

Prevention of SSI:Antibiotics

Supplemental Perioperative O2

Maintenance of Normothermia

Perioperative Fluid Balance

Postoperative Fluid Therapy• Oral fluid intake immediately post surgery is

preferred• IV fluid limited to 1.2mg/kg/hr including all meds-

Typically start at 40 cc/hr• Discontinue IV fluid fluids within 12-24 hours of

surgery• Oliguria as low as 20cc/hr is normal and fluid

boluses should only be used within the clinical context

Goal is to maintain normovolemia while avoiding very restrictive or liberal regimens

Intra-op Enhanced Recovery

• Minimal Invasive Surgery approach whenever feasible

• DVT prophylaxis per standard guidelines• Avoid NG tube• Avoid intraperitoneal drains

Multi-modal/Multi-phasic Analgesia

• Goals:-Achieve pain control and reduce opioid

consumption-Achieve other enhanced recovery objectives-Increase patients satisfaction

• Pre-op:celecoxib,acetaminophen,gabapentin

Regional Analgesia for Abdominal Surgeries

• Multiple options for regional anesthesia

-Thoracic epidural anesthesia(TEA)-Spinal anesthesia with low dose intrathecal

morphine(ITM)-Transverse abdominius plane blocks(TAP block)-Continuous wound infiltration(CWI)-Intraperitoneal local anesthestic(IPLA)-Local infiltration of anesthesia

Post-operative Pain Control

• Multimodal anesthesia:NSAIDs,Acetoaminophenaround clock;oral as soon as possible

• Consider dexamethasone if PONV• Oral narcontic prn,IV dose for breakthrough only• Avoid PCA anesthesia• Consider continuous wound infiltration with local

anesthetics –more research is needed especially with new liposomal anesthetics

Early Feeding After Gyn Surgery

• Oral intake of food started day of surgery

• Several RCT in gyn oncology patients-Return of bowel function-Decrease length of stay-Greater nausea but not vomiting or NG placement

Postoperative Glucose control

Post-op Enhanced Recovery Bundle

• Urinary catheters should be routinely be used for less than 24hrs

-Immediate removal has a higher re-catheterization rate than 6-24 hr removal

• Early mobilization is imperative and should be accompanied within 24hrs after surgery

Extended DVT Prophylaxis• Prospective cohort trials have shown an increased

rate of VTE in cancer patients within 30 dyas of surgery

-Extended ppx decreased VTE 14.3 % vs 6.1%

• Evidence for extended prophylaxis in MIS patient is limited

-Likely beneficial in patients with elevated BMI,previous VTE,decreased mobility

Example of ERP(Enhanced

Recovery Protocol)

ERAS in Korea ?